Treatment of stiff-knee gait in cerebral palsy: a comparison by gait analysis of distal rectus femoris transfer versus proximal rectus release

Two groups of patients with cerebral palsy (CP) were studied pre- and postoperatively by gait analysis after proximal release or distal transfer of the rectus femoris for treatment of knee stiffness in swing phase. In the first group studied, 12 patients underwent proximal rectus femoris muscle release. In the second group, 10 patients underwent distal rectus femoris transfer. After surgery, peak knee flexion was increased 9.1 degrees in swing phase by proximal rectus release and 16.2 degrees by distal rectus transfer. Hip motion throughout the gait cycle was not significantly affected by either operation, and no tendency for a crouch gait was observed after either procedure.     

Comparison of rectus femoris transposition with traditional transfer for treatment of stiff knee gait in patients with cerebral palsy

Purpose To assess the outcome of children with cerebral palsy following reposition of the distal rectus femoris tendon for treatment of stiff knee gait. Methods Children with cerebral palsy with stiff knee gait who underwent rectus femoris transfer were studied retrospectively. Inclusion criteria were cerebral palsy of diplegic or quadriplegic type, preoperative and 1 year postoperative three-dimensional motion analysis, and no other surgery except rectus femoris transfer at the time of study. The patients were separated into two groups: in group I, the rectus femoris was transferred to the distal medial hamstring tendons, either the gracilis or the semitendinosus; in group II, the distal tendon of the rectus femoris was transposed laterally and attached to the iliotibial band/intermuscular septum. Results Peak knee flexion during swing phase, total dynamic knee range of motion, knee range of motion during swing phase, and time to peak knee flexion during swing phase were all improved in both groups. Hip and pelvic kinematics were not influenced by the surgery. Velocity, stride length, and cadence were all improved following the surgery. There was no difference between the transfer group and the transposition group. Conclusion These findings suggest that distal transfer of the rectus femoris is effective in improving swing phase knee function by diminishing the mechanical effect of the dysphasic swing phase activity of the rectus femoris, not by converting the rectus femoris to an active knee flexor. No financial support was received for this study.     

Sagittal knee kinematics after rectus femoris transfer without hamstring lengthening

The purpose of this study was to assess the sagittal knee kinematics of rectus femoris transfer without hamstring lengthening. A retrospective review of seventeen children (29 knees) was performed. Gait analysis was performed prior to surgery and repeated at a minimum of one year after surgery. Sagittal knee kinematics were analyzed. Stance minimum knee flexion increased 7 degrees; swing maximum knee flexion increased 5 degrees; and swing minimum knee flexion increased 5 degrees. The present study confirmed previously reported increases in swing maximum knee flexion. Increases in stance minimum knee flexion and swing minimum knee flexion were also found. These findings have not been previously reported.     

Rectus Femoris Muscle Tightness: lntratester Reliability of an Active Knee Flexion Test

The purpose of this study was to examine the intratester reliability of a test designed to measure tightness in the rectus femoris muscle (RFM). The examiner measured the angle of knee flexion with a pendulum goniometer after active knee flexion with the subject prone and the hips stabilized in extension. The angle of knee flexion represents RFM tightness. After an instruction session, the RFM tightness of both extremities of 20 men was measured during test and retest sessions. The reliability coefficients for test and retest measurements were 0.97 for the left extremity and 0.97 for the right extremity. The author discusses factors that may have contributed to the high reliability, including a well defined and easily observed end point of motion, strict hip stabilization, and accurate instrument placement. If conducted properly, the test should provide clinicians and researchers with an objective and reliable tool for measuring RFM tightness. J Orthop Sports Phys Ther 1985;6(5):289-292.     

Three-dimensional muscle-tendon geometry after rectus femoris tendon transfer

BACKGROUND: Rectus femoris tendon transfer is performed in patients with cerebral palsy to improve knee flexion during walking. This procedure involves detachment of the muscle from its insertion into the quadriceps tendon and reattachment to one of the knee flexor muscles. The purpose of the present study was to evaluate the muscle-tendon geometry and to assess the formation of scar tissue between the rectus femoris and adjacent structures. METHODS: Magnetic resonance images of the lower extremities were acquired from five subjects after bilateral rectus femoris tendon transfer. A three-dimensional computer model of the musculoskeletal geometry of each of the ten limbs was created from these images. RESULTS: The three-dimensional paths of the rectus femoris muscles after transfer demonstrated that the muscle does not follow a straight course from its origin to its new insertion. The typical muscle-tendon path included an angular deviation; this deviation was sharp (>35 degrees ) in seven extremities. In addition, scar tissue between the transferred rectus femoris and the underlying muscles was visible on the magnetic resonance images. CONCLUSIONS: The angular deviations in the rectus femoris muscle-tendon path and the presence of scar tissue between the rectus femoris and the underlying muscles suggest that the beneficial effects of rectus femoris tendon transfer are derived from reducing the effects of the rectus femoris muscle as a knee extensor rather than from converting the muscle to a knee flexor. These findings clarify our understanding of the mechanism by which rectus femoris tendon transfer improves knee flexion.     

Rectus Femoris Distal Tendon Resection Improves Knee Motion in Patients With Spastic Diplegia

Background  

Children with spastic diplegia frequently show excessive knee extension (stiff-knee gait) throughout swing phase, which may interfere with foot clearance. Abnormal rectus femoris activity is commonly associated with a stiff-knee gait. Rectus femoris transfer has been recommended to enhance knee flexion during swing. However, recent studies suggest the transfer does not generate a knee flexor moment but diminishes knee extension moment in swing and MRI studies show the transferred tendons can be constrained by scarring to underlying muscles. Thus, it is possible knee flexion would be improved by distal rectus release rather than transfer since it would not be adherent to the underlying muscles.     

Rectus transfer in spastic diplegia

Objectives  

Change of function of the rectus femoris through medial transfer of its distal tendon. This procedure transforms a hip flexor and knee extensor into a hip and knee flexor. Thus the muscle acts as a hip flexor during the terminal stance phase and swing phase and as a knee flexor during the swing phase. This permits the foot to clear the ground and to improve the spastic gait.     

Surgical treatment of knee dysfunction in cerebral palsy

The prerequisites for normal gait are: (1) stability in the stance phase of gait, (2) clearance of the foot in the swing phase, (3) proper foot preposition in swing, and (4) an adequate step length. In the stance phase, the knee provides shock absorption and energy conservation; in the swing phase, it allows foot clearance. To accomplish these functions, the knee must extend fully in stance and flex approximately 60 degrees in swing. Consequently, balanced muscle action at the hip, knee, and ankle joints, combined with adequate acceleration from the hip flexor and triceps surae muscles, is essential. In the crouch gait of spastic cerebral palsy, hamstring lengthening alone often converts the flexed-knee gait to an extended-knee, stiff-legged gait with inadequate swing-phase knee flexion. This unwanted conversion is due to cospasticity of the quadriceps and hamstring muscles. Restoration of normal knee function in patients with spastic paralysis is more successful when fractional hamstring lengthening is combined with a transfer of the distal rectus femoris tendon to either the iliotibial band or the distal tendon of the semitendinosus.     

Outcome of hamstring lengthening and distal rectus femoris transfer surgery

To evaluate the outcome of hamstring lengthening and distal rectus femoris transfer, a retrospective study was performed comparing preoperative and postoperative gait analysis data from 16 children with neurologic involvement. Postoperatively, the timing of peak knee flexion during swing and the total arc of knee motion significantly improved. Hamstring range of motion and knee extension at terminal swing significantly improved, but stride length and gait velocity did not for the overall population. Patients who used braces postoperatively showed an improvement in stride length and velocity when wearing orthoses. This suggests that postoperative bracing may be needed in some patients to maximize the surgical outcome.     

Rectus femoris muscle flap donor-site morbidity.

Donor-site morbidity in four patients after reconstruction with free neurovascular rectus femoris muscle was examined through a series of strength tests in which the leg with rectus femoris muscle harvested was compared with the contralateral leg with an intact rectus femoris muscle. The tests were conducted with three testing devices: (1) the 'Con-Trex Leg-press' in which the force and power of right and left leg extensions at 0.2 and 0.4 m/s in a knee angle from 50 to 90 degrees were tested separately; (2) the isometric power tester, which enabled the unilateral evaluation of the isometric leg extension at three knee angles: 50, 70 and 90 degrees ; and (3) at the 'SP-Force Platforms' in which the patients performed a counter-movement jump where the amplitude of the ground reaction force, the parameters maximum force, and the jump height were calculated in order to compare the right and left leg during a single dynamic movement. Our results showed that the patients (with one exception) demonstrated a balanced relationship between the donor leg and the intact contralateral leg. The patient that primarily demonstrated a large strength deficit was retested 3 months later and showed, after an extensive rehabilitation and training program, an impressive increase in strength. The authors concluded that there is no significant limitation in the strength of the donor leg after removal of the rectus femoris muscle and consequently no significant functional donor-site morbidity. We believe that for the realisation of such results that the intraoperative linking of the vastus lateralis muscle with the vastus medialis muscle, especially in their lower third, and an extensive postoperative rehabilitation and training program are essential.     

Anatomical assessment of the vastus medialis oblique muscle in patients with osteoarthritis of the knee

Minimally invasive total knee arthroplasty requires subluxation of patella laterally without eversion. The anatomy of the vastus medialis oblique muscle (VMO), which affects the surgical exposure of minimally invasive total knee arthroplasty, was investigated. There was no significant difference between men and women with respect to any parameter. The average fiber angle relative to the rectus femoris muscle was 52.9 degrees on anteroposterior view and 49.7 degrees on lateral view. The average insertion height and the distal portion of VMO belly were 17.3% and 38.4% of the patella length from the upper pole of patella, respectively. Female patients had lower VMO attachment and VMO belly, and a significant sex difference was demonstrated. All patients had attachments beneath the upper pole of the patella.     

人工全膝关节置换术治疗膝关节骨关节炎

[目的]评价人工膝关节置换术治疗骨关节炎的临床疗效。[方法]本院自1994年10月～2003年10月采用人工全膝关节置换术治疗膝关节骨关节炎81例（95膝），男10例，女71例；平均年龄65．5岁（50—82岁）；左膝35例，右膝26例，双侧同时置换17例；保留后交叉韧带假体18膝，后方稳定性假体62膝，活动衬垫15膝。[结果]本组平均随访42个月（14—108个月），应用HSS膝关节评分系统进行分析，优：80膝（84．21％），良：10膝（10．53％），可：3膝（3．16％），差：2膝（2．10％）。优良率94．74％。[结论]作者认为人工全膝关节置换术能有效的缓解膝关节骨关节炎的疼痛，改善膝关节功能。正确的选择假体、精细的手术操作和严格的术后康复是保证手术效果的关键。     

A modified longitudinally split segmental rectus femoris muscle flap transfer for facial reanimation: anatomic basis and clinical applications.

The present study was conducted to investigate the intra-muscular neurovascular anatomy and the intra-muscular tendon distribution of the rectus femoris muscle to reassess the reliability of technique of harvesting a longitudinally split segmental muscle flap, and to present our clinical experience on usefulness of the longitudinally split segmental rectus femoris muscle flap as a method for reconstruction of the paralysed face in a series of 25 patients. Twenty fresh cadavers were systemically injected with lead oxide, gelatin and water. Based on the anatomy of intra-muscular neurovascular structure in the rectus femoris muscle, 25 consecutive patients with established facial paralysis were treated by using a two-stage method combining neurovascular free-muscle transfer with cross-face nerve grafting. Follow-ups were 15-24 months. All of the 25 patients showed significantly improvement in the appearance of the oral commissure and oral competence. Satisfactory results of facial reanimation were obtained in 23 patients. Among these cases, near-natural facial expression was achieved. Recovery continued up to 2 years postoperatively. There were two cases having poor movement of transferred muscle 2 years postoperatively. No complications occurred in the donor site. In conclusion, the present study has demonstrated the suitability for subdivision of the segment muscle flap of the rectus femoris into two functional units with a common neurovascular pedicle. This series has further demonstrated the safety and reliability of using the rectus femoris muscle flap for facial reanimation.     

Sagittal knee kinematics following combined hamstring lengthening and rectus femoris transfer

The purpose of this study was to review knee kinematics following combined hamstring lengthening and rectus femoris transfer. Previous findings reported in the literature include kinematic changes in the magnitude of stance-phase maximum knee flexion, stance-phase minimum knee flexion (extension), and swing-phase maximum knee flexion; the timing of swing-phase maximum knee flexion and swing-phase minimum knee flexion (extension); and total knee excursion. Twenty-three children underwent bilateral (22) or unilateral (1) hamstring lengthening and rectus femoris transfer (45 knees) at the Shriners Hospitals for Children in Lexington, KY between January 1996 and December 2001. Sagittal knee kinematic data were obtained as part of a complete gait study accomplished before surgery and at 1 year after surgery. Values were compared using a paired t test method set at a p < .05 level to determine statistical significance. Changes were seen in the magnitude of stance-phase maximum knee flexion, stance-phase minimum knee flexion (extension), swing-phase maximum knee flexion, and swing-phase minimum knee flexion (extension); in the timing of swing-phase maximum knee flexion; and in total knee excursion.     

The total condylar knee prosthesis in osteoarthritis

In 124 patients with osteoarthritis 152 knee arthroplasties were evaluated with a mean follow-up of 7 years (range 5.2–9.1 years). Forty-six patients (53 knees) were either dead or otherwise lost to follow-up. Thus, 99 knee arthroplasties were evaluated. Three arthroplasties had been revised. Of the remaining 96 knee arthroplasties, 95% had achieved a satisfactory result. Five arthroplasties were unacceptable. One had a poor result and four a fair result. The reason for the poor/fair results was in one case a loose patellar component and in one case malposition of the components and ligament insufficiency. In 54.2% of the arthroplasties, there were radiolucent lines beneath the tibial component. There was one fatal pulmonary embolism, and four knees with superficial wound infection. One of these probably went on to late loosening. There was one case of peroneal nerve palsy. Three cases of deep vein thrombosis were diagnosed.     

Free functional rectus femoris muscle transfer for restoration of extension of the foot after lower leg compartment syndrome

In severely injured lower extremities with loss of the anterior compartment, the free functional rectus femoris musculocutaneous flap was used to restore extension of the foot and in soft-tissue reconstruction. From June 2000-July 2002, 3 patients were treated with this technique. Mean follow-up of the 3 patients was 27 months. Electromyography and the Stanmore system (recording pain, need for orthosis, ability to wear normal shoes, activity level, muscle power, active extension of the foot, and foot posture) were used to assess results of functional rectus femoris transfer. One patient had an excellent result, one patient had a good result, and one patient had a poor result, as assessed by the Stanmore system. Free functional rectus femoris transfer can obtain excellent results in treating foot-drop and soft-tissue defects due to lower leg compartment syndrome and loss of all muscles of the anterior compartment. (c)     

Electromyographic analysis of a modified maneuver for quadriceps femoris muscle setting with co-contraction of the hamstrings.

A "quadriceps femoris muscle setting" is isometric quadriceps femoris exercise which can be widely used in early knee rehabilitation. However this exercise cannot obtain enough co-contraction of the hamstrings. Isolated quadriceps femoris contraction in knee extension imposes severe strain to anterior cruciate ligament. We succeeded in developing a simple training maneuver that is effective in obtaining co-contraction of the hamstrings--a modified maneuver for the quadriceps femoris muscle setting with the contralateral lower limb raised (MQS). In this study, we analyzed the effect of this maneuver by EMG quantification. Twenty-eight healthy young adult men performed sequential trials consisting of normal quadriceps femoris muscle setting (NQS) and MQS. Electromyographic activity was recorded from surface electrodes on the gluteus maximus, vastus medialis, rectus femoris, vastus lateralis, semitendinosus and biceps femoris (long head), and normalized to values derived from maximal isometric trials. The % maximal voluntary isometric contraction (%MVIC) of the vastus medialis, vastus lateralis and rectus femoris did not vary in the each maneuver. However, the %MVIC of the hamstrings varied significantly in the MQS. This study suggests that effective co-contraction of the hamstrings can be obtained in MQS by adjusting the load to the raised lower limb.     

Surgical management of congenital and habitual dislocation of the patella

Twelve patients with congenital dislocation of the patella (CDP) and 23 patients with habitual dislocation of the patella (HDP) were followed for 2-15 years after surgical stabilization of the patella. The underlying pathology in both conditions was contracture of the quadriceps mechanism, which was more severe in CDP. Surgical stabilization in most cases included an extensive lateral release, medial plication, and transfer of the lateral half of the patella tendon. Lengthening of the rectus femoris tendon was required in many cases. With appropriate operative procedures, satisfactory results were achieved in 36 of the 41 knees (87.8%).