Does additional patella tendon shortening influence the effects of multilevel surgery to correct flexed knee gait in cerebral palsy: A randomized controlled trial

Distal femoral osteotomy and patellar tendon advancement for the treatment of crouch gait in patients with bilateral spastic cerebral palsy

BACKGROUND

Crouch gait, or flexed knee gait, represents a common gait pattern in patients with spastic bilateral cerebral palsy (CP). Distal femoral extension and/or shortening osteotomy (DFEO/DFSO) and patellar tendon advancement (PTA) can be considered as viable options when knee flexion contractures are involved. Better outcomes have been reported after a combination of both, independently of the presence of knee extensor lag. In this study, we evaluated the clinical and kinematic outcomes of these procedures.

PATIENTS AND METHODS

We reviewed a cohort of 52 limbs (28 patients) who were treated for crouch gait by DFEO/DFSO alone (group 1, n = 15) or DFEO/DFSO + PTA (group 2, n = 37) as a part of single event multilevel surgery (SEMLS). The mean age at surgery was 14 years, and the mean follow-up time was 18 months. The physical examination data and three-dimensional standardized gait analysis were collected and analyzed before the surgery and postoperatively.

RESULTS

Overall knee range of motion improved in all limbs. The knee flexion decreased significantly in both groups at initial, mid, and terminal stance. Hip flexion significantly decreased in mid-stance for limbs in group 2. Both clinical and gait parameters were most improved in limbs who underwent DFEO/DFSO + PTA. Increased pelvic tilt was observed in both groups after surgery.

CONCLUSION

Although DFEO/DFSO alone was successful in correcting knee flexion contractures, PTA has helped to improve knee extensor lag and knee extension during gait.

LEVEL OF EVIDENCE

Therapeutic level IV.

Does patella lowering as part of multilevel surgery improve knee kinematics in children with cerebral palsy and crouch gait? A meta-analysis of comparative studies

Purpose

To evaluate differences in knee kinematic outcomes of patellar-lowering surgery, specifically patellar tendon advancement or patellar tendon shortening, compared with no-patellar-lowering surgery in multilevel surgery for children with cerebral palsy and crouch gait.

Methods

Four databases were searched to retrieve studies published from inception until 2023. Three reviewers independently screened for studies with observational or randomized control designs, comparing two groups of patients with cerebral palsy and crouch gait who underwent multilevel surgery (with patellar-lowering surgery versus no-patellar-lowering surgery), where various gait analysis outcomes were reported (CRD42023450692). The risk of bias was assessed with the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool.

Results

Seven studies (249 patients and 368 limbs) met the eligibility criteria. Patients undergoing patellar-lowering surgery demonstrated statistically significant improvements in knee flexion at initial contact (mean difference = -6.39; 95% confidence interval = [-10.4, -2.75]; p = 0.0006; I2 = 84%), minimum knee flexion in stance (mean difference = -14.27; 95% confidence interval = [-18.31, -10.23]; p < 0.00001; I2 = 89%), and clinical knee flexion contracture (mean difference = -5.6; 95% confidence interval = [-9.59, -1.6]; p = 0.006; I2 = 95%), with a significant increase in anterior pelvic tilt (mean difference = 2.97; 95% confidence interval = [0.58, 5.36]; p = 0.01; I2 = 15%). However, improvements in gait deviation index and decrease in peak knee flexion in swing did not reach statistical significance. Subgroup analysis reduced heterogeneity and revealed (1) greater improvement using patellar tendon shortening versus patellar tendon advancement techniques; (2) lack of knee flexion contracture improvement in high-quality or longer-term studies; (3) longer-term improvement only in minimum knee flexion in stance, with a decrease in peak knee flexion in swing; and (4) an inability to assess the potential benefit of rectus femoris procedure and hamstring preservation.

Conclusions

Overall, the combination of patellar-lowering surgery with multilevel surgery demonstrated superior improvements in stance-phase knee kinematics compared with multilevel surgery alone, despite an increase in anterior pelvic tilt and a longer-term knee flexion reduction during the swing phase.

Level of evidence

Level III, Systematic review of level III studies.

Patellar tendon shortening surgery restores the knee extensor mechanism in flexed knee gait in children with cerebral palsy

BACKGROUND

This study evaluated a patellar tendon shortening (PTS) surgical procedure that uses an overlapping repair combined with an additional Tycron non-absorbable suture to support the shortening in children with Cerebral Palsy (CP). This study aimed to outline this surgical technique and to evaluate its effectiveness in restoring the knee extensor mechanism.

METHODS

The sagittal plane lower limb kinematics, peak knee extensor moment, gait deviation index (GDI), localised movement deviation profile (MDP), temporospatial parameters, passive knee extension ROM, quadriceps lag, and knee extensor strength were calculated pre- and postoperatively. To determine significant differences a robust linear regression model with high breakdown point and high efficiency was fitted to the data.

RESULTS

In this retrospective cohort study, a total of 41 patients with CP who were treated with unilateral or bilateral PTS in isolation or as part of single event multilevel surgery (SEMLS), with a mean age of 11.1 years were included. The knee extension angle improved at initial contact (p < 0.0001), and during stance phase (p < 0.0001). The peak internal knee extensor moment decreased during early (p = 0.0014) and late stance phase (p < 0.0001). The quadriceps lag decreased (p < 0.0001) and knee extensor strength increased (p < 0.0001). The GDI improved (p < 0.0001), as well as the localised MDP for sagittal angles (p < 0.0001) and moments (p = 0.0001). Walking speed (p = 1.0) remained unchanged, but the cadence decreased (p = 0.024) and step length increased (p = 0.0001).

CONCLUSIONS

The knee extension angle and moment during stance phase improved significantly. The children with CP in this study showed improvements in knee extensor strength and quadriceps lag. Thereby it can be concluded that the PTS procedure was able to restore the knee extensor mechanism effectively.

Research trends in the orthopedic surgical management of cerebral palsy: a cross-analytical study of publications in the past decade

Little is known about the trends in orthopedic surgical management of cerebral palsy (CP). In this cross-analytical study we examined alterations in research publications in this field in the past 10 years through four databases. Thus, we divided publications into old (2012-2017) and recent (2018-2022). To determine if the focus of research in this field has changed, we compared both periods based on publication's (authors' number, journal, country, design), patients' (number, gender, age, CP type), and surgery-related (indication, number, category, type) characteristics. Publications showed a positive trend over the past 10 years with a peak in 2020. The number of publications was similar between old and recent ones (47.58% vs. 52.42%). Most research outputs were from the United States and Germany. Differences were noted between recent and old publications regarding journals (p = 0.0001), journal category (p = 0.023), authors' number (p = 0.006), and patients' age (p = 0.02). The impact factor was also different (p = 0.0001). However, no differences were noted regarding other characteristics (p > 0.05). The research output regarding surgical orthopedic management in CP has increased in the past decade with no difference between 2012-2017 and 2018-2022. Except for the number of authors, journal name, and patients' age, no significant differences were noted between both periods.

Evaluation of a technique of patellar tendon shortening to correct patella alta associated with severe crouch gait in cerebral palsy

This study was undertaken to evaluate the results of patella tendon shortening to correct patella alta in the context of surgery for the management of severe crouch gait. Our aim was to ascertain whether the corrected position of the patella and improvement of the power of the quadriceps were maintained for 4 years or more. Twenty older children (mean age: 14.2 years) with long-standing crouch gait secondary to cerebral diplegia underwent surgery to correct crouch gait that included the patellar tendon shortening. The technique for plicating the tendon differed for skeletally mature and immature patients. The length of the patellar tendon was measured by the Koshino Index. The strength of the quadriceps muscle was assessed by manual muscle testing and with a dynamometer and extensor lag, if present, was measured with a goniometer. In all 40 knees, the patella was brought to a more distal position and the position was maintained for a mean duration of 84 months (Koshino Index: preoperative 1.3 ± 0.10; 3-month postoperative 0.95 ± 0.05; final follow-up 0.95 ± 0.04). The results were the same for the techniques used for skeletally mature and immature patients. The power of the quadriceps improved [Medical Research Council (MRC) grade 3 to MRC grade 4] and the improvement was maintained. The technique of patella tendon shortening was effective in correcting patella alta and improving quadriceps power. The shortened patellar tendon did not stretch over the period of follow-up. Level of evidence: III.

Distal femoral extension osteotomy and patellar tendon advancement or shortening in ambulatory children with cerebral palsy: A modified Delphi consensus study and literature review

PURPOSE

In children with cerebral palsy, flexion deformities of the knee can be treated with a distal femoral extension osteotomy combined with either patellar tendon advancement or patellar tendon shortening. The purpose of this study was to establish a consensus through expert orthopedic opinion, using a modified Delphi process to describe the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. A literature review was also conducted to summarize the recent literature on distal femoral extension osteotomy and patellar tendon shortening/patellar tendon advancement.

METHOD

A group of 16 pediatric orthopedic surgeons, with more than 10 years of experience in the surgical management of children with cerebral palsy, was established. The group used a 5-level Likert-type scale to record agreement or disagreement with statements regarding distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening. Consensus for the surgical indications for distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening was achieved through a modified Delphi process. The literature review, summarized studies of clinical outcomes of distal femoral extension osteotomy/patellar tendon shortening/patellar tendon advancement, published between 2008 and 2022.

RESULTS

There was a high level of agreement with consensus for 31 out of 44 (70%) statements on distal femoral extension osteotomy. Agreement was lower for patellar tendon advancement/patellar tendon shortening with consensus reached for 8 of 21 (38%) of statements. The literature review included 25 studies which revealed variation in operative technique for distal femoral extension osteotomy, patellar tendon advancement, and patellar tendon shortening. Distal femoral extension osteotomy and patellar tendon advancement/patellar tendon shortening were generally effective in correcting knee flexion deformities and extensor lag, but there was marked variation in outcomes and complication rates.

CONCLUSION

The results from this study will provide guidelines for surgeons who care for children with cerebral palsy and point to unresolved questions for further research.

LEVEL OF EVIDENCE

level V.

What happens to the patella height in patients with cerebral palsy as they age

We aimed to investigate the progression of patella alta (PA) in patients with cerebral palsy (CP) using the Koshino-Sugimoto (KS) index and assess associated risk factors. Participants in our retrospective study met the following inclusion criteria: patients with CP who visited our institute from May 2003 to December 2019, were ≤18 years of age, were followed up for >2 years and had at least two lateral knee radiographs. KS indices of both knee radiographs were measured for each patient. A linear mixed model was implemented. Our participants included 222 CP patients. KS index values were measured via 652 knee radiographs. Reference values of the KS index for those between 4 and 18 years of age were determined according to Gross Motor Function Classification System (GMFCS) levels. In all GMFCS levels, the KS index decreased with patients' ages (P < 0.0001). In groups where the KS index increased, GMFCS levels IV (P = 0.0045) and V (P = 0.0040) were statistically significant. Change in the KS index values indicates that PA improves as patients age within all GMFCS levels. However, in patients with GMFCS levels of IV and V, progressive PA is expected.

Biomechanical assessment of patellar tendon advancement in patients with cerebral palsy and crouch gait

BACKGROUND

Patellar height is a valuable measure to evaluate the effect of patellar tendon advancement (PTA) on knee function. In the literature, there is no validated procedure to measure the patellar height. In this study we aimed to (1) determine the patella position through musculoskeletal modeling, (2) investigate the effects of two surgical procedures applied for PTA, and (3) assess the effect of PTA in combination with single-event multilevel surgery (SEMLS) on the knee kinematics of patients with cerebral palsy (CP) and crouch gait.

METHOD

Three-dimensional gait and X-ray data of children with CP and crouch gait were retrospectively analyzed if they had received a SEMLS in combination with PTA (PTA group, n = 18) or without PTA (NoPTA group, n = 18). A computational musculoskeletal model was used to quantify patella position, knee extension moment arm, and knee kinematics pre- and postoperatively.

RESULTS

Patellar height significantly decreased in the PTA group (P = 0.004), while there was no difference in the NoPTA group (P > 0.05). The bony procedure for PTA provided a better Insall-Salvati ratio than the soft tissue procedure. The peak knee extension moment arm significantly increased in the PTA group (P = 0.008). In terms of postoperative knee joint kinematics, the PTA group was closer to typically developed children than the NoPTA group.

CONCLUSION

Musculoskeletal modeling was found to be an effective tool for the determination of the patellar height. PTA improved the patella position, knee extension moment arm, and knee kinematics and was an effective procedure for the surgical management of crouch gait in patients with CP.

The Impact of Patellar Tendon Advancement on Knee Joint Moment and Muscle Forces in Patients with Cerebral Palsy

Background: Patellar tendon advancement (PTA) is performed for the treatment of crouch gait in patients with cerebral palsy (CP). In this study, we aimed to determine the influence of PTA in the context of single-event multilevel surgery (SEMLS) on knee joint moment and muscle forces through musculoskeletal modeling; Methods: Gait data of children with CP and crouch gait were retrospectively analyzed. Patients were included if they had a SEMLS with a PTA (PTA group, n = 18) and a SEMLS without a PTA (NoPTA group, n = 18). A musculoskeletal model was used to calculate the pre- and postoperative knee joint moments and muscle forces; Results: Knee extensor moment increased in the PTA group postoperatively (p = 0.016), but there was no statistically significant change in the NoPTA group (p > 0.05). The quadriceps muscle forces increased for the PTA group (p = 0.034), while there was no difference in the NoPTA group (p > 0.05). The hamstring muscle forces increased in the PTA group (p = 0.039), while there was no difference in the NoPTA group (p > 0.05); Conclusions: PTA was found to be an effective surgery for the treatment of crouch gait. It contributes to improving knee extensor moment, decreasing knee flexor moment, and enhancing the quadriceps and hamstring muscle forces postoperatively.

The influence of preoperative knee flexion contracture severity on short-term outcome of orthopedic surgery in ambulatory children with bilateral cerebral palsy

BACKGROUND

Indications and cutoff value of deformities to determine surgical procedures for flexed knee gait are not clear. The aim was to determine the influence of none or mild, and moderate preoperative knee flexion contracture on the improvement of gait after orthopedic surgery in children with bilateral cerebral palsy (CP).

METHODS

Inclusion criteria; bilateral CP, Gross Motor Function Classification System level I-III, and pre- and post operative-gait analysis. The 132 individuals identified were categorized into 2 groups based on the severity of knee flexion contracture (group 1: none or less than 11°; group 2: greater than or equal to 11°), and then matched according to the exact same soft tissue and/or bony orthopedic surgical procedures performed. The indication for surgery was to prevent progressive development of knee flexion contracture and stance phase flexed knee gait. Pre- and postoperative physical examination and gait analysis data were analyzed retrospectively.

RESULTS

Sixty (30 + 30) children, with mean age 10.6 years in each group, were included. The average follow-up time was 17 months. Gait Deviation Index (GDI) improved in group 1 from mean 66 (SD 19) to 74 (15), p = 0.004, and in group 2 from 60 (13) to 69 (15), p = 0.001. Knee flexion in stance improved in group 1 from 21.4 (16.1) to 12.1 (16.0) degrees, p = 0.002, and in group 2 from 32.2 (14.2) to 17.0 (15.9), p = 0.001. Step length improved in both groups, p = 0.017 and p = 0.008, respectively. Only in group 2 significant improvement was noted in walking speed, p = 0.018 and standing function, Gross Motor Function Measure (GMFM-D), p = 0.001. Knee flexion contracture decreased in group 1 from mean 4.6 (5.3) to 2.1 (8.3) degrees, p = 0.071 and in group 2 from 17.2 (4.9) to 9.6 (9.3), p = 0.001. There was no statistical difference between groups in pre-post improvement of GDI or other variables, except GMFM-D.

CONCLUSIONS

Relative mild to moderate preoperative knee flexion contracture does not influence the short-term improvement of gait after orthopedic surgery in children with bilateral CP.

Outcomes of Patellar Tendon Imbrication With Distal Femoral Extension Osteotomy for Treatment of Crouch Gait

BACKGROUND

Crouch gait is a frequent gait abnormality observed in children with cerebral palsy. Distal femoral extension osteotomy (DFEO) with the tightening of the extensor mechanism is a common treatment strategy to address the pathologic knee flexion contracture and patella alta. The goal of this study was to review the results of a patellar tendon imbrication (PTI) strategy to address quadriceps insufficiency in the setting of children undergoing DFEO.

METHODS

After institutional review board approval, all patients with crouch gait treated at a single institution with DFEO and PTI were identified. Clinical, radiographic, and instrumented gait analysis data were analyzed preoperatively and at 1 year following surgery.

RESULTS

Twenty-eight patients (54 extremities) with a diagnosis of cerebral palsy and crouch gait were included. Significant improvements were appreciated in the degree of knee flexion contracture, quadriceps strength, knee extensor lag, and popliteal angle (P<0.01). Knee flexion at initial contact and during mid-stance improved significantly (P<0.0001), and knee moments in late stance were significantly reduced (P<0.01). The anterior pelvic tilt, however, significantly increased postoperatively (P<0.0001). Radiographic improvements were seen in the knee flexion angle and patellar station as assessed by the Koshino Sugimoto Index (P<0.0001). Four patients (14.2%) developed a recurrence of knee flexion contracture requiring further intervention.

CONCLUSIONS

PTI is a simplified and safe technique to address quadriceps insufficiency when performing DFEO. The short-term results of patients who underwent DFEO with PTI demonstrated improvements in clinical, radiographic, and gait analysis variables of the knee. Investigating long-term outcomes, comparing techniques, and assessing quality of life measures are important next steps in research.

LEVEL OF EVIDENCE

Level IV-case series.

Patella Alta in Ambulatory Children With Cerebral Palsy: Prevalence and Functional Significance

BACKGROUND

Gait dysfunction associated with patella alta (PA) in subjects with cerebral palsy (CP) has been presumed but not objectively established clinically or through biomechanical modeling. It is hypothesized that PA is associated with increasing level of motor impairment, increasing age, obesity, and worse stance phase knee kinematics and kinetics in children with CP.

METHODS

Retrospective case series of 297 subjects with CP studied in our Motion Analysis Center. Data analyzed included patient demographics (age, body mass index, CP classification), patella height (Koshino-Sugimoto Index), and knee kinematics and kinetics.

RESULTS

PA was present in 180 of 297 subjects (61%), in 68 of the 146 (47%) with unilateral CP, and 112 of 151 subjects (74%) with bilateral CP. For unilateral CP, the prevalence of PA was not significantly different between Gross Motor Function Classification System (GMFCS) I and II (P=0.357). For bilateral CP, the prevalence of PA in GMFCS III was significantly greater than in GMFCS I and II (P=0.02). Regression analysis showed a significant trend between increasing age and PA in unilateral and bilateral groups (P<0.001 and 0.001, respectively). The prevalence of PA was not significantly different across body mass index categories for either unilateral or bilateral groups. There were only 2 of 10 significant correlations between PA and gait parameters for subjects with unilateral CP functioning at the GMFCS I and II levels. There were 8 of 12 significant correlations between PA and gait parameters for subjects with bilateral CP functioning at the GMFCS I, II, and III levels.

CONCLUSIONS

PA is common in ambulatory children with CP across topographic types and motor functional levels. PA is well tolerated with respect to gait dysfunction in unilateral CP, but may contribute to crouch gait in bilateral CP. Gait dysfunction cannot be inferred from the radiographic assessment of patellar height, and radiographic evidence of PA by itself does not justify surgical correction with patellar tendon advancement or shortening.

LEVEL OF EVIDENCE

Level III-prognostic, retrospective series.

Outcome domains and measures after lower limb orthopaedic surgery for ambulant children with cerebral palsy: an updated scoping review

AIM

To determine the reported outcome domains and measures used to assess lower limb orthopaedic surgery of ambulant children and young people with cerebral palsy (CP) and map these outcomes to the International Classification of Functioning, Disability and Health - Children and Youth (ICF-CY) framework.

METHOD

This updated scoping review included studies published between January 2016 and July 2019 in five databases: MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies were included if participants were ambulant individuals with CP aged between 0 and 20 years who had undergone lower limb orthopaedic surgery. Health outcome domains and measures were identified and classified using the ICF-CY framework.

RESULTS

Forty-four eligible studies were identified with a total of 40 different outcome domains recorded. Among eligible studies, 44 (100%) measured body function and structural impairment and seven (16%) measured activity limitation and participation restriction. The most frequently reported outcome was gait pattern (n=37, 84%). Few studies reported adverse effects of surgery (n=13, 30%). Twenty-nine different outcome measures were identified. Patient-reported outcomes measures were used in 10 studies (23%).

INTERPRETATION

The review highlights a heterogeneity in the reported outcome domains and measures used in CP studies. The majority of the reported outcomes focus on the ICF-CY domain of body function and structure. The review also highlights a notable shift towards patient-reported outcomes in recent years. Development of a core outcome set for lower limb orthopaedic surgery would guide researchers to use more consistent and complete measurement sets.

Crouch gait or flexed-knee gait in cerebral palsy: Is there a difference? A systematic review

BACKGROUND

Crouch or flexed-knee gait is one of the most common pathological gait patterns in cerebral palsy (CP). Differences exist in definitions used; the degree of knee flexion, inclusion of hip or ankle position, and timing in the gait cycle. This ambiguity may be responsible for variations in prevalence rates and difficulty comparing data across studies.

RESEARCH QUESTION

What are the kinematic parameters used to define crouch or flexed-knee gait in CP gait? A secondary aim was to examine the quality of data reporting, focusing on the sample characteristics, inclusion/exclusion criteria and the choice of limb included for analysis.

METHODS

Articles included in this review reported on a specified cohort of adults or children with crouch or flexed-knee gait assessed with 3-dimensional gait analysis. A customised data extraction and quality assessment table was designed specific to the research question.

RESULTS

The majority (75 %) of included studies used the term crouch gait. Where the pattern was defined, 80 % of crouch papers and 94 % of flexed-knee gait papers based this solely on knee position. Kinematic parameters were clearly defined when they provided objective values of knee flexion, supported this with rationale and provided a reference point in the gait cycle. Only 22 % of crouch papers and 19 % of flexed-knee gait papers provided this information. The majority of studies (67 % crouch; 90 % flexed-knee) specified which limb(s) were included for analysis with the majority including both limbs. Objective values of knee flexion ranged from 8 o to 30 o.

SIGNIFICANCE

This review highlights that crouch and flexed knee are synonymous and ambiguity exists in the kinematic definition making it difficult to make compare data amongst study cohorts. Future research should provide detailed definitions including the threshold value of knee flexion, how it was derived, the timing in the gait cycle and the limb(s) included in analysis.

What's New in the Orthopaedic Treatment of Ambulatory Children With Cerebral Palsy Using Gait Analysis

BACKGROUND

Limb deformities in ambulatory children with cerebral palsy (CP) are common. The natural history of lower extremity deformities is variable and the impact on gait is managed with many treatment modalities. Effective interventions must consider the underlying pathophysiology, patient-specific goals, and incorporate objective outcome assessment. Evaluation and treatment include observation, tone management multilevel orthopaedic surgery to address muscle contractures and bony deformities, and the use of gait analysis for preoperative and postoperative assessment.

METHODS

A PubMed search of the orthopaedic literature for studies published between January 2016 and February 2019 was performed. Eligible abstracts included the use of 3-dimensional instrumented gait analysis in the evaluation and treatment of the lower extremities in ambulatory children with CP. Seven hundred twenty abstracts were reviewed, with 84 papers identified as eligible, of which 45 full manuscripts were included for detailed review.

RESULTS

The review summarized recent advances regarding the treatment of torsional alignment, knee deformities and clinical gait evaluation with visual assessment tools compared with instrumented gait analysis.

CONCLUSIONS

Gait analysis of ambulatory children with CP remains essential to evaluation and surgical decision-making. Promising results have been reported with the goal of maintaining or reaching a higher level of function and increased endurance.

LEVEL OF EVIDENCE

Level IV-literature review.

Orthopaedic management of knee joint impairment in cerebral palsy: A systematic review and meta-analysis

BACKGROUND

The optimal management of impaired knee joint function in patients with cerebral palsy (CP) remains a significant and ongoing challenge in paediatric orthopaedic surgery.

RESEARCH QUESTION

What are the clinical and functional outcomes after operative and non-operative orthopaedic interventions for knee joint impairment in patients with CP?

METHODS

This systematic review and meta-analysis of orthopaedic interventions for the management of knee joint impairment in paediatric CP patients evaluated study-level data in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. We performed searches of the following electronic databases from their dates of inception to November 2019: Medline (Ovid), Embase (Ovid) and Pubmed. We extracted mean differences in pre-operative and post-operative measurements for the following outcomes: minimum knee flexion in stance; knee flexion at initial contact; maximum knee flexion in swing; range of motion; popliteal angle; fixed flexion deformity angle; and mean pelvic tilt.

RESULTS

Sixty-nine retrospective cohort studies, prospective cohort studies and RCTs comprising 2991 patients were included with 4578 knees analysed. Included studies were of sufficient quality as assessed by the MOOSE checklist. Operative interventions showed significant improvement in knee flexion at initial contact, knee flexion in stance, range of motion, popliteal angle and fixed flexion deformity which were comparable when subgrouped according to operative technique. In contrast, non-operative techniques and botulinum toxin injection did not confer significant improvements. Operative interventions for knee joint impairment led to increased mean pelvic tilt and reduced maximum knee flexion in swing.

SIGNIFICANCE

This review provides strong evidence that operative interventions for the management of knee joint impairment in cerebral palsy patients improve knee kinematics and clinical examination findings.

[Precise diagnosis and treatment of spastic cerebral palsy]

Objective

To summarize the advancement of precise diagnosis and treatment for spastic cerebral palsy in recent years.

Methods

The literature and own experiences were reviewed, and the surgical method, precise diagnosis, and personalized treatment of spastic cerebral palsy based on the classification of spastic cerebral palsy were summarized and analyzed.

Results

The common classification of spastic cerebral palsy are gross motor function classification system (GMFCS) and manual ability classification system (MACS). The surgical methods of spastic cerebral palsy can be divided into soft tissue surgery, nerve surgery, and bone and joint surgery. The precise diagnosis of spastic cerebral palsy includes qualitative diagnosis, localization diagnosis, and quantitative diagnosis. Based on precise diagnosis and classification, one or more corresponding surgical methods are selected for treatment.

Conclusion

The manifestations of spastic cerebral palsy are so diverse that it is necessary to select rational surgeries based on precise diagnosis to achieve individualized treatment.

Association of back pain and pelvic tilt during gait in individuals with cerebral palsy

BACKGROUND

Back pain prevalence may increase with lumbar lordosis during standing in individuals with cerebral palsy (CP). Multiple interventions undertaken in individuals with CP have been shown to increase anterior pelvic tilt.

RESEARCH QUESTION

Are pelvic tilt and trunk tilt (proxy measurements for lumbar lordosis) during gait associated with back pain prevalence in ambulatory individuals with CP?

METHODS

A retrospective investigation was performed among all patients with cerebral palsy visiting a single clinical motion analysis laboratory over a 3.5 year period (January 2015 - May 2018) who also had complete pain questionnaire data. Back pain prevalence and its association with sagittal plane kinematic parameters (pelvic tilt and trunk tilt) were analyzed.

RESULTS

Among the 700 patients that met the inclusion criteria, 594 were children and 106 were adults. Back pain prevalence was 11.1% in children and 36.8% in adults. As pelvic tilt and age increased, back pain increased (odds ratio 95% confidence interval: 1.002-1.061 and 1.052-1.109, respectively). Walking with an assistive device was not associated with back pain, nor was trunk tilt.

SIGNIFICANCE

Back pain was more common with increasing age in ambulatory individuals with CP. After controlling for assistive device use and age, there was a weak relationship between pelvic tilt and back pain. Future studies are needed to determine if this is this a causal relationship.

Distal Femoral Shortening Osteotomy for Severe Knee Flexion Contracture and Crouch Gait in Cerebral Palsy

Although there have been advancements of surgical techniques to correct gait abnormalities seen in patients with cerebral palsy, the crouch gait remains one of the most difficult problems to treat. The purpose of this retrospective study was to examine our results of distal femoral shortening osteotomy (DFSO) and patellar tendon advancement (PTA), performed in patients with crouch gait associated with severe knee flexion contracture. A total of 33 patients with a mean fixed knee contracture of 38° were included in the study. The mean age at the time of surgery was 12.2 years and the mean follow-up was 26.9 months. The measurements of clinical, radiological, and gait parameters were performed before and after surgery. The mean degrees of knee flexion contracture, Koshino index of patella height, and Gait Deviation Index were found to be significantly improved at the time of final follow-up. The maximum knee extension during the stance phase improved by an average of 25°, and the range of knee motion during gait increased postoperatively. On the other hand, the mean anterior pelvic tilt increased by 9.9°. Also, the maximum knee flexion during the swing phase decreased and the timing of peak knee flexion was observed to be delayed. We conclude that combined procedure of DFSO and PTA is an effective and safe surgical method for treating severe knee flexion contracture and crouch gait. However, the surgeons should be aware of the development of increased anterior pelvic tilt and stiff knee gait after the index operation.

Multilevel Surgery for Children With Cerebral Palsy: A Meta-analysis

CONTEXT

Multilevel surgery (MLS) is standard care for reducing musculoskeletal disorders among children with spastic cerebral palsy (CP).

OBJECTIVE

To summarize the literature examining effects of MLS and satisfaction with MLS for children with CP.

DATA SOURCES

Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched.

STUDY SELECTION

Studies in which authors reported effects of or satisfaction with MLS in children with CP were selected.

DATA EXTRACTION

Two authors screened and extracted data on gross motor function, gait speed, gait (eg, Gait Profile Score), range of motion, strength, spasticity, participation, quality of life, satisfaction, and adverse events.

RESULTS

Seventy-four studies (3551 participants) were identified. One was a randomized controlled trial (RCT) (n = 19); the remainder were cohort studies. Pooled analysis of cohort studies revealed that MLS did not have a long-term effect on gross motor function (standardized mean difference [SMD]: 0.38; 95% confidence interval [CI]: -0.25 to 1.01) or gait speed (SMD: 0.12; 95% CI: -0.01 to 0.25) but did improve gait (SMD: -0.80; 95% CI: -0.95 to -0.65). The RCT also revealed no effect of MLS on gross motor function but improvements in the Gait Profile Score at 1 year. Participation and quality of life were reported in only 5 studies, and adverse events were adequately reported in 17 studies.

LIMITATIONS

Data were largely from cohort studies.

CONCLUSIONS

Findings reveal that gait, but not gross motor function, improves after MLS. RCTs and improved reporting of studies of MLS are required.

Mid-term development of hamstring tendon length and velocity after distal femoral extension osteotomy in children with bilateral cerebral palsy: a retrospective cohort study

AIM

Flexed knee gait can be treated with distal femoral extension osteotomy (DFEO) and additional patellar tendon advancement (PTA) in children with cerebral palsy (CP). This study assesses changes in hamstring muscle tendon length (MTL) and velocity after DFEO (+PTA).

METHOD

Nineteen children (mean age 13y [standard deviation 3y] at surgery) with CP and flexed knee gait who were treated with DFEO (15 limbs) or DFEO+PTA (10 limbs) were retrospectively included in this study. Gait analyses were performed preoperatively (E0), 1 year postoperatively (E1), and for 10 limbs additionally 2 to 5 years postoperatively (E2). Hamstring MTL and velocities were assessed at all examination dates using OpenSim.

RESULTS

Hamstring MTL and velocity did not change significantly over time. From E0 to E1, knee flexion in stance improved for both DFEO and DFEO+PTA (p<0.05), knee flexion in swing only improved after DFEO+PTA (p<0.05). The improved knee flexion in stance and swing was maintained at E2.

INTERPRETATION

DFEO led to a significant improvement in knee kinematics at E1 which was maintained at E2. DFEO seems to prevent recurrent hamstring tightness but does not lead to lengthened or fastened hamstrings.

WHAT THIS PAPER ADDS

Distal femoral extension osteotomy (DFEO) does not change hamstring muscle tendon length. DFEO does not change hamstring lengthening velocity. DFEO leads to a significant improvement in knee kinematics. Changes in knee kinematics after DFEO can be maintained at mid-term. DFEO seems to prevent recurrent hamstring tightness.

The increase of anterior pelvic tilt after crouch gait treatment in patients with cerebral palsy

BACKGROUND

The increase of anterior pelvic tilt (APT) has been described after the treatment of crouch gait in cerebral palsy (CP). The ideal treatment option for flexed knee gait in CP should provide knee extension improvement in the stance phase without generating the increase of APT.

RESEARCH QUESTION

The purpose of this study was to compare three different approaches used for the treatment of crouch gait in CP [distal femur extension osteotomy (DFEO), patellar tendon shortening (PTS) and the combination of DFEO +PTS] regarding the increase of APT after the interventions.

METHODS

The inclusion criteria were: (1) diagnosis of spastic diplegic CP, (2) GMFCS levels I-III, (3) patients who underwent DFEO and/or PTS and (4) with complete documentation in the gait laboratory before and after the intervention. The included patients were divided into 3 groups, according to the procedures performed for crouch gait treatment: PTS (19 patients), DFEO (54 patients) and PTS + DFEO (22 patients).

RESULTS

During stance phase, knee flexion decreased from 41.6⁰ to 13.6⁰ in the PTS group (p < 0.001), from 46.0⁰ to 30.7⁰ in the DFEO group (p < 0.001) and from 52.3⁰ to 29.5⁰ in the PTS + DFEO group (p < 0.001). APT increased 14⁰ (p < 0.001) in the PTS group, 7.1° (p < 0.001) in the DFEO group and 6.6⁰ (p < 0.001) in the PTS + DFEO group after surgical intervention. The PTS group presented a more significant deterioration of pelvic tilt than the DFEO (p = 0.002) and PTS + DFEO (p = 0.001) groups. The increase of APT was higher when HSL was also performed in the PTS + DFEO group (p = 0.016).

SIGNIFICANCE

The increase of APT was observed in all studied groups, but it was more significant for those who underwent a PTS. The inclusion of HSL in the surgical plan was related a higher increase of APT in the PTS + DFEO group.