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

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

Nabian MH ，Zadegan SA ，Mallet C ，Neder Y ，Ilharreborde B ，Simon AL ，Presedo A ... -  《-》

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

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. 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. 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. 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 IV-case series.

Hyer LC ，Carpenter AM ，Saraswat P ，Davids JR ，Westberry DE ... -  《-》

Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy. Surgical technique.

Novacheck TF ，Stout JL ，Gage JR ，Schwartz MH ... -  《-》

Long-Term Outcomes of Distal Femoral Extension Osteotomy and Patellar Tendon Advancement in Individuals with Cerebral Palsy.

Boyer ER ，Stout JL ，Laine JC ，Gutknecht SM ，Araujo de Oliveira LH ，Munger ME ，Schwartz MH ，Novacheck TF ... -  《-》

How does patellar tendon advancement alter the knee extensor mechanism in children treated for crouch gait?

The patellar tendon advancement (PTA) procedure, often coupled with a distal femoral extension osteotomy (DFEO), is increasingly used to treat persistent crouch gait. In this study, we investigated relationships between patella position, knee flexion, and the patellar tendon moment arm in children treated with the DFEO and PTA procedures. We retrospectively analyzed pre- and post-operative radiographs and gait metrics from 63 knees that underwent DFEO and PTA procedures at Gillette Children's Specialty Healthcare. A computational musculoskeletal model of the knee was used to simulate the PTA procedure and predict the effects on the patellar tendon moment arm. Approximately 80% of the knees exhibited patella alta prior to surgery. Post-operatively, 86% of the knees exhibited patella baja. The surgically altered patella position produced a 13% increase in the patellar tendon moment arm in extended knee postures, which agreed well with model predictions. However, the computational model also suggests that baja may compromise patellar tendon moment arms in flexed knee postures. Crouch gait was significantly reduced postoperatively, with a 27 ± 18° reduction in average knee flexion in stance. There was considerable inter-subject variability in outcomes with nine knees not exhibiting a meaningful enhancement of knee extension (<15° change). The subjects who improved were significantly younger and exhibited greater enhancement of the patellar tendon moment arm after surgery. This study shows that the PTA procedure enhances the lever arm of the knee extensor mechanism, and this factor may be important in resolving crouch gait.

Bittmann MF ，Lenhart RL ，Schwartz MH ，Novacheck TF ，Hetzel S ，Thelen DG ... -  《-》