Distal Femoral Extension Osteotomy Research Articles

"Coronal Split/Overlap Repair" Patellar Tendon Shortening in Skeletally Immature Patients.

"Coronal split/overlap repair" patellar tendon shortening (PTS) is a technique that is utilized to treat patella alta and can be combined with distal femoral extension osteotomy (DFEO) for the treatment of crouch gait in skeletally immature patients with cerebral palsy. The patellar tendon is split in the coronal plane. The ventral patellar tendon flap is released from its patellar attachment and is reflected distally over its tibial attachment, exposing a dorsal flap. Two patellar/tibial no. 5 Ethibond (Ethicon) sutures are passed through 2 crossing patellar tunnels and 2 parallel tibial tunnels. The patella is then pushed distally until its distal pole lies at the level of the tibiofemoral joint. The Ethibond sutures are tied and tensioned to the desired level. The knee should be able to be passively flexed to 90°. The intact redundant dorsal flap of the patellar tendon is imbricated. Lastly, the ventral flap is advanced proximally and sutured to the anterior surface of the patella and to the edges of the dorsal flap without shortening. A hinged knee brace is utilized postoperatively with a range of motion of 0° to 30°, progressing to 90° by 6 weeks. No resistive quadriceps contractions are permitted for the first 3 weeks. Patellar tendon advancement in skeletally immature patients can be performed by releasing the tibial attachment and the free end is advanced deep to the T-shaped tibial periosteal flap1-3. Other PTS techniques can be grouped into the categories of (1) patellar tendon imbrication4, (2) patellar tendon detaching techniques in which the tendon is detached from the patellar attachment or cut in its midsubstance and shortened2,5-7, and (3) patellar tendon semi-detaching techniques in which patellar tendon flaps are created and shortened8,9. The presently described technique is a semi-detaching technique, preserving a good part of the patellar tendon while avoiding complete dehiscence of the extensor mechanism. Moreover, the 2 patellar/tibial sutures would protect the patellar tendon repair and allow early rehabilitation and knee range-of-motion exercises. Satisfactory correction of the patella alta was reported with PTS techniques with or without DFEO to correct concomitant fixed flexion deformity in patients with cerebral palsy. Furthermore, there was reported improvement of total knee range of motion with restoration of adequate knee extension during the stance phase1,3,8. Reported complications with this technique were mainly superficial infection. Any substantial fixed flexion deformity of the knee (>10°) should be corrected with hamstring lengthening or DFEO prior to PTS.A mid-patellar coronal split is made with use of a no.-15 blade and extended proximally and distally with use of 2 mosquito clips.To avoid difficulties with crossing of the patellar sutures, always keep the straight needle inside the 1st tunnel until the 2nd tunnel is created and its respective suture is passed.To distalize the patella, the patellar/tibial sutures are tied in a simple knot and held by a mosquito clip in order to allow retensioning until the desired patellar height is reached.The 2 patellar/tibial suture knots are slid to the proximal and distal ends of the surgical field. 3DGA = 3-dimensional gait analysisADL = activities of daily livingCP = cerebral palsyCPM = continuous passive motionDFEO = distal femoral extension osteotomyFAQ = Functional Assessment QuestionnaireFMS = Functional Mobility ScaleGMFCS = Gross Motor Function Classification SystemGMFM = Gross Motor Function MeasureGPS = Gait Profile ScoreGVS = Gait Variable ScoreK-wires = Kirschner wiresPTA = patellar tendon advancementPTS = patellar tendon shorteningSEMLS = single event multi-level surgery.

Distal Femoral Extension Osteotomy with a Retrograde Nail for Treatment of pediatric Crouch Gait

Distal Femoral Extension Osteotomy with a Retrograde Nail for Treatment of pediatric Crouch Gait

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

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. 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. 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. 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 V.

Distal Femoral Extension Osteotomy and Patellar Tendon Advancement in Management of Fixed Knee Flexion Deformity and Crouch Gait in Cerebral Palsy

Abstract Background Cerebral palsy (CP) is generally associated with musculoskeletal deformities that occur during body growth. Fixed knee flexion deformity (FKFD) results from long standing knee flexion that is due to progressive contracture of spastic hamstrings combined with a quadriceps weakness. Fixed knee flexion compromises the passive mechanisms of joint stabilization at mid and terminal stance in children with CP. The aim of this study is to highlight the results of distal femoral extension osteotomy and patellar tendon advancement (DFEO + PTA) for management of FKFD in crouching CP patients with spastic or mixed tone diplegic ambulatory cerebral palsy children. Patients and Methods A prospective study was conducted involving twenty CP patients with fixed knee flexion deformity (14 males and 6 females). The 20 cases with fixed knee flexion deformity were GMFCS level II (4 cases), and III (16 cases). All patients were clinically and radiologically assessed according to knee flexion angle, extension lag, koshino index and the Gross motor function measure pre- and post-operative. All patients underwent DFEO ± PTA. Eighteen limbs had DFEO on the RT side, and twenty on the LT side. Results The mean age of the patients was 11.18±3.23 (6-16) years. The period of follow up ranged from 12 to 24 months (The mean follow up was 16.20 ± 2.46). At last follow up, the median knee flexion angle improved from 25 to 0. The median extension lag improved from 17.5 to 0. The mean koshino index improved from 1.59 ± 0.32 to 1.05 ± 0.10. the GMFM improved from 52.86 ± 7.36 to 68.15 ± 5. 82. Conclusion The combined procedure (DFEO + PTA) is effective in increasing knee extension in the stance phase, reducing knee pain and improving knee extension strength.

Intraoperative neuromonitoring during distal femoral extension osteotomy in children with cerebral palsy.

The most common treatment method for a fixed knee flexion contracture more than 10 degrees in cerebral palsy (CP) is distal femoral extension osteotomy (DFEO). However, a serious complication after a DFEO is neurological impairment. Its rates were reported as 5- 40%. Intraoperative neuromonitoring (IONM), widely used in spinal surgery and in other fields, is a valuable tool to define any neurological injury during operation. The aim of our study was to determine surgical steps with risk of neurological injury and to report if precautions would be effective in recovering signal loss. We performed IONM during DFEO of 23 knees of 12 children with CP. IONM was performed by recording somatosensory evoked potentials, transcranial motor evoked potentials and free-run electromyography during defined steps throughout the surgery. Preoperative and postoperative popliteal angles, flexion contractures and physeal posterior distal femoral angles were evaluated. We detected alert signals at osteotomy or manipulation steps of surgeries of all patients. We observed persistent alert signals in two cases (2 out of 23 knees; Group 2). In this group, the action potentials recovered only after 5 and 10 degrees of undercorrection at the osteotomy sites. Alert signals disappeared after a brief period of waiting in other cases. Throughout mean 37 months of follow-up, none of our patients experienced any neurological complication. The study concludes that the surgical steps in DFEO with a higher risk for a neurological complication were the osteotomy and manipulation steps. Alert signals were detected with the help of IONM, and preventive measures were effective in recovering neuromonitoring recordings.

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.

Anterior distal femoral hemiepiphysiodesis with and without patellar tendon shortening for fixed knee flexion contractures in children with cerebral palsy.

PurposeSurgery is often required for fixed knee flexion contractures in patients with neuromuscular conditions. Anterior distal femoral hemiepiphysiodesis (ADFH) is an alternative to distal femoral extension osteotomy (DFEO) in skeletally immature patients. ADFH is typically not accompanied by patellar tendon shortening surgery (PTS). Our purpose was to compare ADFH alone versus ADFH with PTS for treatment of fixed knee flexion contractures and crouched gait in children with cerebral palsy (CP).MethodsRetrospective review of pre- and postoperative gait analysis data for children with CP who underwent ADFH alone, or ADFH with PTS. Data were analysed using linear mixed models to control for covariates.ResultsIn total, 25 participants (42 limbs) were included, 17 male and eight female, mean age at surgery 12.9 (sd 1.9) years. Both groups experienced significant improvement in popliteal angle, knee extension range of motion (ROM) and knee extension in stance phase. Greater improvement was seen for all variables in the ADFH/PTS group, mainly due to greater popliteal angle and knee flexion during gait preoperatively in that group (p ≤ 0.02) rather than the procedure performed (p ≥ 0.19). There was no difference between groups postoperatively. Rate of contracture resolution was 0.5° to 1.0° per month, faster in larger contractures (p = 0.02).ConclusionsADFH with and without PTS is effective in improving knee extension in skeletally immature patients with CP, correcting contractures at a rate of 0.5° to 1.0° per month. Combined ADFH and PTS surgery may be preferable in patients with larger contractures of up to 30° to 35°.Level of evidenceIII

Do Not Do this Case Report: Recurrence of Knee Flexion Contracture after Extension Osteotomy in Congenital Patellar Dislocation: The Importance of a Thorough Patient Evaluation

Background: Congenital patellar dislocation (CPD) is a rare disorder which presents with hypoplastic and irreducible patellae. It is accompanied by flexion contracture of the knee joint, genu valgum, and external tibial rotation.&#x0D; Case Report: A seven-year-old girl with CPD who was misdiagnosed as having cerebral palsy (CP) crouch gait and underwent distal femoral extension osteotomy (DFEO) without paying attention to the dislocated patellae, is presented. Recurrence ensued, and the patient was referred for further evaluation. After a second surgery to address the dislocated patellae, the flexion contracture and gait pattern improved significantly.&#x0D; Conclusion: The case underscores the importance of a systematic, thorough physical examination, without which uncommon diagnoses will be overlooked, exposing the patient to further morbidity and complications.

Distal Femoral Extension Osteotomy with 90° Pediatric Condylar Locking Compression Plate and Patellar Tendon Advancement for the Correction of Crouch Gait in Cerebral Palsy.

Background:Various treatment modalities are available for the correction of crouch gait, ranging from hamstring lengthening to a combination of soft-tissue and bony procedures. We report the results of distal femoral extension osteotomy (DFEO) fixed with 90° pediatric condylar locking compression plate (LCP) and patellar tendon advancement (PTA) for crouch gait in children with cerebral palsy.Materials and Methods:A total of 26 patients (52 knees) with a mean age of 14.36 years (range 11.6–20 years) who presented with crouch gait were treated with DFEO and PTA. Patients were analyzed prospectively using clinical (knee flexion deformity, knee range of motion, extensor lag), functional (modified Ashworth, Tardieu scores, muscle strength, gross motor functional classification system [GMFCS], functional mobility scale [FMS], gross motor functional measure [GMFM]) and radiological (Koshino Index) outcome measures and followed up at a mean of 22 months (range 12–53 months).Results:There was an improvement in all outcome measures postoperatively, with improved function and independence. The mean knee flexion deformity improved significantly from 20.7° ± 6.59 to 0.67° ± 2.62, mean muscle strength of quadriceps improved from 3.01 ± 0.5 to 3.5 ± 0.54 and mean extensor lag improved from 20° ± 7.14 to 4.13° ± 4.16. The mean Koshino Index improved from 1.4 ± 0.16 to 1.0 ± 0.08. The mean GMFM-D improved from 15.58 ± 6.2 to 26.31 ± 5.8 and mean FMS for 5 m improved from 2.9 ± 1.09 to 3.6 ± 0.84, indicating significant improvement in household ambulation. There were four complications; transient peroneal nerve palsy in 3 patients, which recovered completely and 1 superficial wound dehiscence. There was no loss of fixation, tendon pull-out or deep infection.Conclusion:The combined procedure of DFEO and PTA can correct knee flexion deformity, restore knee extensor strength, and improve function in patients with crouch gait. The pediatric condylar LCP provides stable fixation to allow early mobilization and faster rehabilitation.

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

BackgroundThe 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. MethodsWe 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. ResultsApproximately 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. ConclusionsThis 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.

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

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). 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. 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. 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. 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.

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

We examined long-term outcomes across the domains of the International Classification of Functioning, Disability and Health for 2 groups of participants with cerebral palsy who demonstrated crouch gait at clinical gait analysis. One group underwent a distal femoral extension osteotomy with patellar tendon advancement (DFEO + PTA). The other group received other treatments (non-DFEO + PTA). Fifty-one participants returned for a long-term gait analysis, physical examination, energy consumption test, knee radiographs, and questionnaires (median, 13 years post-DFEO + PTA or post-baseline [range, 8 to 21 years]). A subset of participants in the DFEO + PTA group also had a short-term analysis (9 to 24 months postoperatively). Participants were reasonably well-matched at baseline, although the DFEO + PTA group demonstrated greater crouch: minimum knee flexion, a median of 37° (width of the interquartile range, 12°) compared with 27° (9°); and knee flexion contracture, a median of 15° (10°) compared with 10° (5°). The gait deviation index (GDI) and sagittal plane knee kinematics were most improved at short term for the DFEO + PTA participants, with a subsequent slight decline at long-term analysis. Fewer DFEO + PTA participants were in crouch at long term (37% compared with 65%). At the long-term assessment, group scores for function, mobility, participation, quality of life, and most pain questionnaires were similar. Knee pain and osteoarthritis ratings did not differ between the groups. At long-term analysis, DFEO + PTA improves stance phase knee extension and knee flexion contracture compared with conventional treatment, but these benefits do not translate to improved activity, participation, or knee pain in early adulthood. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The effect of distal femoral extension osteotomy on muscle lengths after surgery.

PurposeThe distal femoral extension osteotomy (DFEO) is often used in the treatment of crouch gait to help compensate for knee flexion contractures. The effects of DFEO on skeletal and muscle lengths are incompletely understood, but are important to consider in planning concomitant surgeries such as patellar tendon advancement (PTA). Therefore, the purpose of this study was to quantify the changes in femur, quadriceps, and hamstring lengths with DFEO, and to determine the sensitivity to surgical factors such as wedge location and magnitude.MethodsA musculoskeletal model with six degrees of freedom tibiofemoral and patellofemoral joints was used for analysis. A wedge was removed from the distal femur and the remaining bone segments were plated together to simulate the DFEO. After simulating the knee’s post-operative equilibrium, the surgically-induced changes in muscle and bone lengths were analysed.ResultsRelative to the pre-operative state, DFEO stretches the hamstrings while shortening the femur and quadriceps. A more posterior wedge apex location (i.e. creation of a cuneiform wedge) diminished the stretch of the hamstrings, but induced greater shortening of the femur and quadriceps. More proximal wedge locations necessitated greater translation of the distal fragment to maintain the knee joint axis.ConclusionReduced quadriceps length after DFEO shown in this study is consistent with the need for simultaneous PTA. The induced hamstring stretch also may represent a potential mechanism for post-operative nerve palsies. Overall, the numerical results provide a firmer basis for planning the specifics of DFEO such that desired muscle lengths and joint alignment are achieved.

Evidence of knee extensor dysfunction during sit-to-stand following distal femoral extension osteotomy and patellar tendon advancement in young adults with cerebral palsy: A pilot study

A distal femoral extension osteotomy with patellar tendon advancement (DFEO+PTA) is a common treatment for individuals with cerebral palsy (CP) who walk in crouch. Musculoskeletal modeling suggests that the typical patella baja position post-DFEO+PTA may limit one’s abilities to perform sit-to-stand (STS) tasks; however, STS function has not been assessed. Our purpose was to compare how well individuals who received a DFEO+PTA can perform a 5-times STS test (FTSST) eight or more years after surgery compared to their peers who did not receive a DFEO+PTA (non-DFEO+PTA group).Twenty-one participants completed the task (12 DFEO+PTA, 9 non-DFEO+PTA). Three-dimensional kinematics and kinetics were captured. Kinetics were non-dimensionalized to facilitate group comparisons.Non-DFEO+PTA participants performed the FTSST moderately faster than the DFEO+PTA group (median(IQR), 14.6(9.3) seconds vs. 20.3(10.1) seconds, non-parametric effect size ɣ=0.97, p=0.241). Peak negative knee power was larger for the non-DFEO+PTA group (Mean±SD, −0.063±0.025 vs. −0.048± 0.020, Cohen’s d=0.66, p=0.165). A similar but weaker trend was observed for negative hip power (median(IQR) −0.120(0.066) vs. −0.105(0.044), ɣ=0.43, p=0.671). Both groups used their hips approximately twice as much as their knees to perform the task.The functional deficit among DFEO+PTA participants may be due to patella baja decreasing the knee extensor moment arm, which concurs with the modeling prediction. The group differences may also be due to the non-DFEO+PTA group being slightly higher functioning. Future research is warranted to determine if optimizing patella position during a DFEO+PTA may improve unaided STS function without compromising gait improvements.

Long‐term outcomes after distal femoral extension osteotomy and patellar tendon advancement in individuals with cerebral palsy

Long‐term outcomes after distal femoral extension osteotomy and patellar tendon advancement in individuals with cerebral palsy

O109: Differences in muscle tendon length and velocity of the hamstrings and vastus after distal femoral extension osteotomy with and without additional patella tendon advancement in children with cerebral palsy (CP)

With the widespread use of minimally invasive techniques, robot-assisted urologic surgery has become widely adopted. Despite their infrequency, visceral and gastrointestinal complications could be life-threatening.To identify the main gastrointestinal injuries that occur in a robot-assisted urologic surgery. To know the overall incidence and how is their management.Search in PubMed of articles related to visceral and gastrointestinal complications in robot-assisted urology surgery, written in English or Spanish. Relevant publications as well literature reviews and chapters from books were reviewed.Along with vascular injuries, visceral and gastrointestinal lesions are among most dangerous complications. A complete preoperative study to individualize each patient characteristics and the correct use of imaging could help us to avoid complications in the first place. To know all the risky steps in the different robotic urologic procedures will let us anticipate the damage. Knowledge of main and most dangerous injuries in the different abdominal and pelvic organs is fully recommended. Early diagnosis and evaluation of lesions will let us an acute management during surgery. Recognition delay could change a repairable injury into a life-threatening situation.Despite the undeniable benefits of robotic approach, there are minor and major gastrointestinal injuries that all urologic surgeons must know. Those related with trocar placement are especially important. Immediate diagnosis and management is mandatory.Con el uso generalizado de técnicas mínimamente invasivas la cirugía urológica asistida por robot ha sido ampliamente adoptada. A pesar de su infrecuencia, las complicaciones viscerales y gastrointestinales podrían poner en peligro la vida.Identificar las principales lesiones gastrointestinales que ocurren en una cirugía urológica asistida por robot. Conocer la incidencia general y cómo es su manejo.Búsqueda en PubMed de artículos relacionados con complicaciones viscerales y gastrointestinales en cirugía urológica asistida por robot, escritos en inglés o español. Se revisaron publicaciones relevantes, así como revisiones de literatura y capítulos de libros.Junto con las lesiones vasculares, las lesiones viscerales y gastrointestinales se encuentran entre las complicaciones más peligrosas. Un estudio preoperatorio completo para individualizar las características de cada paciente y el uso correcto de la toma de imágenes podría ayudarnos a evitar complicaciones en primer lugar. Conocer todos los pasos arriesgados en los diferentes procedimientos urológicos robóticos nos permitirá anticipar los daños. El conocimiento de las lesiones principales y más peligrosas en los diferentes órganos abdominales y pélvicos es altamente recomendable. El diagnóstico precoz y la evaluación de las lesiones nos permitirán un manejo agudo durante la cirugía. El retraso en el reconocimiento podría convertir una lesión reparable a una situación potencialmente mortal.A pesar de los beneficios innegables del enfoque robótico, hay lesiones gastrointestinales menores y mayores que todos los cirujanos urológicos deben saber. Los relacionados con la colocación de trocares son especialmente importantes. El diagnóstico y el manejo inmediatos son obligatorios.

O53: Mid-term results after distal femoral extension osteotomy in children with cerebral palsy (CP) – a musculoskeletal analysis

O53: Mid-term results after distal femoral extension osteotomy in children with cerebral palsy (CP) – a musculoskeletal analysis

Does patella lowering improve crouch gait in cerebral palsy? Comparative retrospective study

BackgroundPatella lowering aims to improve quadriceps function as a means of correcting crouch gait in patients with cerebral palsy. Few studies have assessed the effects of patella lowering as a component of multilevel surgery. HypothesisIncluding patella lowering into the components of multilevel surgery is beneficial in patients with crouch gait and patella alta. Material and methodsIn 12 lower limbs with patella alta (Caton-Deschamps index>1.4) in 41 children with cerebral palsy, patella lowering was performed, without distal femoral extension osteotomy or hamstring release. Among limbs with similar surgical procedures (e.g., hamstring lengthening, rectus femoris transfer) except for patella lowering, controls were selected retrospectively by matching on a propensity score for patella lowering. The propensity score was computed based on preoperative knee flexion contracture, knee extension lag, and minimum knee flexion at mid-stance. Clinical and 3D kinematic data were compared between the two groups. ResultsThe improvement in minimum knee flexion at mid-stance was significantly greater in the group with patellar lowering (−24°±12°vs. −12°±7°). The Gait Deviation Index improved similarly in the two groups. Knee flexion contracture improved only in the group with patellar lowering. Extension lag did not improve in either group. Peak knee flexion during the swing phase remained unchanged in both groups. DiscussionPatellar lowering is effective in diminishing minimum knee flexion at mid-stance in patients with patella alta and crouch gait due to cerebral palsy. Patellar lowering has not adverse effects on gait. These findings cannot be assumed to apply to patients with normal patellar height. Level of evidenceIV (retrospective study).

The effectiveness of posterior knee capsulotomies and knee extension osteotomies in crouched gait in children with cerebral palsy.

Crouched gait is common in children with cerebral palsy (CP), and there are various treatment options. This study evaluated the effectiveness of single-event multilevel surgery including posterior knee capsulotomy or distal femoral extension osteotomy to correct knee flexion contracture in children with CP. Gait analyses were carried out to evaluate gait preoperatively and postoperatively. Significant improvements were found in physical examination and kinematic measures, which showed that children with CP and crouched gait who develop knee flexion contractures can be treated effectively using single-event multilevel surgery including a posterior knee capsulotomy or distal femoral extension osteotomy.

Anterior distal femoral hemiepiphysiodesis in the treatment of fixed knee flexion contracture in neuromuscular patients

Patients with neuromuscular diseases such as cerebral palsy (CP) and meningomyelocele (MMC) are prone to develop fixed knee flexion contracture. Distal femoral extension osteotomy allows acute correction of the deformity, but it is an extensive surgical procedure, and the complication rate is rather high. Immobilization can prolong the rehabilitation period, and may even result in deteriorated walking ability. The aim of this retrospective study was to evaluate the results of using anterior hemiepiphysiodesis of the distal femur to treat fixed flexion contracture of the knee. We studied 21 patients in our department from 2003 to 2009. Mean age was 10years (5-15). Twelve suffered from MMC, five from CP, two from arthrogryposis, one had an enzyme defect, and one had Down's syndrome. Thirteen patients had a bilateral and eight a unilateral procedure. None of the patients underwent any other procedures. Two staples or 8-plates were inserted using two parapatellar incisions. Nine were operated on with staples and 12 with 8-plates. The plates or staples were removed when the desired effect of full knee extension was achieved or the patient reached skeletal maturity. Mean fixed flexion contracture was 20° (10°-40°). Staples or 8-plates were removed after a mean of 24 (6-42) months. Mean fixed flexion contracture at removal was 10° (0°-30°). Two complications were seen: one infection and one supracondylar fracture. Anterior distal femoral hemiepiphysiodesis using 8-plates or staples seems to be effective for correcting fixed knee flexion deformity in skeletally immature individuals. The complication rate is low (10%). Our results are comparable to those of Kramer, Klatt, and Stevens. This procedure should be the primary treatment for fixed knee flexion contractures in neuromuscular patients with sufficient remaining growth.