Distal Rectus Femoris Transfer Research Articles

Comparison of Surgical Outcomes for Distal Rectus Femoris Transfer and Resection Surgeries in Children With Cerebral Palsy With Stiff Knee Gait.

Children with cerebral palsy (CP) often present with a stiff knee gait pattern because of rectus femoris (RF) spasticity and/or contracture. Rectus femoris transfers (RFTs) and resections are surgical procedures aimed at reducing muscle stiffness, thereby improving knee flexion during the swing phase of gait. Previous research has consistently demonstrated objective benefits of rectus transfer using instrumented gait analysis (IGA). Rectus femoris resection (RFR), a relatively simpler procedure, shows similar improvement in knee range of motion during gait. The objective of this study was to compare surgical outcomes between rectus transfers and resections using 3-dimensional IGA. Children with spastic CP who had RFTs or resections were retrospectively matched by walking speed and preoperative knee kinematics from 3-dimensional IGA (peak and timing of peak knee flexion in swing). Secondary outcomes included knee range of motion and maximum knee extension during gait. Twenty-eight children were included in both the transfer group [age 9.4±2 y; Gross Motor Function Classification System (GMFCS) I (3 children), II (15 children), III (8 children), and IV (2 children)] and the resection group [age 10.6±2.5 y; GMFCS I (1 child), II (14 children), and III (13 children)]. Both surgical groups showed statistically significant short-term postsurgical improvements in peak knee flexion during swing (P<0.001 for the transfer group and P=0.003 for the resection group) and Duncan-Ely test (P=0.004 for the transfer group and P<0.001 for the resection group). Further analysis by GMFCS level showed children at GMFCS levels III/IV had a greater tendency to crouch after RFT when compared with children at GMFCS levels I/II. This tendency was not observed in the RFR group. Both transfer and resection surgeries significantly improved gait kinematics short-term outcomes in children with spastic CP who present with stiff knee gait pattern. Further studies are required to compare long-term outcomes of both surgeries. Level III-retrospective matched-cohort study.

Distal rectus femoris surgery in children with cerebral palsy: results of a Delphi consensus project.

PurposeThe purpose of this study was for an international panel of experts to establish consensus indications for distal rectus femoris surgery in children with cerebral palsy (CP) using a modified Delphi method.MethodsThe panel used a five-level Likert scale to record agreement or disagreement with 33 statements regarding distal rectus femoris surgery. The panel responded to statements regarding general characteristics, clinical indications, computerized gait data, intraoperative techniques and outcome measures. Consensus was defined as at least 80% of responses being in the highest or lowest two of the five Likert ratings, and general agreement as 60% to 79% falling into the highest or lowest two ratings. There was no agreement if neither threshold was reached.ResultsConsensus or general agreement was reached for 17 of 33 statements (52%). There was general consensus that distal rectus femoris surgery is better for stiff knee gait than is proximal rectus femoris release. There was no consensus about whether the results of distal rectus femoris release were comparable to those following distal rectus femoris transfer. Gross Motor Function Classification System (GMFCS) level was an important factor for the panel, with the best outcomes expected in children functioning at GMFCS levels I and II. The panel also reached consensus that they do distal rectus femoris surgery less frequently than earlier in their careers, in large part reflecting the narrowing of indications for this surgery over the last decade.ConclusionThis study can help paediatric orthopaedic surgeons optimize decision-making for, and outcomes of, distal rectus femoris surgery in children with CP.Level of evidenceV

Rectus Femoris Transfer Surgery Worsens Crouch Gait in Children With Cerebral Palsy at GMFCS Levels III and IV.

Previous study has shown that children with cerebral palsy (CP) functioning at Gross Motor Function Classification System (GMFCS) levels III and IV do not benefit from distal rectus femoris transfer (DRFT) due to lack of improvement in stance knee extension. The fate of knees in such subjects who do not undergo DRFT is unknown. The purpose of this study was to compare knee kinematic outcomes in patients with CP and stiff knee gait who underwent single-event multilevel surgery with and without DRFT. Preoperative and postoperative gait analysis data were retrospectively reviewed for ambulatory (GMFCS levels I to IV) patients with CP with crouch and stiff knee gait whom underwent single-event multilevel surgery, including hamstring lengthening either with DRFT (N=34) or without DRFT (N=40). Statistical analyses included t tests and χ tests, and multiple regression analysis was performed to adjust for covariates. Data were stratified by GMFCS level groups I/II and III/IV. Improved maximum knee extension in stance was seen for both the DRFT (P=0.0002) and no DRFT groups (P≤0.0006) at GMFCS levels I/II, and the no DRFT group at GMFCS levels III/IV (P=0.02). Excessive stance knee flexion persisted for those at GMFCS level III/IV after DRFT. Maximum knee flexion in swing was maintained after DRFT, but significantly decreased in the no DRFT group (P<0.002) for both GMFCS groups. Change in total knee range of motion improved after DRFT only in the GMFCS I/II group subjects with unilateral involvement (P=0.01). Timing of maximum knee flexion in swing improved for all patients regardless of DRFT or GMFCS level group (P<0.0001). In patients with CP functioning at GMFCS levels III and IV, DRFT results in persistent crouch postoperatively. Given the importance of maintaining upright posture in these patients, we do not recommend DRFT in patients functioning at GMFCS levels III and IV. Level III-retrospective comparative study.

DOES RECTUS FEMORIS TRANSFER INCREASE KNEE FLEXION DURING STANCE PHASE IN CEREBRAL PALSY?

ABSTRACTObjective: To evaluate whether distal rectus femoris transfer (DRFT) is related to postoperative increase of knee flexion during the stance phase in cerebral palsy (CP). Methods: The inclusion criteria were Gross Motor Function Classification System (GMFCS) levels I-III, kinematic criteria for stiff-knee gait at baseline, and individuals who underwent orthopaedic surgery and had gait analyses performed before and after intervention. The patients included were divided into the following two groups: NO-DRFT (133 patients), which included patients who underwent orthopaedic surgery without DRFT, and DRFT (83 patients), which included patients who underwent orthopaedic surgery that included DRFT. The primary outcome was to evaluate in each group if minimum knee flexion in stance phase (FMJFA) changed after treatment. Results: The mean FMJFA increased from 13.19° to 16.74° (p=0.003) and from 10.60° to 14.80° (p=0.001) in Groups NO-DRFT and DRFT, respectively. The post-operative FMJFA was similar between groups NO-DRFT and DRFT (p=0.534). The increase of FMJFA during the second exam (from 13.01° to 22.51°) was higher among the GMFCS III patients in the DRFT group (p<0.001). Conclusion: In this study, DRFT did not generate additional increase of knee flexion during stance phase when compared to the control group. Level of Evidence III, Retrospective Comparative Study.

Proximal rectus femoris release does not influence the effects of distal rectus femoris transfer on the knee in cerebral palsy

Introduction: Single event multilevel surgery (SEMLS) purpose is to improve the cerebral palsy (CP) children’s gait by associating multiple surgeries on the same therapeutic time. It is therefore complex to isolate the effect of these actions in this multifocal context. To address this problem we chose to specifically identify the effect of hamstrings lengthening (HL) in CP children with crouch gait. The aims of this study were to describe the specific parameters influenced by HL and to classify the positive or not-positive effect of HL in SEMLS. Patients/materials andmethods: 42 CP children (12±3 years) were divided into two groups: 31 (G1=60 lower limbs (LL)) and 11 (G2=20 LL), respectively having followed and not-followed HL among all the associated surgeries. All patients had clinical gait analysis before and 1.9±0.8 years after surgery. The GDI is calculated [1]. All kinematic data (angles, velocities) were doublenormalized and conditioned in two vectors. A homogeneity test (G1 vs G2) selected the kinematic parameters influenced by HL (t-test, p<0.005). Principal component analysis identified theminimumdescriptors characterizing the effect of HL. Several classifiers (Regularized Discriminant Analysis (RDA) and linear or nonlinear Support Vector Machines (SVM)) were supervised by 6 experts’ opinions. Experts’ opinions were based on video and kinematic curves comparison between pre and post-surgery conditions. The classifiers performances in learning, validation (leave one out) and generalization were compared. Results: GDI results showed that 83% of the subjects of G1 were globally improved by SEMLS. Among all the kinematic data, 16 sub-vectors, significantly influenced by HL were selected. Their dimensionality was reduced by principal component analysis. The 6 experts have classified the effect of HL for 37 LL: 24 were positive and 13 not-positive. The classification method with the best performance was the linear SVMwith error rate 0% in learning, 5.4% in validation and 6.5% in generalization. In view of the classification system 1/3 of G1 LL were not improved by HL. Discussion and conclusions: This supervised classification and data conditioning techniques are able to categorize the specific effect of HL among all the associated performed procedures in two classes “positive effect” and “not-positive effect”. While 83% of patients were improved by SEMLS, HL had positively contributed to this improvement in only 70% of these cases. This methodology can be generalized to study the effect of other surgical procedures.

Does Proximal Rectus Femoris Release Influence Kinematics In Patients With Cerebral Palsy and Stiff Knee Gait?

Stiff gait resulting from rectus femoris dysfunction in cerebral palsy commonly is treated by distal rectus femoris transfer (DRFT), but varying outcomes have been reported. Proximal rectus femoris release was found to be less effective compared with DRFT. No study to our knowledge has investigated the effects of the combination of both procedures on gait. We sought to determine whether an additional proximal rectus release affects knee and pelvic kinematics when done in combination with DRFT; specifically, we sought to compare outcomes using the (1) range of knee flexion in swing phase, (2) knee flexion velocity and (3) peak knee flexion in swing phase, and (4) spatiotemporal parameters between patients treated with DRFT, with or without proximal rectus release. Furthermore the effects on (5) anterior pelvic tilt in both groups were compared. Twenty patients with spastic bilateral cerebral palsy treated with DRFT and proximal rectus femoris release were matched with 20 patients in whom only DRFT was performed. Standardized three-dimensional gait analysis was done before surgery, at 1year after surgery, and at a mean of 9years after surgery. Basic statistics were done to compare the outcome of both groups. The peak knee flexion in swing was slightly increased in both groups 1year after surgery, but was not different between groups. Although there was a slight but not significant decrease found the group with DRFT only, there was no significant difference at long-term followup between the groups. Timing of peak knee flexion, range of knee flexion, and knee flexion velocity improved significantly in both groups, and in both groups a slight deterioration was seen with time; there were no differences in these parameters between the groups at any point, however. There were no group differences in spatiotemporal parameters at any time. There were no significant differences in the long-term development of anterior pelvic tilt between the groups. The results of our study indicate that the short- and long-term influences of adding proximal rectus femoris release on the kinematic effects of DRFT and on pelvic tilt in children with cerebral palsy are negligible. Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Outcomes of Rectus Femoris Transfers in Children With Cerebral Palsy

Distal rectus femoris transfer is a widely accepted and effective treatment for children with cerebral palsy presenting with stiff knee gait. Previous research has reported improvement in knee arc of motion regardless of transfer site; however, sample sizes and patient function were unmatched in these studies. The purpose of this study was to compare the outcomes of children with cerebral palsy treated with a distal rectus femoris transfer for stiff knee to 1 of 3 sites: medial to the semitendinosus (ST), medial to the sartorius (SR), or lateral to the iliotibial band (ITB). Sample sizes in the 3 groups were equal and matched by gross motor function of the subjects. The motion analysis laboratory database was queried for subjects who had a rectus femoris transfer with preoperative and postoperative gait studies. The ITB group, 14 subjects (20 limbs), was the smallest group of subjects identified. The ITB group established the sample size for SR and ST groups, which originally had larger sample sizes, but were matched to reflect similar proportions of Gross Motor Functional Classification System Level to the ITB group. There were no significant differences between the 3 rectus femoris transfer groups preoperatively on knee gait variables (P>0.05). Comparison of preoperative to postoperative data demonstrated significant gait improvements in knee arc of motion for the ITB, SR, and ST groups (11 , 12, and 12 degrees, respectively) (P<0.05). There were also significant improvements in timing of peak knee flexion in swing phase and knee extension at initial contact for all 3 groups, but no significant difference was seen between preoperative and postoperative when groups were compared against one another for these measures. Distal rectus transfer continues to be an effective procedure for treating stiff knee gait in cerebral palsy. The location site of the transfer resulted in equally beneficial outcomes; therefore, the transfer site location can be based on surgeon preference and concomitant procedures. III, Retrospective Comparative Study.

Long-Term Results After Distal Rectus Femoris Transfer as a Part of Multilevel Surgery for the Correction of Stiff-Knee Gait in Spastic Diplegic Cerebral Palsy

The evidence for distal rectus femoris transfer as a part of multilevel surgery for the correction of stiff-knee gait in children with spastic diplegic cerebral palsy is limited because of inconsistent outcomes reported in various studies and the lack of long-term evaluations. This study investigated the long-term results (mean, nine years) for fifty-three ambulatory patients with spastic diplegic cerebral palsy and stiff-knee gait treated with standardized distal rectus femoris transfer as a part of multilevel surgery. Standardized three-dimensional gait analysis and clinical examination were carried out before surgery and at one year and nine years after surgery. Patients with decreased peak knee flexion in swing phase who had distal rectus femoris transfer to correct the decreased peak knee flexion in swing phase (C-DRFT) were evaluated separately from those with normal or increased peak knee flexion in swing phase who had distal rectus femoris transfer done as a prophylactic procedure (P-DRFT). A significantly increased peak knee flexion in swing phase was found in the C-DRFT group one year after surgery, while a significant loss (15°) in peak knee flexion in swing phase was noted in the P-DRFT group. A slight but not significant increase in peak knee flexion in swing phase in both groups was noted at the time of the long-term follow-up. A significant improvement in timing of peak knee flexion in swing phase was only found for the C-DRFT group, and was maintained after nine years. Knee motion and knee flexion velocity were significantly increased in both groups and were maintained at long-term follow-up in the C-DRFT group, while the P-DRFT showed a deterioration of knee motion. Distal rectus femoris transfer is an effective procedure to treat stiff-knee gait featuring decreased peak knee flexion in swing phase and leads to a long-lasting increase of peak knee flexion in swing phase nine years after surgery. Patients with more involvement showed a greater potential to benefit from distal rectus femoris transfer. However, 18% of the patients showed a permanently poor response and 15% developed recurrence. In patients with severe knee flexion who underwent a prophylactic distal rectus femoris transfer, a significant loss in peak knee flexion in swing phase was noted and thus a prophylactic distal rectus femoris transfer may not be indicated in these patients. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The effect of distal rectus femoris transfer as a part of multilevel surgery in spastic diplegia—A randomized clinical trial

The effect of distal rectus femoris transfer as a part of multilevel surgery in spastic diplegia—A randomized clinical trial

Distal rectus femoris transfer as part of multilevel surgery in children with spastic diplegia – A randomized clinical trial

The evidence in support of distal rectus femoris transfer (DRFT) as part of single-event multilevel surgery (SEMLS) is limited due to inconsistent outcome reports and a lack of randomized studies. The purpose of this prospective randomized trial was to establish whether the results of SEMLS without DRFT are similar to those of a conventional approach that includes DRFT in the SEMLS. In all, 32 children with spastic diplegia (GMFCS I–III) and an indication for DRFT were recruited and randomized into a DRFT (15 children) and a NON-DRFT group (17 children) using a minimization method. During SEMLS, bilateral DRFT was performed only in the DRFT group. Three-dimensional gait analysis and clinical examination were performed before and 1year after surgery. In both groups a significant increase in range of motion during swing and knee flexion velocity were found, which was significantly higher in the DRFT group. While peak knee flexion in swing (pKFSw) was preserved in the DRFT group and significantly decreased in the NON-DRFT group, pKFSw timing was significantly earlier in both groups. The clinical relevance of the higher overall benefits in the DRFT group is limited, considering that 33% of patients in this group did not benefit from the procedure. Furthermore, 53% of the NON-DRFT patients did not undergo what proved to be an unnecessary DRFT. Subgroup analysis showed benefits for patients with decreased pKFSw, while those with severe flexed-knee gait (normal or increased pKFSw) did not profit from DRFT. This may explain the inconsistent overall results, and DRFT is therefore not recommended as a “prophylactic” procedure in patients with severe flexed-knee gait.

Rectus Femoris Transfer Improves Stiff Knee Gait in Children With Spastic Cerebral Palsy

Stiff knee gait is common among children with ambulatory cerebral palsy (CP). When surgery is indicated, rectus femoris transfer as a primary treatment enhances knee range of motion, reduces time to peak knee flexion, increases peak knee flexion, and reduces toe drag. We determined whether (1) distal rectus femoris transfer improved knee range of motion, time to peak knee flexion, peak knee flexion, and toe drag in children with CP diagnosed with stiff knee gait; and (2) patients in some subgroups (eg, those with relatively high knee range of motion compared with those with low knee range of motion before rectus femoris transfer) had greater improvement in these parameters. We retrospectively reviewed gait data from 56 patients (99 limbs) preoperatively, short-term, and long-term. Subgroup analyses were performed to determine whether patients with high knee range of motion relative to those with low or moderate knee range of motion improved differentially after rectus femoris transfer. The minimum followup was 7 years (mean ± SD, 10 ± 2 years; range, 7-13 years). The mean peak knee flexion increased from baseline to short-term and to long-term followup. Patients with low peak knee flexion had the greatest improvement of peak knee flexion after rectus femoris transfer relative to the moderate and high peak knee flexion subgroups. Similarly, the greatest improvement after rectus femoris transfer for knee range of motion occurred in the low knee range of motion subgroup relative to moderate and high subgroups. Rectus femoris transfer improved mean time to peak knee flexion at short-term and long-term followup compared with baseline. Likewise, there was a decrease in toe drag at short- and long-term after rectus femoris transfer. Distal rectus femoris transfer selectively improved peak knee flexion, toe drag, and reduced time to peak knee flexion in ambulatory children with CP with stiff knee gait. Level IV, therapeutic study. See guidelines for authors for a complete description of levels of evidence.

Multilevel surgery in spastic diplegia with and without concomitant distal rectus femoris transfer—A randomized clinical trial

Multilevel surgery in spastic diplegia with and without concomitant distal rectus femoris transfer—A randomized clinical trial

Predictors of outcome of distal rectus femoris transfer surgery in ambulatory children with cerebral palsy

The objective of this study was to identify the predictors of outcome of distal rectus femoris transfer in cerebral palsy. Preoperative and postoperative gait data for 81 patients were examined, focusing on knee flexion/extension range. Outcome was 'good' for 46 patients and 'poor' for 35. The poor outcome group had no improvement in knee range because of increased crouch postoperatively. Outcome was unrelated to quadriceps strength, crouch, velocity, or type of cerebral palsy. Gross Motor Function Classification System was predictive of outcome, with poor results in all level IV patients (P< or =0.008). In conclusion, Gross Motor Function Classification System IV patients may not benefit from distal rectus femoris transfer because of increased postoperative crouch.

Electromyographic patterns in children with cerebral palsy: Do they change after surgery?

The purpose of this study was to investigate the changes in electromyographic (EMG) patterns after multilevel surgical treatment in children with spastic cerebral palsy. Children with diplegia ( n = 18) and hemiplegia ( n = 16) aging from 6 to 16 years participated in the study. Twenty healthy children within the same age span are presented as reference. Gait analysis and surface electromyograms of seven major lower limb muscles were assessed before and 1–5 years after the multilevel surgery. The most frequent procedures were equinus correction, distal rectus femoris transfer, femoral derotation osteotomy and hamstrings lengthening. The results showed that the EMG pattern of the soleus, lateral gastrocnemius and tibialis anterior muscles became closer to normal after the surgery, while no differences were detected between diplegic and hemiplegic patients. Furthermore, a subgroup of 10 patients showed an increase in medial hamstrings activation during preswing that decreased postoperatively. These findings indicate that changes in EMG patterns should not be ruled out after surgical treatment, although the extent of these changes is limited compared to changes in the kinematics. Abnormal muscle activation before the operation can be related to a compensatory response in some patients and this can be manipulated after surgery.

Predictive Value of the Duncan-Ely Test in Distal Rectus Femoris Transfer

Fifty-six patients who underwent 94 distal rectus femoris transfers and pre- and postoperative gait analyses were retrospectively reviewed. The patients were divided into three groups based on pre- and postoperative Duncan-Ely tests. Group A (34 limbs) had positive tests both before and after surgery. Group B (46 limbs) had positive tests before surgery and negative tests after surgery. Group C (13 limbs) had negative tests both before and after surgery. One limb had a negative test before surgery and a positive test after surgery and was not included in any group. Knee arc increased significantly in both groups with positive preoperative Duncan-Ely tests (groups A and B), but not in the group with negative preoperative tests (group C). The timing of peak knee flexion in swing improved in all groups, but the change was smaller and not statistically significant in the group with negative preoperative tests (group C). The findings of the current study indicate that the Duncan-Ely test may be a helpful predictor of outcome in children for whom distal rectus femoris transfer is being considered. Caution should be exercised when patients have weak quadriceps and a negative Duncan-Ely test before surgery, particularly when concurrent calf lengthening procedures are planned.

Predictive value of the Duncan-Ely test in distal rectus femoris transfer.

Fifty-six patients who underwent 94 distal rectus femoris transfers and pre- and postoperative gait analyses were retrospectively reviewed. The patients were divided into three groups based on pre- and postoperative Duncan-Ely tests. Group A (34 limbs) had positive tests both before and after surgery. Group B (46 limbs) had positive tests before surgery and negative tests after surgery. Group C (13 limbs) had negative tests both before and after surgery. One limb had a negative test before surgery and a positive test after surgery and was not included in any group. Knee arc increased significantly in both groups with positive preoperative Duncan-Ely tests (groups A and B), but not in the group with negative preoperative tests (group C). The timing of peak knee flexion in swing improved in all groups, but the change was smaller and not statistically significant in the group with negative preoperative tests (group C). The findings of the current study indicate that the Duncan-Ely test may be a helpful predictor of outcome in children for whom distal rectus femoris transfer is being considered. Caution should be exercised when patients have weak quadriceps and a negative Duncan-Ely test before surgery, particularly when concurrent calf lengthening procedures are planned.

Effects of Surgical Lengthening of the Hamstrings Without a Concomitant Distal Rectus Femoris Transfer in Ambulant Patients With Cerebral Palsy

Eighteen ambulant patients (32 legs) who had undergone fractional lengthening of the medial and lateral hamstrings without rectus femoris transfer underwent pre- and postoperative gait analysis. A significant increase in the amount of knee extension and a decrease in the amount of peak knee flexion in swing were observed. This decrease in knee flexion signified a change towards more normal speed-related values. Dorsiflexion at initial contact decreased significantly for patients who did not undergo a gastrocnemius lengthening (n = 24). Absolute cadence was significantly lower after surgery, but the change in dimensionless cadence was not significantly different. This difference in the outcome between dimensionless and absolute stride parameters can be attributed to the increase in body height after surgery. The clinical significance of these findings is that it is important to recognize that postoperative effects of surgery on gait in children may, in part, be explained by changes in height and not surgery alone.

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.

Outcome of Hamstring Lengthening and Distal Rectus Femoris Transfer Surgery

Outcome of Hamstring Lengthening and Distal Rectus Femoris Transfer Surgery

2 Distal rectus femoris transfer in CP gait as a simultaneous and as a secondary procedure - is there a difference of its effects?

2 Distal rectus femoris transfer in CP gait as a simultaneous and as a secondary procedure - is there a difference of its effects?