Knee Gait In Cerebral Palsy Research Articles

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

BackgroundThe 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 questionThe 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. MethodsThe 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). ResultsDuring 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). SignificanceThe 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.

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

BackgroundThe aims of this study were to investigate if patellar tendon shortening (PTS) as a part of SEMLS (single event multilevel surgery) is effective for reduction of flexed knee gait in children with cerebral palsy (CP) and, if PTS leads to stiff knee gait. MethodsIn a randomized controlled study 22 children with flexed knee gait (age: 10.4 ± 2.6 years, GMFCS Level I–III) were randomized and allocated to two groups (1: SEMLS + PTS; 2: SEMLS no PTS): SEMLS was performed for correction of flexed knee gait either with or without additional PTS. Before and after surgery (follow up: 12.7 ± 1.6 months) kinematics (3-D motion analysis) and clinical parameters were compared. ResultsTwo children were lost to follow up. Maximum knee extension improved significantly in both groups after SEMLS while the patients with additional PTS showed much more correction (SEMLS + PTS: 37.6° to 11.4°, p = 0.007; SEMLS no PTS: 35.1° to 21.8°, p = 0.016). After surgery peak knee flexion decreased significantly (14.6°, p = 0.004) in the “SEMLS + PTS” group while there was no relevant change in the other group. There was a trend of increase in anterior pelvic tilt after surgery in both groups, but no statistical significant difference. After surgery knee flexion contracture (15.9°, p < 0.001) and popliteal angle (27.2, p = 0.009) measured on clinical examination only decreased significantly in the “SEMLS + PTS” group. ConclusionPTS is effective for correction of flexed knee gait and knee flexion contracture leading to superior stance phase knee extension. However, additional PTS may lead to stiff knee gait and a higher increase of anterior pelvic tilt.

Patella tendon shortening for the correction of flexed knee gait in cerebral palsy – A randomized controlled trial

Patella tendon shortening for the correction of flexed knee gait in cerebral palsy – A randomized controlled trial

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 effects after conversion of biarticular to monoarticular muscles compared with musculotendinous lengthening in children with spastic diplegia

Adverse effects such as increased anterior pelvic tilt (APT) are reported after muscle-tendon lengthening (MTL) for the correction of flexed knee gait in cerebral palsy. The conversion of biarticular muscles (CBM) to monoarticular muscles represents an alternative treatment, but only few short-term results have been published, without comparison with MTL. The long-term outcome of 21 diplegic patients treated with CBM in a prospective study was compared with the results in MTL patients in a matched-pair analysis. Standardized clinical examination and three-dimensional gait analysis were done before surgery, 1 year thereafter, and at long-term follow-up a mean of 9.2 years postoperatively. Mean APT increased one year after surgery in both groups. This increase was higher in MTL patients and statistically significant only for this group. Knee flexion at initial contact and minimum knee flexion in stance were significantly decreased in both groups, while in swing the CBM group tended to show more of a decrease in knee flexion but at the cost of reduced peak flexion. Both groups showed deterioration of kinematic knee parameters through to long-term follow-up; the favourable effects of CBM disappeared, and the two groups displayed comparable average pelvic and knee kinematics. Considering individual patterns the prevalence of increased APT was lower in the CBM group 1 year after surgery, indicating that sparing the semitendinosus may have a positive effect on pelvic stability. However, after 9 years 30% of the patients in both groups showed increased APT indicative of persistent hamstring insufficiency. These results demonstrate that CBM, a significantly more extensive procedure, has no long-term advantage over MTL.

Musculo-tendon length and lengthening velocity of rectus femoris in stiff knee gait

Inappropriate activity of M. rectus femoris (RF) during swing is believed to contribute to stiff knee gait in cerebral palsy. This study used musculoskeletal modeling techniques to analyze rectus femoris musculo-tendon (MT) length and lengthening velocity during stiff knee gait in 35 children with diplegic cerebral palsy (CP). Duncan Ely test scores were used to categorize the patients into four groups with increasing levels of rectus femoris spasticity. Knee kinematics confirmed a significant reduction and delay of maximal peak knee flexion during swing in the patient groups compared to reference values. Maximal musculo-tendon length of M. rectus femoris was reduced and occurred prematurely in swing. Musculo-tendon lengthening velocity was significantly reduced and the timing of the maximal lengthening velocity was shifted into stance phase. The present study demonstrates altered dynamic behavior of the M. rectus femoris in stiff knee gait and the results indicate that maximal knee flexion in swing was not a valid reference for the MT length of the M. rectus femoris. Furthermore, in the patient group maximal musculo-tendon lengthening velocity of the muscle related to the stance phase rather than the stance-swing transition.