0
Scientific Articles   |    
Distal Femoral Extension Osteotomy and Patellar Tendon Advancement to Treat Persistent Crouch Gait in Cerebral Palsy
Jean L. Stout, PT, MS1; James R. Gage, MD1; Michael H. Schwartz, PhD1; Tom F. Novacheck, MD1
1 Center for Gait and Motion Analysis, Gillette Children's Specialty Healthcare, 200 East University Avenue, St. Paul, MN 55101. E-mail address for J.L. Stout: jstout@gillettechildrens.com. E-mail address for T.F. Novacheck: novac001@umn.edu
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Center for Gait and Motion Analysis, Gillette Children's Specialty Healthcare, St. Paul, Minnesota

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Nov 01;90(11):2470-2484. doi: 10.2106/JBJS.G.00327
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: Hallmarks of a persistent crouched walking pattern exhibited by individuals with cerebral palsy usually include loss of an adequate plantar flexion/knee extension couple, hamstring and/or psoas tightness, or contracture in conjunction with quadriceps insufficiency. Traditional treatment addresses the muscle-tightness component, but not the contracture or the muscle insufficiency. This study was performed to evaluate the effectiveness of distal femoral extension osteotomy and/or patellar tendon advancement in the treatment of crouch gait in patients with cerebral palsy.

Methods: A retrospective, nonrandomized, repeated-measures design was used. Individuals with a diagnosis of cerebral palsy were included if they had had (1) a distal femoral extension osteotomy in combination with a distal patellar tendon advancement (thirty-three patients), (2) a distal femoral extension osteotomy without patellar tendon advancement (sixteen), or (3) a distal patellar tendon advancement only (twenty-four). All subjects were evaluated with preoperative and postoperative gait analysis. Gait, radiographic, strength, and functional measures were included in the analysis to assess changes in knee function.

Results: Seventy-three individuals met the criteria for inclusion. A single side was chosen for the analysis of each subject. Ninety percent of the subjects had additional, concurrent surgery. Improvements were noted in the index assessing the level of gait pathology and in functional variables across all groups, and pain was consistently decreased. All preoperative stress fractures healed. Strength levels were maintained across all groups. The Koshino index of patellar height improved from 1.4 to -2.3 in the group treated with patellar tendon advancement only and from 1.5 to -2.9 in the group treated with both osteotomy and tendon advancement. The range of knee flexion improved an average of 15° to 20°, and stance-phase knee flexion was restored to the typical range (9° to 10°) in the groups that had advancement of the patellar tendon as part of the procedure. Individuals who underwent a distal femoral osteotomy only were still in a crouch (a mean of 31° of knee flexion in midstance) at the final assessment.

Conclusions: Inclusion of patellar tendon advancement is necessary to achieve optimal results in the surgical management of a persistent crouch gait exhibited by adolescents and young adults with cerebral palsy. When this procedure is done alone or in combination with a distal femoral extension osteotomy (for the treatment of a knee flexion contracture), knee function in gait can be restored to values within typical limits, with gains in community function.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.
    Register for a FREE limited account to get full access to all CME activities
    Have a subscription to the print edition?
    Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

     
    Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
    by your institution, please contact you librarian or administrator for username and password information. Institutional
    administrators, to reset your institution's master username or password, please contact subs@jbjs.org

    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
    CME Activities Associated with This Article
    Submit a Comment
    Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
    Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

    * = Required Field
    (if multiple authors, separate names by comma)
    Example: John Doe





    Tom F. Novacheck, MD
    Posted on November 26, 2008
    Dr. Novacheck and colleagues respond to Dr. Morais Filho
    Gillette Children's Specialty Healthcare, University of Minnesota Dept of Orthopaedics

    We appreciate Dr. Morais Filho’s interest in this topic and his letter to the editor. His article(1) was published after our article was submitted, so we regret not being able to include it in our literature review. Their approach is different from ours. If full passive knee motion was not obtained with hamstring lengthening, then a femoral extension osteotomy was performed during the same surgical event. Despite this important difference, their findings were similar. Extension osteotomy without retensioning the quadriceps mechanism carries a high risk of persistence of crouch and recurrence of contracture. The similar results in these two publications lends further support to this finding. The ability of patellar advancement to create better correction of crouch and to minimize the risk of recurrence was reported by us and suggested by Morais Filho et al.

    We don't routinely lengthen hamstrings as they are frequently not short in crouch gait(2,3). In addition, we believe that maintaining some tension in the hamstrings may protect the sciatic nerve from stretch injury. We have three comments about the addition of routine hamstring lengthening reported by Morais Filho et al. First, it may explain the finding of better knee extension in stance phase in their study when compared with our report. However, we are concerned that the addition of hamstring lengthening still did not correct crouch and the risk of recurrent knee contracture is not avoided. It is not clear from their article if the single variable, knee extension in stance, was associated with worsening of other gait parameters. The use of global outcomes measures like the GGI addresses this concern.

    Secondly, the concern about the tendency for increased anterior pelvic tilt (reported in both studies) has led us to be cautious in performing hamstring lengthening. Only one-fifth of our patients underwent concomitant hamstring lengthening. As Dr. Morais Filho points out, we were not able to determine risk factors for increased anterior pelvic tilt. Like Dr. Morais Filho’s report, psoas lengthening does not seem to be protective. 45% of our subjects had psoas lengthening. Pelvic tilt outcomes were similar when we compared those who did with those who did not undergo psoas lengthening. Dr. Morais Filho suggests that the use of walking aids after surgery may explain this, as they had two patients who were independent ambulators before surgery who were dependent on crutches or walker postoperatively. Only 2 of our 73 patients changed from independent to dependent ambulation so it seems unlikely that this is a complete explanation. However, we agree that the use of walking aids can significantly alter gait data.

    Finally, we are currently reviewing our hamstring length data before and after distal femoral extension osteotomy and patellar advancement in an effort to further refine the indications for hamstring lengthening in conjunction with these procedures.

    References:

    1. Morais Filho MC, Neves DL, Abreu FB, Juliano Y, Guimarães L. Treatment of fixed knee flexion deformity and crouch gait using distal femur extension osteotomy in cerebral palsy. J Child Orthop (2008) 2:37-43.

    2. Arnold AS, Liu MQ, Schwartz MH, Ounpuu S, Delp SL. The role of estimating muscle-tendon lengths and velocities of the hamstrings in the evaluation and treatment of crouch gait. Gait & Posture 2006;23:273- 281.

    3. Delp SL, Arnold AS, Speers RA, Moore CA. Hamstrings and psoas lengths during normal and crouch gait: implications for muscle-tendon surgery. Journal of Orthopaedic Research. 1996;14:144–151.

    Mauro C Morais Filho
    Posted on November 10, 2008
    The use of distal femur extension osteotomy in cerebral palsy
    AACD- São Paulo- Brazil

    To the Editor:

    I am writing regarding the recent article published in the Journal, "Femoral Extension Osteotomy and Patellar Tendon Advancement to Treat Persistent Crouch Gait in Cerebral Palsy”(1). The topic is controversial and the paper added important information about the treatment of crouch gait in patients with cerebral palsy. In the introduction the authors stated that reports about the use of distal femur extension osteotomy in cerebral palsy are limited; however, they did not cite our article published earlier this year in the Journal of Children’s Orthopaedics (2).

    In that paper, we retrospectively reviewed 12 patients with cerebral palsy (average follow-up of 28 months) who received distal femur extension osteotomy and hamstring lengthening as part of treatment for crouch gait. Our results regarding knee static deformity, hip extension in stance phase, and pelvic anteversion were very similar to the results described by Stout et al.(1)at their average follow-up of 14 months. However, our patients achieved better knee extension in stance phase when compared with the patients in Stout’s study who received only distal femur extension osteotomy. The mean knee flexion in stance phase was reduced from 43 to 22 degrees after treatment in our study; in contrast, Stout et al. reported a decrease in knee flexion from 40 to 31 degrees.

    Considering the definition of crouch gait (3), our use of distal femoral extension osteotomy combined with hamstring lengthening in this population was sufficient to achieve a more normal the gait pattern. However, recurrence of knee flexion contracture occurred in 27% of our cases. We suggest that patellar tendon advancement or shortening may play a role in preventing that recurrence.

    Finally, as described by Stout et al.(1), we also found a substantial postoperative increase (from 12 to 21 degrees) of pelvic anteversion in the sagittal plane in our patients, despite the fact that the majority of patients had received psoas surgical lengthening. The cause of this adverse effect was not determined in Stout’s study. We suspect that there is a relationship between this finding and the use of walking aids after surgery. In our study of 12 patients, the number of patients who required use of crutches or walkers increased from 5 to 7 postoperatively. We believe that use of these walking aids can produce a more anterior position of pelvis,

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References:

    1.Jean L. Stout, James R. Gage, Michael H. Schwartz, and Tom F. Novacheck Distal Femoral Extension Osteotomy and Patellar Tendon Advancement to Treat Persistent Crouch Gait in Cerebral Palsy J Bone Joint Surg Am 2008; 90: 2470-2484

    2. Morais Filho MC, Neves DL, Abreu FB, Juliano Y, Guimarães L. Treatment of fixed knee flexion deformity and crouch gait using distal femur extension osteotomy in cerebral palsy. J Child Orthop (2008) 2:37- 43.

    3. Sutherland DH, Davids JR. Common gait abnormalities of the knee in cerebral palsy. Clin Orthop (1993) 288:139-147.

    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    PubMed Articles
    Guidelines
    Results provided by:
    PubMed
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    02/28/2014
    District of Columbia (DC) - Children's National Medical Center
    12/04/2013
    New York - Icahn School of Medicine at Mount Sinai
    12/31/2013
    S. Carolina - Department of Orthopaedic Surgery Medical Univerity of South Carlonina
    04/02/2014
    W. Virginia - Charleston Area Medical Center