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

Department of Orthopaedics, Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, USA.
Clinical Orthopaedics and Related Research (Impact Factor: 2.77). 12/2011; 470(5):1303-11. DOI: 10.1007/s11999-011-2215-1
Source: PubMed


Background 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. Questions/purposes 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. Methods 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). Results 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. Conclusion 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.

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    • "different from others who found that peak knee flexion in swing was maintained [13] [28]. Increased ''stiffness'' of the vasti may contribute to reduced peak knee flexion in swing. "
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    ABSTRACT: Multilevel surgical intervention is a common approach for the correction of gait abnormalities in children with cerebral palsy (CP). The short-term outcomes for the combination of rectus femoris transfer, hamstring lengthening and gastrocnemius lengthening have been well documented using three-dimensional motion analysis. However, the impact of time, growth, and puberty on these short-term outcomes of this combination of procedures is not well understood. The purpose of this study was to evaluate the long-term outcomes of these procedures on gait in patients with CP. Twenty-two patients underwent rectus femoris transfers, medial hamstring lengthenings and gastrocnemius lengthenings in combination with a selection of other soft tissue and/or bony procedures of the lower limb. All patients had a pre-operative motion analysis and post-operative analysis one and 11 years following surgery. Significant changes in both clinical and gait variables from pre to 1 year post surgery confirmed the short-term gait benefits of this combination of surgical procedures. Long-term follow-up data indicated that the passive range of motion gains noted 1 year after surgery were lost at the knee and ankle. However, the improvements in ankle dorsiflexion and knee extension at initial contact were maintained over 11 years. As well, peak ankle dorsiflexion in stance was maintained and peak ankle plantar flexor moments and powers did not show declines long-term. Peak knee flexion showed a decline over the long-term, however, the timing of peak knee flexion in swing was maintained. When compared to declines in gait kinematics in persons with CP without surgery, these results demonstrate the possible long-term benefits of surgical intervention. Copyright © 2015 Elsevier B.V. All rights reserved.
    Gait & posture 07/2015; 42(3). DOI:10.1016/j.gaitpost.2015.07.003 · 2.75 Impact Factor
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    ABSTRACT: To examine gait patterns and gait quality, 7 twins with cerebral palsy were measured preoperatively and after surgical intervention. The aim was to study differences and/or similarities in gait between twins, the influence of personal characteristics and birth conditions, and to describe the development of gait over time after single event multilevel surgery. A standardized clinical exam and a three-dimensional gait analysis were performed. Gait patterns were classified according to Sutherland and Davids, and the Gillette Gait Index was calculated as a global measure of the gait impairment. Next to subject characteristics at time of first measurement, and at time of birth, birth conditions were collected. Gait patterns were determined as crouch gait in 13 legs, as stiff gait in 6 legs and as jump gait in 8 legs. One leg showed a normal gait pattern. The knee flexion-extension angle correlated most constant with the knee flexion-extension angle of the contralateral leg (range 0.91-0.99). Correlations with the legs of the sibling showed variable correlations (range 0.44-0.99); with all other legs medium to high correlations of 0.73-0.91 were found. The Gillette Gait Index was found to initially decrease after surgical intervention. Similar correlations were found between twins or between legs for the gait pattern expressed by the knee flexion-extension angle, and the Gillette Gait Index improved after surgery. It seems that gait quality in twins with cerebral palsy is characterized predominantly by the traumatic disorder: genetic dispositions and personal characteristics only play a negligible role.
    Research in developmental disabilities 03/2013; 34(5):1595-1601. DOI:10.1016/j.ridd.2013.02.004 · 4.41 Impact Factor
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    ABSTRACT: INTRODUCTION: In children with cerebral palsy the abnormal activity of the rectus femoris (RF) during the swing phase results in "stiff-knee gait". Transferring the RF to a knee flexor tendon improves this stiffness. The effect may be limited by adhesions from scar tissue or from angular deviations along the surgically created muscle tendon route. HYPOTHESIS: The goal of this study was to assess the effect on gait of a single event multilevel surgery protocol, and provide a detailed description of the transfer technique. PATIENTS AND METHODS: Forty-eight RF transfers were studied in 26 children and adolescents 12±3 years old after a follow up of 25±10 months. Quantified gait analysis was performed pre- and postoperatively to calculate spatiotemporal variables, 3D kinematics, the Gait Deviation Index (GDI) and a knee stiffness score (Goldberg index). A standardized surgical procedure was followed: RF release, gracilis tendon preparation as well as the transfer and suture techniques are described. RESULTS: Step length improved. Gait velocity and cadence were not modified. Gait quality improved (+13±11GDI) with an inverse relationship between the preoperative GDI and its improvement. Improvement of the preoperative Goldberg index in 74% of the cases was due to modifications of knee ROM from toe-off to peak flexion (+7°), total knee ROM (+16°) and timing of peak knee flexion in percentage of swing (from 51 to 40% of swing). DISCUSSION: The surgical protocol presented here is discussed in relation to the results. LEVEL OF EVIDENCE: IV, retrospective study.
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