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

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          Abstract

          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.

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          Most cited references21

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          Prevalence of specific gait abnormalities in children with cerebral palsy: influence of cerebral palsy subtype, age, and previous surgery.

          The authors retrospectively reviewed a series of 492 consecutive cerebral palsy patients undergoing computerized motion analysis. The prevalence of 14 specific gait abnormalities was evaluated and compared based on involvement (hemiplegia, diplegia, or quadriplegia), age, and history of previous surgery (lower extremity orthopaedic surgery or rhizotomy). Stiff knee in swing, equinus, and intoeing were all seen in more than 50% of the subjects in each of the hemiplegic, diplegic, and quadriplegic groups. Increased hip flexion and crouch were also present in more than 50% of the subjects in the diplegic and quadriplegic groups, and hip adduction occurred in more than 50% of the quadriplegic subjects. The likelihood of having stiff knee in swing, out-toeing, calcaneus deformity, and crouch increased with prior surgery. The likelihood of having rotational malalignment of the leg (internal hip rotation with out-toeing), calcaneus, out-toeing, varus and valgus foot deformities, and hip internal rotation increased with age. These findings provide important information for counseling ambulatory children with cerebral palsy and their families.
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            Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy.

            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. 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. 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 degrees to 20 degrees, and stance-phase knee flexion was restored to the typical range (9 degrees to 10 degrees) 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 degrees of knee flexion in midstance) at the final assessment. 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.
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              Correction of severe crouch gait in patients with spastic diplegia with use of multilevel orthopaedic surgery.

              Severe crouch gait in patients with spastic diplegia causes excessive loading of the patellofemoral joint and may result in anterior knee pain, gait deterioration, and progressive loss of function. Multilevel orthopaedic surgery has been used to correct severe crouch gait, but no cohort studies or long-term results have been reported, to our knowledge. In order to be eligible for the present retrospective cohort study, a patient had to have a severe crouch gait, as defined by sagittal plane kinematic data, that had been treated with multilevel orthopaedic surgery as well as a complete clinical, radiographic, and instrumented gait analysis assessment. The surgical intervention consisted of lengthening of contracted muscle-tendon units and correction of osseous deformities, followed by the use of ground-reaction ankle-foot orthoses until stable biomechanical realignment of the lower limbs during gait was achieved. Outcome at one and five years after surgery was determined with use of selected sagittal plane kinematic and kinetic parameters and valid and reliable scales of functional mobility. Knee pain was recorded with use of a Likert scale, and all patients had radiographic examination of the knees. Ten subjects with severe crouch gait and a mean age of 12.0 years at the time of surgery were studied. After surgery, the patients walked in a more extended posture, with increased extension at the hip and knee and reduced dorsiflexion at the ankle. Pelvic tilt increased, and normalized walking speed was unaltered. Knee pain was diminished, and patellar fractures and avulsion injuries healed. Improvements in functional mobility were found, and, at the time of the five-year follow-up, fewer patients required the use of wheelchairs or crutches in the community than had been the case prior to intervention. Multilevel orthopaedic surgery for older children and adolescents with severe crouch gait is effective for relieving stress on the knee extensor mechanism, reducing knee pain, and improving function and independence.
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                Author and article information

                Journal
                Indian J Orthop
                Indian J Orthop
                IJOrtho
                Indian Journal of Orthopaedics
                Medknow Publications & Media Pvt Ltd (India )
                0019-5413
                1998-3727
                Jan-Feb 2019
                : 53
                : 1
                : 45-52
                Affiliations
                [1] Department of Paediatric Orthopaedics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
                Author notes
                Address for correspondence: Dr. Alaric Aroojis, Department of Paediatric Orthopaedics, Bai Jerbai Wadia Hospital For Children, Parel, Mumbai - 400 012, Maharashtra, India. E-mail: aaroojis@ 123456gmail.com
                Article
                IJOrtho-53-45
                10.4103/ortho.IJOrtho_410_17
                6394194
                30905981
                c564736d-eeae-4a21-94b3-f6c319afa6d3
                Copyright: © 2019 Indian Journal of Orthopaedics

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                Categories
                Symposium - Cerebral Palsy

                Orthopedics
                cerebral palsy,crouch gait,distal femur osteotomy,locking compression plate,patellar tendon

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