Purpose The purpose of this study was to evaluate the results of distal femur extension osteotomy and medial hamstring lengthening in the treatment of fixed knee flexion deformity in patients with spastic diparetic cerebral palsy. Methods A retrospective study was done in a group of 12 diparetic cerebral palsy patients. A distal femur extension osteotomy was performed as part of multilevel surgery on lower limbs. The fixed knee flexion deformity was measured during physical examination, whereas hip and knee flexion in the stance phase and anterior pelvic tilt were both analyzed at kinematics. The pre-and post-surgery results were compared and analyzed statistically. A medical record review was done in order to identify the complications. The mean follow-up was 28 months. Results A significant reduction of fixed knee flexion deformity at physical examination and knee flexion in the stance phase at kinematics was observed, but with no decrease in hip flexion. As a non-desired effect, there was an increase in anterior pelvic tilt after surgical procedures. With regard to complications, a single patient had skin breakdown at a calcaneous area on one side and the recurrence of deformity was seen in 27% of cases. Conclusions In this study, in which fixed knee flexion deformity did not exceed 40°before surgery, the distal femur extension osteotomy was effective in increasing knee extension in the stance phase. However, an increase in anterior pelvic tilt, deformity recurrence and necessity for walking aids are possible complications of this procedure.

No abstract

OBJECTIVE: To identify gait patterns in a large group of children with diplegic cerebral palsy and to characterize each group according to age, Gross Motor Function Classification System (GMFCS) level, Gait Deviation Index (GDI) and previous surgical procedures. METHODS: One thousand eight hundred and five patients were divided in seven groups regarding observed gait patterns: jump knee, crouch knee, recurvatum knee, stiff knee, asymmetric, mixed and non-classified. RESULTS: The asymmetric group was the most prevalent (48.8%). The jump knee (9.6 years old) and recurvatum (9.4 years old) groups had mean age lower than the other groups. The lowest GDI (43.58) was found in the crouch group. There were more children classified within GMFCS level III in the crouch and mixed groups. Previous surgical procedures on the triceps surae were more frequent in stiff knee and mixed groups. The jump knee group received less and the stiff-knee group more surgical procedures at hamstrings than others. CONCLUSIONS: The asymmetrical cases were the most frequent within a group of diplegic patients. Individuals with crouch gait pattern were characterized by the lowest GDI and the highest prevalence of GMFCS III, while patients with stiff knee exhibited a higher percentage of previous hamstring lengthening in comparison to the other groups. Level of Evidence III, Retrospective Comparative Study.

Proximal femur external rotation osteotomy is a common procedure used for the correction of increased femur anteversion and hip internal rotation in cerebral palsy (CP). Different levels of osteotomy have been used at the proximal femur, but there are no studies in the literature comparing the results in CP. Patients with spastic CP, Gross Motor Function Classification System (GMFCS) I-III, who had undergone a femoral rotational osteotomy from August 1998 to August 2007, and with complete documentation at gait laboratory were included in the study. Patients were divided into two groups according to the level of osteotomy at the proximal femur. Group A [Dynamic Compression Plate (DCP) group] included 24 patients (36 osteotomies), and the osteotomy in this group was performed below the lesser trochanter. In Group B (Blade Plate group), 29 patients (35 osteotomies) were included and the level of osteotomy was above the lesser trochanter. Age at surgery, sex distribution, follow-up time, previous surgical procedures, surgical procedures performed in the same session as femur osteotomy, GMFCS level, topographic classification, clinical findings (internal and external hip rotation, and femur anteversion), and hip rotation at kinematics were analyzed and the results were compared between groups. Groups A and B were matched in terms of the sex distribution, follow-up time, GMFCS levels, and severity of clinical findings and hip internal rotation at kinematics before surgery. The mean age of the patients at surgery was 9.24 years in group A and 12 years in group B, and this difference was significant on performing statistical analysis (P=0.004). The number of patients who had undergone previous hip adductors' tenotomy was higher in group B (P=0.036). Improvements in clinical and kinematics parameters were observed in both groups after femur osteotomy (P<0.001). The increase in hip external rotation at clinical examination and the reduction in hip internal rotation at kinematics did not show differences between groups A and B on performing statistical analysis. However, reduction of femoral anteversion (P=0.032) and hip internal rotation (P=0.002) were more remarkable in group B. In conclusion, reduction of hip internal rotation and femur anteversion at physical examination were more significant in patients with intertrochanteric osteotomies; however, improvement in kinematics was observed in both groups after surgical procedures.

The aim of this study was to evaluate the influence of the Gross Motor Function Classification System (GMFCS) on the outcomes of rectus femoris transfer (RFT) for patients with cerebral palsy and stiff knee gait. We performed a retrospective review of patients seen at our gait laboratory from 1996 to 2013. Inclusion criteria were (i) spastic diplegic cerebral palsy, (ii) GMFCS levels I-III, (iii) reduced peak knee flexion in swing (PKFSw<55°), and (iv) patients who underwent orthopedic surgery with preoperative and postoperative gait analysis. Patients were divided into two groups according to whether they received a concurrent RFT or not at the time of surgery: non-RFT group (185 knees) and RFT group (123 knees). The primary outcome was the overall knee range of motion (KROM) derived from gait kinematics. The secondary outcomes were the PKFSw and the time of peak knee flexion in swing (tPKFSw). We observed a statistically significant improvement in KROM only for patients in the RFT group (P<0.001). However, PKFSw and tPKFSw improved in both groups after surgery (P<0.001 for all analyses). In the RFT group, the improvement in KROM was observed only for patients classified as GMFCS levels I and II. In the non-RFT group, no improvement in KROM was observed in any GMFCS level. In this study, patients at GMFCS levels I and II were more likely to benefit from the RFT procedure.

Objective: 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.

No abstract

Objectives: To show the preoperative planning and results from surgical treatment for paralytic hip dislocation among patients with cerebral palsy. The techniques used were proximal femoral varus derotation osteotomy in association with Dega iliac osteotomy, without opening the joint capsule. Methods: We performed a retrospective review of ten hips in eight patients with spastic quadriplegic cerebral palsy who underwent surgical treatment between 2003 and 2005, with the same surgical technique. The pre and postoperative clinical and radiological parameters, and the preoperative planning using an image intensifier, were assessed. The clinical parameters analyzed were: pain, hygiene-related difficulties and positioning difficulties. The radiological parameters were Reimer's index, the acetabular index and the neck-shaft angle. These results were subjected to statistical analysis. Results: We obtained good results with this technique. After a mean follow-up of three years, all the hips were observed to be stable at the last assessment, and there was a high degree of satisfaction among the families in relation to the treatment. We also showed that preoperative planning using an image intensifier allowed us to reduce and stabilize these hips without the need for capsuloplasty. Conclusion: The authors conclude that in treating hip dislocation among spastic quadriplegic cerebral palsy patients, capsuloplasty is unnecessary for stabilizing the coxofemoral joint.