Anterior distal femoral hemiepiphysiodesis in children with cerebral palsy: Establishing surgical indications and techniques using the modified Delphi method and literature review

Abstract

Purpose: The purpose of this study was to develop consensus for the surgical indications of anterior distal femur hemiepiphysiodesis in children with cerebral palsy using expert surgeon opinion through a modified Delphi technique. Methods: The panel used a 5-level Likert-type scale to record agreement or disagreement with 27 statements regarding anterior distal femur hemiepiphysiodesis. Consensus was defined as at least 80% of responses being in the highest or lowest 2 of the Likert-type ratings. General agreement was defined as 60%–79% falling into the highest or lowest 2 ratings. Results: For anterior distal femur hemiepiphysiodesis, 27 statements were surveyed: consensus or general agreement among the panelists was achieved for 22 of 27 statements (22/27, 82%) and 5 statements had no agreement (5/27, 18%). There was general consensus that anterior distal femur hemiepiphysiodesis is indicated for ambulatory children with cerebral palsy, with at least 2 years growth remaining, and smaller (<30 degrees) knee flexion contractures and for minimally ambulatory children to aid in standing/transfers. Consensus was achieved regarding the importance of close radiographic follow-up after screw insertion to identify or prevent secondary deformity. There was general agreement that percutaneous screws are preferred over anterior plates due to the pain and irritation associated with plates. Finally, it was agreed that anterior distal femur hemiepiphysiodesis was not indicated in the absence of a knee flexion contracture. Conclusion: Anterior distal femur hemiepiphysiodesis can be used to treat fixed knee flexion contractures in the setting of crouch gait, but other associated lever arm dysfunctions must be addressed by single-event multilevel surgery. Level of evidence: V

Distal femoral extension osteotomy and patellar tendon advancement or shortening in ambulatory children with cerebral palsy: A modified Delphi consensus study and literature review

“…Areas with lower levels of agreement were reported in skeletally immature patients with crouch gait and extensor lag, because of the overlap in indications between DFEO and ADFH. 13 There was uncertainty about the timing of PTS, given that correction of KFD is acute with DFEO and gradual with guided growth. 4,13 Results: literature review…”

“…7 In consider ation of this background, a group of 16 orthopedic sur geons with fellowship training in pediatric orthopedics used a modified Delphi process to develop consensus guidelines for the management of various aspects of lower limb deformities in ambulatory children with CP. 7,[11][12][13] The management of flexed knee/crouch gait has been considered to be one of the more difficult problems to address and achieve consistently good longterm out comes, in ambulatory children with CP. 4,5,14 The introduc tion of surgical techniques including transfer of the medial hamstrings to the distal femur, as well as anterior distal femoral hemiepiphysiodesis (ADFH), means that the role of distal femoral extension osteotomy (DFEO) combined with patellar tendon advancement (PTA) or patellar tendon shortening (PTS) need to be reevaluated and better defined.…”

“…4,5,14 The introduc tion of surgical techniques including transfer of the medial hamstrings to the distal femur, as well as anterior distal femoral hemiepiphysiodesis (ADFH), means that the role of distal femoral extension osteotomy (DFEO) combined with patellar tendon advancement (PTA) or patellar tendon shortening (PTS) need to be reevaluated and better defined. 12,13 For this reason, our group addressed the indi cations and outcome assessment for DFEO and PTA/PTS, following previous studies addressing hamstring lengthen ing, transfer of the hamstrings to the distal femur, and the role of guided growth (ADFH) for small flexion deformi ties of the knee. [12][13][14] CP participated in the consensusseeking process.…”

“…12,13 For this reason, our group addressed the indi cations and outcome assessment for DFEO and PTA/PTS, following previous studies addressing hamstring lengthen ing, transfer of the hamstrings to the distal femur, and the role of guided growth (ADFH) for small flexion deformi ties of the knee. [12][13][14] CP participated in the consensusseeking process. Group members had a mean of >20 years of experience (range = 10-41 years) in the orthopedic care of children with CP and a mean of 20 years (range = 7-31 years) of experience in the interpretation of clinical gait analysis.…”

“…The modified Delphi process has been described in previous publications, to which the reader is referred. [11][12][13]…”