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

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.

Intraoperative neuromonitoring during distal femoral extension osteotomy in children with cerebral palsy

“…There was no correlation between NC and the amount of correction, concomitant surgeries, tourniquet time, malnutrition level or emotional state. Aroojis et al [13] reported 3 transient peroneal palsies after DFEO and PTA in 52 knees. Asirwatham et al [12] reported an 8.6% rate of NC.…”

“…In cases of fixed knee flexion of 10-30 degrees, DFEO was proven to be valuable in preventing and treating crouch gait [4,5,9,21]. It has been reported that combination with patellar tendon advancement might give better functional results [4][5][6]9,13].…”

“…DFEO is susceptible to complications such as nonunion, delayed union, local wound problems and transient or permanent NC [12]. NCs following DFEO have been reported to be 5-40% and were attributed to nerve stretch or mechanical insult to the nerve body [3,5,9,[11][12][13].…”

“…There is a 5-40 % risk of transient or permanent neurological injury with DFEO, and it has not changed since the first reports of this complication [3,5,9,[11][12][13]. The reported reasons for it were nerve stretch with the correction, direct injury at the time of osteotomy or distractor placement, excessive correction, concomitant hamstring tenotomy, compression by the posterior bony protrusion and postoperative immobilization of the knee in full extension [5,11,12].…”

Distal Femoral Extension Osteotomy with a Retrograde Nail for Treatment of pediatric Crouch Gait

“…Distal femoral extension osteotomy (DFEO) for the treatment of patients with fixed flexion deformities associated with arthritic conditions and neuromuscular disorders is a wellestablished procedure [1][2][3].The use of 90⁰ locking plates for the correction of persistent crouch gait in pediatric cerebral palsy patients has been described with favorable results, including improved mobility, decreased flexion deformity and extensor lag, and increased muscle strength [1][2][3][4] Reported complications with this technique in cerebral palsy patients vary with modern reports ranging from less than 5% to 19% [1,3,4]. Frequent complications with use of plate fixation in DFEO include delayed union or nonunion, fixation failure, loss of correction, and neurovascular injury [2,5].…”