Rectus Femoris Distal Tendon Resection Improves Knee Motion in Patients With Spastic Diplegia

Abstract

Background Children with spastic diplegia frequently show excessive knee extension (stiff-knee gait) throughout swing phase, which may interfere with foot clearance. Abnormal rectus femoris activity is commonly associated with a stiff-knee gait. Rectus femoris transfer has been recommended to enhance knee flexion during swing. However, recent studies suggest the transfer does not generate a knee flexor moment but diminishes knee extension moment in swing and MRI studies show the transferred tendons can be constrained by scarring to underlying muscles. Thus, it is possible knee flexion would be improved by distal rectus release rather than transfer since it would not be adherent to the underlying muscles. Questions/purposes We therefore determined whether rectus femoris distal tendon resection improves knee ROM and kinematic characteristics of stiff-knee gait in patients with spastic diplegia. Patients and MethodsWe studied 45 patients who underwent rectus femoris distal tendon resection as a part of multilevel surgery. Rectus femoris procedures were indicated based on kinematic characteristics of stiff-knee gait. All patients were walkers and had a mean age at surgery of 13 years (range, 6-22 years). We obtained gait analyses before surgery and at mean 2-year followup. We based postoperative assessment on clinical evaluation and gait analysis data. Results At followup, rectus femoris distal tendon resection was associated with improved knee ROM and timing of peak knee flexion in swing, and the absolute values of peak knee flexion became normal for those patients who showed abnormal preoperative values.

A Systematic Review of the Effects of Single-Event Multilevel Surgery on Gait Parameters in Children with Spastic Cerebral Palsy

“…Table 1 provides an overview of the 50 studies conducted within the 24 selected articles. All articles were published by a range of international research groups based in different countries (Austria (n = 7) [ 10 – 12 , 14 , 18 , 26 , 28 ], USA (n = 5) [ 16 , 17 , 19 , 20 , 22 ], Australia (n = 2) [ 15 , 21 ], Germany (n = 7) [ 8 , 13 , 23 , 24 , 27 , 29 , 30 ], Switzerland (n = 1) [ 9 ], France (n = 1) [ 25 ] and the United Kingdom (n = 1) [ 31 ]). The focus area of the SEMLS intervention ranged from General multi-level surgeries, Lever arm dysfunction, Multi-level tendon surgeries, Gait pattern to Operative techniques, which resulted in a variety of type of interventions as part of the SEMLS as presented in Table 1 .…”

“…Knee ROM changes were found in 81% of the studies [ 10 , 11 , 14 , 23 – 26 , 29 – 31 ], while knee extension at IC changed in all studies (100%) [ 8 , 10 , 12 , 14 – 16 , 19 – 24 , 26 , 28 – 31 ] and in 80% of the studies during stance phase [ 8 , 10 – 12 , 14 , 20 , 21 , 23 , 24 , 26 , 29 – 31 ]. In addition, Peak knee flexion during the swing phase changed in 53% of the studies [ 14 – 16 , 20 , 23 – 25 , 29 , 30 ], while the timing of the peak knee flexion changes in 53% of the studies [ 19 , 22 – 25 , 31 ], after the SEMLS intervention…”

“…Improvements, defined as significant changes getting closer to the reference norm values, were reported for stride length (46% of the studies [ 10 – 12 , 14 , 18 – 20 , 24 , 27 ]), pelvic ROM (50% [ 10 , 12 , 19 , 29 ]), hip ROM (22% [ 10 , 14 ]), minimal hip flexion in stance (16% [ 11 , 20 , 29 ]), knee ROM (81% [ 10 , 11 , 14 , 23 – 26 , 29 – 31 ]), knee flexion at IC (100% [ 8 , 10 , 12 , 14 – 16 , 19 – 24 , 26 , 28 – 31 ]), minimal knee flexion in stance (80% [ 8 , 10 – 12 , 14 , 20 , 21 , 23 , 24 , 26 , 29 – 31 ]), timing of peak knee flexion (53% [ 14 – 16 , 20 , 23 – 25 , 29 , 30 ]), dorsiflexion at IC (81% [ 10 – 12 , 14 …”

“…Mixed results of the SEMLS interventions were found for cadence (18% improvements [ 10 , 11 , 18 , 19 ], 21% deterioration [ 24 , 27 , 29 ]), velocity (24% improvements [ 10 – 12 , 14 , 27 ], 7% deterioration [ 27 ])), maximum hip flexion in swing phase (9% improvements [ 11 ], 9% deterioration [ 14 ]), maximum knee flexion in swing phase (14% improvements [ 15 , 24 , 25 ], 39% deterioration [ 14 , 16 , 20 , 23 , 24 , 29 , 30 ]), maximum ankle dorsiflexion in stance (79% improvements [ 11 , 15 , 16 , 19 , 21 , 26 , 27 , 30 ], 4% deterioration [ 20 ]), and mean foot progression (92% improvement [ 9 , 13 , 15 – 17 , 20 , 31 ], 8% deterioration [ 17 ]). Deterioration was reported for mean pelvic tilt parameter in 24% of the studies [ 10 , 21 , 30 ].…”

“…The focus areas of the SEMLS interventions varied substantially between the 24 articles and ranged from a general focus [ 8 – 12 ] to more specific focus such as a lever-arm dysfunction [ 13 – 17 ], multi-tendon lengthening (MTL) [ 18 – 20 ], specific gait patterns [ 21 – 25 ], and different operative techniques focus [ 26 – 31 ]. The effect of these SEMLS interventions, within each focus area, on 3DGA parameters are discussed below.…”