Top

International Orthopaedics

Published in:

01-06-2021 | Original Paper

Recurrence of knee flexion contracture after surgical correction in children with cerebral palsy

Authors: Supitchakarn Cheewasukanon, Phatcharapa Osateerakun, Noppachart Limpaphayom

Published in: International Orthopaedics | Issue 6/2021

Abstract

Purpose

Knee flexion contracture (FC) and crouch gait are challenging to treat in children with cerebral palsy (CCP), and recurrent knee FC after surgery is a severe complication. The aim was to identify factors associated with recurrent knee FC after surgery.

Methods

The records of 62 CCP (age 10.6±2.6 years) who underwent surgery and were followed for > six months were reviewed. Knee FC was treated by hamstring lengthening, posterior knee capsulotomy, and femoral shortening/extension osteotomy until full extension was obtained. Kaplan-Meier analysis was used to estimate the probability of the correction being maintained. Cox proportional hazard modeling was used to compare parameters between patients with and without recurrent knee FC, with the time to recurrence as the endpoint. Potential confounding factors were included in the multivariate analysis.

Results

In total, the procedure was performed on 122 knees. The average weight-for-age z score was −1.3±1.2. The average follow-up period was 5.4±4.2 years. Knee FC recurrence was observed in 37 knees (30%). The average recurrence-free time was 4.9 years, with most cases of recurrence (33 knees) occurring within six years after surgery. The factors associated with recurrence were age (HR, 1.19) and a required posterior knee capsulotomy procedure (HR, 4.53).

Conclusion

Recurrent knee FC after correction is associated with CCP who are older at the time of operation and when posterior knee capsulotomy is performed. The age at operation should be optimized. The sequence of procedures should be performed only as necessary to minimize the chance of post-operative muscle weakness and recurrence.

Temelli Y, Akalan NE (2009) Treatment approaches to flexion contractures of the knee. Acta Orthop Traumatol Turc 43(2):113–120. https://doi.org/10.3944/aott.2009.113CrossRefPubMed

Joseph B, Reddy K, Varghese RA, Shah H, Doddabasappa SN (2010) Management of severe crouch gait in children and adolescents with cerebral palsy. J Pediatr Orthop 30(8):832–839. https://doi.org/10.1097/BPO.0b013e3181fbfd0eCrossRefPubMed

Galey SA, Lerner ZF, Bulea TC, Zimbler S, Damiano DL (2017) Effectiveness of surgical and non-surgical management of crouch gait in cerebral palsy: a systematic review. Gait Posture 54:93–105. https://doi.org/10.1016/j.gaitpost.2017.02.024CrossRefPubMed

Dreher T, Vegvari D, Wolf SI, Geisbusch A, Gantz S, Wenz W et al (2012) Development of knee function after hamstring lengthening as a part of multilevel surgery in children with spastic diplegia: a long-term outcome study. J Bone Joint Surg Am 94(2):121–130. https://doi.org/10.2106/jbjs.j.00890CrossRefPubMed

Putz C, Blessing AK, Erhard S, Fiethen K, Geisbusch A, Niklasch M et al (2019) Long-term results of multilevel surgery in adults with cerebral palsy. Int Orthop 43(2):255–260. https://doi.org/10.1007/s00264-018-4023-7CrossRefPubMed

Woratanarat P, Dabney KW, Miller F (2009) Knee capsulotomy for fixed knee flexion contracture. Acta Orthop Traumatol Turc 43(2):121–127. https://doi.org/10.3944/aott.2009.121CrossRefPubMed

Baumann JU, Ruetsch H, Schurmann K (1980) Distal hamstring lengthening in cerebral palsy. An evaluation by gait analysis. Int Orthop 3(4):305–309. https://doi.org/10.1007/bf00266026CrossRefPubMed

Beals RK (2001) Treatment of knee contracture in cerebral palsy by hamstring lengthening, posterior capsulotomy, and quadriceps mechanism shortening. Dev Med Child Neurol 43(12):802–805. https://doi.org/10.1111/j.1469-8749.2001.tb00166.xCrossRefPubMed

Taylor D, Connor J, Church C, Lennon N, Henley J, Niiler T et al (2016) The effectiveness of posterior knee capsulotomies and knee extension osteotomies in crouched gait in children with cerebral palsy. J Pediatr Orthop B 25(6):543–550. https://doi.org/10.1097/BPB.0000000000000370CrossRefPubMed

10.

McCarthy J, Wade Shrader M, Graham K, Veerkamp M, Brower L, Chambers H et al (2020) Establishing surgical indications for hamstring lengthening and femoral derotational osteotomy in ambulatory children with cerebral palsy. J Child Orthop 14(1):50–57. https://doi.org/10.1302/1863-2548.14.190173CrossRefPubMedPubMedCentral

11.

Grujic H, Aparisi T (1982) Distal hamstring tendon release in knee flexion deformity. Int Orthop 6(2):103–106. https://doi.org/10.1007/bf00268652CrossRefPubMed

12.

de Morais Filho MC, Neves DL, Abreu FP, Juliano Y, Guimaraes L (2008) Treatment of fixed knee flexion deformity and crouch gait using distal femur extension osteotomy in cerebral palsy. J Child Orthop 2(1):37–43. https://doi.org/10.1007/s11832-007-0073-xCrossRefPubMedPubMedCentral

13.

Klotz MCM, Hirsch K, Heitzmann D, Maier MW, Hagmann S, Dreher T (2017) Distal femoral extension and shortening osteotomy as a part of multilevel surgery in children with cerebral palsy. World J Pediatr 13(4):353–359. https://doi.org/10.1007/s12519-016-0086-yCrossRefPubMed

14.

Limpaphayom N, Prasongchin P (2011) Re-exploration of the rectus femoris tendon to sartorius transfer in children with spastic cerebral palsy. Asian Biomed 5(1):143–149. https://doi.org/10.5372/1905-7415.0501.018CrossRef

15.

Dhawlikar SH, Root L, Mann RL (1992) Distal lengthening of the hamstrings in patients who have cerebral palsy. Long-term retrospective analysis. J Bone Joint Surg Am 74(9):1385–1391. https://doi.org/10.2106/00004623-199274090-00012CrossRefPubMed

16.

Chang WN, Tsirikos AI, Miller F, Lennon N, Schuyler J, Kerstetter L et al (2004) Distal hamstring lengthening in ambulatory children with cerebral palsy: primary versus revision procedures. Gait Posture 19(3):298–304. https://doi.org/10.1016/s0966-6362(03)00070-5CrossRefPubMed

17.

Westberry DE, Davids JR, Jacobs JM, Pugh LI, Tanner SL (2006) Effectiveness of serial stretch casting for resistant or recurrent knee flexion contractures following hamstring lengthening in children with cerebral palsy. J Pediatr Orthop 26(1):109–114. https://doi.org/10.1097/01.bpo.0000187990.71645.aeCrossRefPubMed

18.

Long JT, Cobb L, Garcia MC, McCarthy JJ (2020) Improved clinical and functional outcomes in crouch gait following minimally invasive hamstring lengthening and serial casting in children with cerebral palsy. J Pediatr Orthop 40(6):e510–e515. https://doi.org/10.1097/BPO.0000000000001437CrossRefPubMed

19.

Miller F (2004) Knee operative procedures. In: Miller F (ed) Cerebral palsy. Springer, Singapore, pp 955–978

20.

Rodda JM, Graham HK, Carson L, Galea MP, Wolfe R (2004) Sagittal gait patterns in spastic diplegia. J Bone Joint Surg (Br) 86(2):251–258. https://doi.org/10.1302/0301-620X.86B2.13878CrossRef

21.

Choi JY, Kim SK, Park ES (2019) The effect of botulinum toxin injections on gross motor function for lower limb spasticity in children with cerebral palsy. Toxins (Basel) 11(11):651. https://doi.org/10.3390/toxins11110651CrossRef

22.

Oftedal S, Bell KL, Davies PS, Ware RS, Boyd RN (2014) Validation of accelerometer cut points in toddlers with and without cerebral palsy. Med Sci Sports Exerc 46(9):1808–1815. https://doi.org/10.1249/MSS.0000000000000299CrossRefPubMed

23.

Sung KH, Lee J, Chung CY, Lee KM, Cho BC, Moon SJ et al (2017) Factors influencing outcomes after medial hamstring lengthening with semitendinosus transfer in patients with cerebral palsy. J Neuroeng Rehabil 14(1):83. https://doi.org/10.1186/s12984-017-0296-0CrossRefPubMedPubMedCentral

24.

McGinley JL, Dobson F, Ganeshalingam R, Shore BJ, Rutz E, Graham HK (2012) Single-event multilevel surgery for children with cerebral palsy: a systematic review. Dev Med Child Neurol 54(2):117–128. https://doi.org/10.1111/j.1469-8749.2011.04143.xCrossRefPubMed

25.

Putz C, Mertens EM, Wolf SI, Geisbusch A, Niklasch M, Gantz S et al (2018) Equinus correction during multilevel surgery in adults with cerebral palsy. Foot Ankle Int 39(7):812–820. https://doi.org/10.1177/1071100718765161CrossRefPubMed

26.

Putz C, Wolf SI, Mertens EM, Geisbusch A, Gantz S, Braatz F et al (2017) Effects of multilevel surgery on a flexed knee gait in adults with cerebral palsy. Bone Joint J 99(9):1256–1264. https://doi.org/10.1302/0301-620X.99B9.BJJ-2016-1155.R1CrossRefPubMed

27.

Park H, Park BK, Park KB, Abdel-Baki SW, Rhee I, Kim CW et al (2019) Distal femoral shortening osteotomy for severe knee flexion contracture and crouch gait in cerebral palsy. J Clin Med 8(9):1354. https://doi.org/10.3390/jcm8091354CrossRefPubMedCentral

28.

Aiona M, Do KP, Feng J, Jabur M (2017) Comparison of rectus femoris transfer surgery done concomitant with hamstring lengthening or delayed in patients with cerebral palsy. J Pediatr Orthop 37(2):107–110. https://doi.org/10.1097/BPO.0000000000000596CrossRefPubMed

29.

Sousa TC, Nazareth A, Rethlefsen SA, Mueske NM, Wren TA, Kay RM (2019) Rectus femoris transfer surgery worsens crouch gait in children with cerebral palsy at GMFCS levels III and IV. J Pediatr Orthop 39(9):466–471. https://doi.org/10.1097/BPO.0000000000000988CrossRefPubMed

30.

Novacheck TF, Stout JL, Gage JR, Schwartz MH (2009) Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy. Surgical technique. J Bone Joint Surg Am 91(Suppl 2):271–286. https://doi.org/10.2106/jbjs.i.00316CrossRefPubMed

31.

Healy MT, Schwartz MH, Stout JL, Gage JR, Novacheck TF (2011) Is simultaneous hamstring lengthening necessary when performing distal femoral extension osteotomy and patellar tendon advancement? Gait Posture 33(1):1–5. https://doi.org/10.1016/j.gaitpost.2010.08.014CrossRefPubMed

32.

Stout JL, Gage JR, Schwartz MH, Novacheck TF (2008) Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy. J Bone Joint Surg Am 90(11):2470–2484. https://doi.org/10.2106/JBJS.G.00327CrossRefPubMed

33.

Boyer ER, Stout JL, Laine JC, Gutknecht SM, Araujo de Oliveira LH, Munger ME et al (2018) Long-term outcomes of distal femoral extension osteotomy and patellar tendon advancement in individuals with cerebral palsy. J Bone Joint Surg Am 100(1):31–41. https://doi.org/10.2106/JBJS.17.00480CrossRefPubMed

34.

Holm I, Nordsletten L, Steen H, Folleras G, Bjerkreim I (1994) Muscle function after mid-shaft femoral shortening. A prospective study with a two-year follow-up. J Bone Joint Surg (Br) 76(1):143–146. https://doi.org/10.1302/0301-620x.76b1.8300660CrossRef

35.

Barker KL, Simpson AH (2004) Recovery of function after closed femoral shortening. J Bone Joint Surg (Br) 86(8):1182–1186. https://doi.org/10.1302/0301-620x.86b8.15194CrossRef

36.

Morais Filho MC, Blumetti FC, Kawamura CM, Fujino MH, Matias MS, Lopes JAF (2020) Comparison of the results of primary versus repeat hamstring surgical lengthening in cerebral palsy. J Pediatr Orthop 40(5):e380–e384. https://doi.org/10.1097/BPO.0000000000001464CrossRefPubMed

Title: Recurrence of knee flexion contracture after surgical correction in children with cerebral palsy
Authors: Supitchakarn Cheewasukanon
Phatcharapa Osateerakun
Noppachart Limpaphayom
Publication date: 01-06-2021
Publisher: Springer Berlin Heidelberg
Published in: International Orthopaedics / Issue 6/2021
Print ISSN: 0341-2695
Electronic ISSN: 1432-5195
DOI: https://doi.org/10.1007/s00264-021-05035-z

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Recurrence of knee flexion contracture after surgical correction in children with cerebral palsy

Abstract

Purpose

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 6/2021

Ultrasound-guided adductor canal block combined with lateral femoral cutaneous nerve block for post-operative analgesia following total knee arthroplasty: a prospective, double-blind, randomized controlled study

Intramedullary nailing via suprapatellar approach versus locked plating of proximal extra-articular tibial fractures: a randomized control trial

Risk factors associated with post-operative neurological deterioration in patients with thoracic disc disorders with myelopathy

Effects of implant rotational malposition on contact surface area after implantation of the augmented glenoid baseplate in the setting of glenoid bone loss

Correction to: Molecular mechanisms of mechanical load-induced osteoarthritis

Effect of lengthening speed on the quality of callus and complications in patients with congenital pseudarthrosis of tibia