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DOI: 10.1055/s-0044-1786541
Treatment for Knee Flexion Contracture in Cerebral Palsy
Article in several languages: español | English- Abstract
- Introduction
- Treatment
- Hamstring Surgery
- Distal Femoral Extensor Osteotomy
- Anterior Physiodesis of the Distal Femur
- Final Considerations
- Referencias
Abstract
Full knee extension is essential for gait. Patients with cerebral palsy frequently have extension deficits of different magnitudes, which compromise walking and even standing up. The treatment of knee flexion contracture begins by addressing the spasticity of the involved muscles and includes physical therapy. For structured extension deficits, the treatment is surgical, using different techniques depending on the magnitude of the contracture and the patient's age. Soft tissue techniques include functional hamstring lengthening and muscle transfers. For capsular contracture, bone surgery is preferable and extends the proximal femur either progressively, through anterior physiodesis in pediatric patients, or acutely, by extensor distal femoral osteotomy. A high patella is common and requires correction during the same surgical procedure to maintain the efficiency of the extensor apparatus.
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Introduction
Knee extension during walking is critical for the initial contact phase and single-leg midstance when passive extension results from the second rocker of the ankle and it is blocked in extension, conserving energy and maintaining limb stability to support the entire body weight.[1] [2] It is critical that the ground reaction force at such a stage passes in front of the knee to achieve this passive extensor effect, as well as the adequate action of the soleus to block the anterior translation of the tibia and enable knee extension. A ground reaction force vector passing behind the knee tends to bend it even more in single-leg loading, generating higher flexion and, as a result, a co-contraction of the permanent extensor apparatus. This co-contraction stresses the patella and elongates the patellar tendon, leading to secondary high patella and insufficiency of the extensor apparatus ([Figure 1]).[1] [2]
Knee flexion in cerebral palsy may originate primarily from muscle spasticity, especially in the hamstring group. Secondarily, the muscles shorten, and capsular retractions occur, leading to structured knee flexion. Tertiarily, knee flexion may compensate other lower extremity deformities, such as club foot, limb length discrepancy, or hip flexion, which is common in these patients.[3] [4] [5] [6] [7] [8]
In the clinical evaluation, it is fundamental to verify the patient's degree of spasticity according to the Ashworth scale. The popliteal angle will determine the clinical length of the hamstrings, which is normally lower than 40°. It is also critical to measure it with the pelvis level by bending the contralateral hip to avoid the effect of anterior pelvic tilt on the hamstrings (bilateral popliteal angle) ([Figure 2]). The knee extension deficit is determined with the patient in the supine position, with 0° to 5° of hyperextension being normal. It is also important to determine the sufficiency of the extensor apparatus through the extensor lag or the difference in degrees between active and passive extension ([Figure 3]). One must not forget to check the influence of other joints on the knee, especially if there is structured hip flexion or equinus deformity of the ankle.[9]
Gait analysis enables the determination of the kinematic profile of the knee in permanent flexion and the length of the hamstrings to define if their lengthening is required. This analysis also shows the kinematics of adjacent joints, especially in the pelvis, as well as ankle position ([Figure 4]).[9] [10]
As for classification, we will refer to knee flexion in diplegia, which accounts for most issues, and the classification of the evolution of Roda's diplegic gait ([Figure 5]). A knee jumping during complete extension and flexion results from spasticity, which requires treatment. However, flexion is more structured in advanced stages, and its treatment is direct.[2]
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Treatment
For flexion due to primary alterations, the spasticity requires pharmacological treatment with the administration of botulinum toxin in the hamstrings or surgical selective dorsal rhizotomy. Physical therapy and orthotic treatment help align the limb and keep the knee in extension. Treatment of secondary alterations, including muscle shortening and structured deformities, uses different surgical techniques, such as, hamstring lengthening or transfer, distal femoral extensor osteotomy, and anterior physiodesis of the distal femur. The resolution of tertiary alterations relies on correcting the alteration of the adjacent joint, such as management of the equinus deformity, hip flexion, and limb dysmetria.[11]
Regarding surgical treatment, particularly for secondary alterations (muscle and capsular retractions), always consider first treating spasticity and correcting adjacent segments and associated skeletal deformities, often in the context of multilevel surgery. Do not overcorrect, since knee overcorrections may be very difficult to solve. Therefore, apply the concept of “surgical dose” and consider the skeletal maturity and degree of functionality of the patient.
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Hamstring Surgery
Isolated hamstring surgery is usually indicated for mild to moderate structured flexions ranging from 5° to 20°, with a popliteal angle greater than 60°. These values reveal an actual shortening of the hamstrings, which can be demonstrated by the gait laboratory. An important concept is that, in the presence of an anterior pelvic tilt, hamstring lengthening is not recommended, since it generates a higher anterior tilt (because the hamstrings are fundamentally hip extensors and pelvic retroverters) ([Figure 6]). An overcorrection may lead to recurvatum of the knee, whose treatment is a challenge.
When lengthening the hamstrings, it is often advisable to lengthen the medial muscles through muscle fasciotomies to preserve muscle strength. Never perform tenotomies at this level. This procedure is indicated for mild flexion ranging from 5° to 10° in highly-functional patients, classified as grades 1 to 3 in the gross motor function classification system (GMFCS). Avoid over-lengthening to avoid anterior pelvic tilt or recurvatum of the knee. Today, lengthening of the lateral knee region is no longer performed in functional patients due to the risk of overcorrection.[11] [12] [13]
Semitendinosus transfer to the adductor magnus is a technique to transform this muscle from biarticular to monoarticular, thereby removing its flexor function on the knee and maintaining its extensor function on the hip and pelvis ([Figure 7]). However, its role in preventing anterior pelvic tilt is not clear. The procedure is indicated for flexions ranging from 10° to 20°, patients with a higher functional compromise (GMFCS grades 3 to 4), or more functional patients with more severe early flexion. This procedure can be added to others, such as anterior knee physiodesis in small or prepubertal patients.[11]
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Distal Femoral Extensor Osteotomy
Distal femoral extensor osteotomy is the gold standard for the definitive treatment of structured knee flexion in patients with flexion ranging from 10° to 40°, close to skeletal maturity (with fewer than 2 years of growth remaining) ([Figure 8]). Lengthening the hamstrings after osteotomy is often not required, since extensor osteotomy tightens the hamstrings, preserving their hip extensor function. As a result, hamstring lengthening can produce overcorrection or anterior pelvic tilt.[14] [15]
It is critical to consider patellar descent, which virtually always accompanies the extensor osteotomy due to the insufficiency of the extensor apparatus and the high patella presented by these patients.[15] [16] [17] [18]
Subjects with more severe flexion (> 40°), in addition to the extensor osteotomy, can undergo femoral shortening to generate a precarious standing position or gait, with supplementary optional hamstring lengthening and regular patellar descent.[3] [19]
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Anterior Physiodesis of the Distal Femur
This procedure became very popular in patients with an immature skeleton (fewer than two years of growth remaining), obviously, as it generates a progressive extension of the knee at the level of the distal femoral physis. It is indicated for flexion ranging from 10° to 30°, and it may include a supplementary hamstring lengthening or transfer. Among the different techniques, screws have shown advantages over figure-eight plates or anterior tension bands, since they present fewer local complications and lower levels of postoperative pain and stiffness. As a result, screws enable early mobilization with similar correction rates, being currently recommended for knee flexion in patients with an immature skeleton ([Figure 9]).[20] [21] [22] [23]
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Final Considerations
Knee flexion is a common alteration in patients with childhood cerebral palsy. Always consider treating spasticity first. In addition, consider the correction of compromised adjacent segments (hip, foot, and ankle). Consider hamstring lengthening (with or without transfer) in patients with mild to moderate flexion but no anterior pelvic tilt.
Distal femoral extensor osteotomy is the gold standard to definitively correct flexion in patients close to skeletal maturity, virtually always adding patellar descent. Anterior physiodesis of the distal femur is indicated in prepubertal patients with mild to moderate flexion, almost always accompanied by a soft tissue procedure. Avoid overcorrecting and consider the previous functional capacity of each patient.
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No conflict of interest has been declared by the author(s).
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Referencias
- 1 Sutherland DH, Davids JR. Common gait abnormalities of the knee in cerebral palsy. Clin Orthop Relat Res 1993; (288) 139-147
- 2 Rodda JM, Graham HK, Carson L, Galea MP, Wolfe R. Sagittal gait patterns in spastic diplegia. J Bone Joint Surg Br 2004; 86 (02) 251-258
- 3 Ganjwala D, Shah H. Management of the knee problems in spastic cerebral palsy. Indian J Orthop 2019; 53 (01) 53-62
- 4 Arnold AS, Anderson FC, Pandy MG, Delp SL. Muscular contributions to hip and knee extension during the single limb stance phase of normal gait: a framework for investigating the causes of crouch gait. J Biomech 2005; 38 (11) 2181-2189
- 5 Ounpuu S, Gage JR, Davis RB. Three-dimensional lower extremity joint kinetics in normal pediatric gait. J Pediatr Orthop 1991; 11 (03) 341-349
- 6 Kirtley C. Support and forward progression. In: Clinical gait analysis: theory and practice. London: Churchill Livingstone; 2006: 237-254
- 7 Horstmann HM, Bleck EE. Knee. In: Orthopaedic management in serebral palsy. 2nd ed.. London: Mac Keith Press; 2007: 303-343
- 8 Trost J. Physical assessment and observational gait analysis. In: Gage JR. editor. The treatment of gait problems in cerebral palsy. London: Mac Keith Press; 2004: 71-89
- 9 Temelli Y, Akalan NE. [Treatment approaches to flexion contractures of the knee]. Acta Orthop Traumatol Turc 2009; 43 (02) 113-120
- 10 Gage JR. Treatment principles for crouch gait. In: Gage JR. editor. The treatment of gait problems in cerebral palsy. London: Mac Keith Press; 2004: 382-397
- 11 Young JL, Rodda J, Selber P, Rutz E, Graham HK. Management of the knee in spastic diplegia: what is the dose?. Orthop Clin North Am 2010; 41 (04) 561-577
- 12 Sung KH, Chung CY, Lee KM. et al. Long term outcome of single event multilevel surgery in spastic diplegia with flexed knee gait. Gait Posture 2013; 37 (04) 536-541
- 13 De Mattos C, Patrick Do K, Pierce R, Feng J, Aiona M, Sussman M. Comparison of hamstring transfer with hamstring lengthening in ambulatory children with cerebral palsy: further follow-up. J Child Orthop 2014; 8 (06) 513-520
- 14 Rutz E, Gaston MS, Camathias C, Brunner R. Distal femoral osteotomy using the LCP pediatric condylar 90-degree plate in patients with neuromuscular disorders. J Pediatr Orthop 2012; 32 (03) 295-300
- 15 Das SP, Pradhan S, Ganesh S, Sahu PK, Mohanty RN, Das SK. Supracondylar femoral extension osteotomy and patellar tendon advancement in the management of persistent crouch gait in cerebral palsy. Indian J Orthop 2012; 46 (02) 221-228
- 16 Stout JL, Gage JR, Schwartz MH, Novacheck TF. Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy. J Bone Joint Surg Am 2008; 90 (11) 2470-2484
- 17 Novacheck TF, Stout JL, Gage JR, Schwartz MH. Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy. Surgical technique. J Bone Joint Surg Am 2009; 91 (Suppl. 02) 271-286
- 18 Ganjwala D. Multilevel orthopedic surgery for crouch gait in cerebral palsy: An evaluation using functional mobility and energy cost. Indian J Orthop 2011; 45 (04) 314-319
- 19 Taylor D, Connor J, Church C. et al. The effectiveness of posterior knee capsulotomies and knee extension osteotomies in crouched gait in children with cerebral palsy. J Pediatr Orthop B 2016; 25 (06) 543-550
- 20 Al-Aubaidi Z, Lundgaard B, Pedersen NW. Anterior distal femoral hemiepiphysiodesis in the treatment of fixed knee flexion contracture in neuromuscular patients. J Child Orthop 2012; 6 (04) 313-318
- 21 Klatt J, Stevens PM. Guided growth for fixed knee flexion deformity. J Pediatr Orthop 2008; 28 (06) 626-631
- 22 Long JT, Laron D, Garcia MC, McCarthy JJ. Screw Anterior Distal Femoral Hemiepiphysiodesis in Children With Cerebral Palsy and Knee Flexion Contractures: A Retrospective Case-control Study. J Pediatr Orthop 2020; 40 (09) e873-e879
- 23 Nazareth A, Gyorfi MJ, Rethlefsen SA, Wiseley B, Noonan K, Kay RM. Comparison of plate and screw constructs versus screws only for anterior distal femoral hemiepiphysiodesis in children. J Pediatr Orthop B 2020; 29 (01) 53-61
Address for correspondence
Publication History
Received: 14 November 2023
Accepted: 01 April 2024
Article published online:
03 May 2024
© 2024. Sociedad Chilena de Ortopedia y Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
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Referencias
- 1 Sutherland DH, Davids JR. Common gait abnormalities of the knee in cerebral palsy. Clin Orthop Relat Res 1993; (288) 139-147
- 2 Rodda JM, Graham HK, Carson L, Galea MP, Wolfe R. Sagittal gait patterns in spastic diplegia. J Bone Joint Surg Br 2004; 86 (02) 251-258
- 3 Ganjwala D, Shah H. Management of the knee problems in spastic cerebral palsy. Indian J Orthop 2019; 53 (01) 53-62
- 4 Arnold AS, Anderson FC, Pandy MG, Delp SL. Muscular contributions to hip and knee extension during the single limb stance phase of normal gait: a framework for investigating the causes of crouch gait. J Biomech 2005; 38 (11) 2181-2189
- 5 Ounpuu S, Gage JR, Davis RB. Three-dimensional lower extremity joint kinetics in normal pediatric gait. J Pediatr Orthop 1991; 11 (03) 341-349
- 6 Kirtley C. Support and forward progression. In: Clinical gait analysis: theory and practice. London: Churchill Livingstone; 2006: 237-254
- 7 Horstmann HM, Bleck EE. Knee. In: Orthopaedic management in serebral palsy. 2nd ed.. London: Mac Keith Press; 2007: 303-343
- 8 Trost J. Physical assessment and observational gait analysis. In: Gage JR. editor. The treatment of gait problems in cerebral palsy. London: Mac Keith Press; 2004: 71-89
- 9 Temelli Y, Akalan NE. [Treatment approaches to flexion contractures of the knee]. Acta Orthop Traumatol Turc 2009; 43 (02) 113-120
- 10 Gage JR. Treatment principles for crouch gait. In: Gage JR. editor. The treatment of gait problems in cerebral palsy. London: Mac Keith Press; 2004: 382-397
- 11 Young JL, Rodda J, Selber P, Rutz E, Graham HK. Management of the knee in spastic diplegia: what is the dose?. Orthop Clin North Am 2010; 41 (04) 561-577
- 12 Sung KH, Chung CY, Lee KM. et al. Long term outcome of single event multilevel surgery in spastic diplegia with flexed knee gait. Gait Posture 2013; 37 (04) 536-541
- 13 De Mattos C, Patrick Do K, Pierce R, Feng J, Aiona M, Sussman M. Comparison of hamstring transfer with hamstring lengthening in ambulatory children with cerebral palsy: further follow-up. J Child Orthop 2014; 8 (06) 513-520
- 14 Rutz E, Gaston MS, Camathias C, Brunner R. Distal femoral osteotomy using the LCP pediatric condylar 90-degree plate in patients with neuromuscular disorders. J Pediatr Orthop 2012; 32 (03) 295-300
- 15 Das SP, Pradhan S, Ganesh S, Sahu PK, Mohanty RN, Das SK. Supracondylar femoral extension osteotomy and patellar tendon advancement in the management of persistent crouch gait in cerebral palsy. Indian J Orthop 2012; 46 (02) 221-228
- 16 Stout JL, Gage JR, Schwartz MH, Novacheck TF. Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy. J Bone Joint Surg Am 2008; 90 (11) 2470-2484
- 17 Novacheck TF, Stout JL, Gage JR, Schwartz MH. Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy. Surgical technique. J Bone Joint Surg Am 2009; 91 (Suppl. 02) 271-286
- 18 Ganjwala D. Multilevel orthopedic surgery for crouch gait in cerebral palsy: An evaluation using functional mobility and energy cost. Indian J Orthop 2011; 45 (04) 314-319
- 19 Taylor D, Connor J, Church C. et al. The effectiveness of posterior knee capsulotomies and knee extension osteotomies in crouched gait in children with cerebral palsy. J Pediatr Orthop B 2016; 25 (06) 543-550
- 20 Al-Aubaidi Z, Lundgaard B, Pedersen NW. Anterior distal femoral hemiepiphysiodesis in the treatment of fixed knee flexion contracture in neuromuscular patients. J Child Orthop 2012; 6 (04) 313-318
- 21 Klatt J, Stevens PM. Guided growth for fixed knee flexion deformity. J Pediatr Orthop 2008; 28 (06) 626-631
- 22 Long JT, Laron D, Garcia MC, McCarthy JJ. Screw Anterior Distal Femoral Hemiepiphysiodesis in Children With Cerebral Palsy and Knee Flexion Contractures: A Retrospective Case-control Study. J Pediatr Orthop 2020; 40 (09) e873-e879
- 23 Nazareth A, Gyorfi MJ, Rethlefsen SA, Wiseley B, Noonan K, Kay RM. Comparison of plate and screw constructs versus screws only for anterior distal femoral hemiepiphysiodesis in children. J Pediatr Orthop B 2020; 29 (01) 53-61