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

Rutz, Erich; Novacheck, Tom F.; Dreher, Thomas; Davids, Jon R.; McCarthy, James J.; Kay, Robert M.; Shore, Benjamin J.; Shrader, M. Wade; Veerkamp, Matthew; Chambers, Hank; Narayanan, Unni G.; Pierz, Kristan; Rhodes, Jason; Shilt, Jeffrey S.; Theologis, Tim; Campenhout, Anja Van; Graham, Kerr

doi:10.1177/18632521221137391

Cited by 7 publications

(6 citation statements)

References 32 publications

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“…42 These indications are in line with recent expert consensus. 76 This study has certain limitations that should be noted. In the first place, despite an exhaustive review of the literature published to date, the analysis was confined to only seven studies comparing MLS with PLS and no-PLS.…”

Section: Discussionmentioning

confidence: 89%

Does patella lowering as part of multilevel surgery improve knee kinematics in children with cerebral palsy and crouch gait? A meta-analysis of comparative studies

Galán-Olleros,

Lerma-Lara,

Torres-Izquierdo

et al. 2023

Journal of Children's Orthopaedics

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Purpose: To evaluate differences in knee kinematic outcomes of patellar-lowering surgery, specifically patellar tendon advancement or patellar tendon shortening, compared with no-patellar-lowering surgery in multilevel surgery for children with cerebral palsy and crouch gait. Methods: Four databases were searched to retrieve studies published from inception until 2023. Three reviewers independently screened for studies with observational or randomized control designs, comparing two groups of patients with cerebral palsy and crouch gait who underwent multilevel surgery (with patellar-lowering surgery versus no-patellar-lowering surgery), where various gait analysis outcomes were reported (CRD42023450692). The risk of bias was assessed with the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool. Results: Seven studies (249 patients and 368 limbs) met the eligibility criteria. Patients undergoing patellar-lowering surgery demonstrated statistically significant improvements in knee flexion at initial contact (mean difference = −6.39; 95% confidence interval = [−10.4, −2.75]; p = 0.0006; I2 = 84%), minimum knee flexion in stance (mean difference = −14.27; 95% confidence interval = [−18.31, −10.23]; p < 0.00001; I2 = 89%), and clinical knee flexion contracture (mean difference = −5.6; 95% confidence interval = [−9.59, −1.6]; p = 0.006; I2 = 95%), with a significant increase in anterior pelvic tilt (mean difference = 2.97; 95% confidence interval = [0.58, 5.36]; p = 0.01; I2 = 15%). However, improvements in gait deviation index and decrease in peak knee flexion in swing did not reach statistical significance. Subgroup analysis reduced heterogeneity and revealed (1) greater improvement using patellar tendon shortening versus patellar tendon advancement techniques; (2) lack of knee flexion contracture improvement in high-quality or longer-term studies; (3) longer-term improvement only in minimum knee flexion in stance, with a decrease in peak knee flexion in swing; and (4) an inability to assess the potential benefit of rectus femoris procedure and hamstring preservation. Conclusions: Overall, the combination of patellar-lowering surgery with multilevel surgery demonstrated superior improvements in stance-phase knee kinematics compared with multilevel surgery alone, despite an increase in anterior pelvic tilt and a longer-term knee flexion reduction during the swing phase. Level of evidence: Level III, Systematic review of level III studies.

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Section: Discussionmentioning

confidence: 89%

Does patella lowering as part of multilevel surgery improve knee kinematics in children with cerebral palsy and crouch gait? A meta-analysis of comparative studies

Galán-Olleros,

Lerma-Lara,

Torres-Izquierdo

et al. 2023

Journal of Children's Orthopaedics

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“…Rutz et al in the recent modified Delphi consensus study cited the importance of using FiberTape cerclage to the imbricated patellar tendon 11 . This offers secure fixation and prevents tendon rupture.…”

Section: Discussionmentioning

confidence: 99%

Patellar Tendon Rupture During Postoperative Physiotherapy for Crouch Gait

Shah,

Raibagkar,

Bansal

et al. 2023

JBJS Case Connector

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Introduction: A 14-year-old adolescent girl with spastic diplegic cerebral palsy underwent bilateral distal femur extension osteotomy and patellar tendon plication. Two and a half months after surgery, during physiotherapy, she sustained mid-substance tear of the left patellar tendon. The girl was successfully managed with patellar tendon repair and augmentation with tensor fascia lata autograft. Conclusion: Patellar tendon rupture during rehabilitative physiotherapy after patellar tendon plication surgery is rare. Postoperative protocols in patients with cerebral palsy are crucial and should progress gradually to improve knee range of motion. This report highlights that patellar tendon repair with fascia lata augmentation yields good outcome.

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“…Patellar tendon advancement in skeletally immature patients can be performed by releasing the tibial attachment and the free end is advanced deep to the T-shaped tibial periosteal flap 1-3 . Other PTS techniques can be grouped into the categories of (1) patellar tendon imbrication 4 , (2) patellar tendon detaching techniques in which the tendon is detached from the patellar attachment or cut in its midsubstance and shortened 2,5-7 , and (3) patellar tendon semi-detaching techniques in which patellar tendon flaps are created and shortened 8,9 .…”

Section: Alternativesmentioning

confidence: 99%

“Coronal Split/Overlap Repair” Patellar Tendon Shortening in Skeletally Immature Patients

Kenawey,

Morakis,

Alshryda

2024

JBJS Essential Surgical Techniques

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Background: “Coronal split/overlap repair” patellar tendon shortening (PTS) is a technique that is utilized to treat patella alta and can be combined with distal femoral extension osteotomy (DFEO) for the treatment of crouch gait in skeletally immature patients with cerebral palsy. Description: The patellar tendon is split in the coronal plane. The ventral patellar tendon flap is released from its patellar attachment and is reflected distally over its tibial attachment, exposing a dorsal flap. Two patellar/tibial no. 5 Ethibond (Ethicon) sutures are passed through 2 crossing patellar tunnels and 2 parallel tibial tunnels. The patella is then pushed distally until its distal pole lies at the level of the tibiofemoral joint. The Ethibond sutures are tied and tensioned to the desired level. The knee should be able to be passively flexed to 90°. The intact redundant dorsal flap of the patellar tendon is imbricated. Lastly, the ventral flap is advanced proximally and sutured to the anterior surface of the patella and to the edges of the dorsal flap without shortening. A hinged knee brace is utilized postoperatively with a range of motion of 0° to 30°, progressing to 90° by 6 weeks. No resistive quadriceps contractions are permitted for the first 3 weeks. Alternatives: Patellar tendon advancement in skeletally immature patients can be performed by releasing the tibial attachment and the free end is advanced deep to the T-shaped tibial periosteal flap 1–3 . Other PTS techniques can be grouped into the categories of (1) patellar tendon imbrication 4 , (2) patellar tendon detaching techniques in which the tendon is detached from the patellar attachment or cut in its midsubstance and shortened 2,5–7 , and (3) patellar tendon semi-detaching techniques in which patellar tendon flaps are created and shortened 8,9 . Rationale: The presently described technique is a semi-detaching technique, preserving a good part of the patellar tendon while avoiding complete dehiscence of the extensor mechanism. Moreover, the 2 patellar/tibial sutures would protect the patellar tendon repair and allow early rehabilitation and knee range-of-motion exercises. Expected Outcomes: Satisfactory correction of the patella alta was reported with PTS techniques with or without DFEO to correct concomitant fixed flexion deformity in patients with cerebral palsy. Furthermore, there was reported improvement of total knee range of motion with restoration of adequate knee extension during the stance phase 1,3,8 . Reported complications with this technique were mainly superficial infection. Important Tips: Any substantial fixed flexion deformity of the knee (>10°) should be corrected with hamstring lengthening or DFEO prior to PTS.A mid-patellar coronal split is made with use of a no.-15 blade and extended proximally and distally with use of 2 mosquito clips.To avoid difficulties with crossing of the patellar sutures, always keep the straight needle inside the 1st tunnel until the 2nd tunnel is created and its respective suture is passed.To distalize the patella, the patellar/tibial sutures are tied in a simple knot and held by a mosquito clip in order to allow retensioning until the desired patellar height is reached.The 2 patellar/tibial suture knots are slid to the proximal and distal ends of the surgical field. Acronyms and Abbreviations: 3DGA = 3-dimensional gait analysisADL = activities of daily livingCP = cerebral palsyCPM = continuous passive motionDFEO = distal femoral extension osteotomyFAQ = Functional Assessment QuestionnaireFMS = Functional Mobility ScaleGMFCS = Gross Motor Function Classification SystemGMFM = Gross Motor Function MeasureGPS = Gait Profile ScoreGVS = Gait Variable ScoreK-wires = Kirschner wiresPTA = patellar tendon advancementPTS = patellar tendon shorteningSEMLS = single event multi-level surgery

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

Cited by 7 publications

References 32 publications

Does patella lowering as part of multilevel surgery improve knee kinematics in children with cerebral palsy and crouch gait? A meta-analysis of comparative studies

Does patella lowering as part of multilevel surgery improve knee kinematics in children with cerebral palsy and crouch gait? A meta-analysis of comparative studies

Patellar Tendon Rupture During Postoperative Physiotherapy for Crouch Gait

“Coronal Split/Overlap Repair” Patellar Tendon Shortening in Skeletally Immature Patients

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