Treatment of knee contracture in cerebral palsy by hamstring lengthening, posterior capsulotomy, and quadriceps mechanism shortening

Beals, Rodney K.

doi:10.1017/s0012162201001451

Cited by 79 publications

(31 citation statements)

References 7 publications

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“…Similarly, there are studies documenting complications following hamstring lengthening such as recurrence of deformity,23 development of recurvatum of knee due to spastic rectus femoris, and increased forward tilt of pelvis in ambulatory patients 24. As most of the patients in our study had hamstring surgery at the same time along with Achilles tendon lengthening and as these patients also received knee gaitors or KAFOs after surgery, such complications were not observed till the time of follow-up.…”

Section: Methodssupporting

confidence: 54%

Single-stage multilevel soft-tissue surgery in the lower limbs with spastic cerebral palsy: Experience from a rehabilitation unit

Gupta¹,

Srivastava²,

Taly³

et al. 2008

Indian J Orthop

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Background:To assess the effect of single-stage multilevel soft-tissue surgery (Single Event Multiple Level Resections, SEMLR) on deformities and locomotion in patients with cerebral palsy (CP) with static contracture(s) in lower limbs.Patients and Methods:Study included 34 patients (M:F, 23:11) with mean age of 9.53 ± 3.92 years (4–16 years). Among them 22 had diplegia and four each had quadriplegia and right and left hemiplegia. Fourteen patients (41.2%) had their intelligence quotient (IQ) in the normal range (IQ ≥ 80), while others had mental retardation (MR) of varying severity: borderline MR (IQ = 70–79) in 12, mild MR (IQ = 50–69) in 5, and moderate MR (IQ = 35–49) in patients 3. All patients underwent surgery (total number of procedures 153, average 4.5 procedures/patient) over a period of 30 months (April 2005 to September 2007). Improvement in functional abilities and locomotion was assessed using Gross Motor Functional Classification Scale (GMFCS) scores and by physical examination.Results:Significant improvement in function was observed (P = 0.000) after surgery when comparing the preoperative and postoperative GMFCS scores. All patients were maintaining ambulation at a mean follow-up duration of 13.12 ± 6.07 months (3–24 months), with five patients using knee-ankle-foot orthoses (KAFO), 22 using ankle-foot orthoses (AFO), and six patients using knee gaiters. Sixteen patients were using walker, and two were using crutches as assistive devices.Conclusion:This study suggests that CP patients with good trunk control and static contractures at multiple joints in the lower limbs can be made ambulant with single-stage multilevel soft-tissue surgery. It has to be a team effort of the surgeon and the rehabilitation team in the postoperative period for the attainment of satisfactory goal.

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Section: Methodssupporting

confidence: 54%

Single-stage multilevel soft-tissue surgery in the lower limbs with spastic cerebral palsy: Experience from a rehabilitation unit

Gupta¹,

Srivastava²,

Taly³

et al. 2008

Indian J Orthop

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“…Finally, we simulated patella alta and baja by changing the length of the patellar tendon. This approach likely represents differences between normal controls and CP patients with alta (Lotman, 1976), and simulates patellar tendon shortening procedures that shift the patella into baja (Beals, 2001). However, our model does not directly emulate the PTA procedure in which patella position is modulated by distally moving the tendon insertion down the tibia (Novacheck et al, 2009).…”

Section: Discussionmentioning

confidence: 99%

Influence of patellar position on the knee extensor mechanism in normal and crouched walking

Lenhart

Brandon

et al. 2017

Journal of Biomechanics

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Patella alta is common in cerebral palsy, especially those with crouch gait. Correction of patella alta has been advocated in the treatment of crouch, however the appropriate degree of correction and the implications for knee extensor function remain unclear. Therefore, the goal of this study was to assess the impact of patellar position on quadriceps and patellar tendon forces during normal and crouch gait. To this end, a lower extremity musculoskeletal model with a novel 12 degree of freedom knee joint was used to simulate normal gait in a healthy child, as well as mild (23 deg min knee flexion in stance), moderate (41 deg), and severe (67 deg) crouch gait in three children with cerebral palsy. The simulations reveal that quadriceps and patellar tendon forces increase dramatically with crouch, but are modulated by patellar position. For example with a normal patellar tendon position, peak patellar tendon forces were 0.7 times body weight in normal walking, but reached 2.2, 3.2 and 5.4 times body weight in mild, moderate and severe crouch. Moderate patella alta acted to reduce quadriceps and patellar tendon loads in crouch gait, due to an enhancement of the patellar tendon moment arms with alta in a flexed knee. In contrast, patella baja reduced the patellar tendon moment arm in a flexed knee and thus induced an increase in the patellar tendon loads needed to walk in crouch. Functionally, these results suggest that patella baja could also compromise knee extensor function for other flexed knee activities such as chair rise and stair climbing. The findings are important to consider when using surgical approaches for correcting patella alta in children who exhibit crouch gait patterns.

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“…In such a surgery, several bony and soft-tissue procedures are combined in a single session. One commonly used surgical soft-tissue procedure is medial hamstring lengthening [3–10]. In a high number of children with SP, SEMLS including medial hamstring lengthening, seems successful in correcting the flexed knee gait pattern [8, 11–13].…”

Section: Introductionmentioning

confidence: 99%

Knee Moment-Angle Characteristics and Semitendinosus Muscle Morphology in Children with Spastic Paresis Selected for Medial Hamstring Lengthening

et al. 2016

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To increase knee range of motion and improve gait in children with spastic paresis (SP), the semitendinosus muscle (ST) amongst other hamstring muscles is frequently lengthened by surgery, but with variable success. Little is known about how the pre-surgical mechanical and morphological characteristics of ST muscle differ between children with SP and typically developing children (TD). The aims of this study were to assess (1) how knee moment-angle characteristics and ST morphology in children with SP selected for medial hamstring lengthening differ from TD children, as well as (2) how knee moment-angle characteristics and ST morphology are related. In nine SP and nine TD children, passive knee moment-angle characteristics and morphology of ST (i.e. fascicle length, muscle belly length, tendon length, physiological cross-sectional area, and volume) were assessed by hand-held dynamometry and freehand 3D ultrasound, respectively. At net knee flexion moments above 0.5 Nm, more flexed knee angles were found for SP compared to TD children. The measured knee angle range between 0 and 4 Nm was 30% smaller in children with SP. Muscle volume, physiological cross-sectional area, and fascicle length normalized to femur length were smaller in SP compared to TD children (62%, 48%, and 18%, respectively). Sixty percent of the variation in knee angles at 4 Nm net knee moment was explained by ST fascicle length. Altered knee moment-angle characteristics indicate an increased ST stiffness in SP children. Morphological observations indicate that in SP children planned for medial hamstring lengthening, the longitudinal and cross-sectional growth of ST muscle fibers is reduced. The reduced fascicle length can partly explain the increased ST stiffness and, hence, a more flexed knee joint in these SP children.

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Treatment of knee contracture in cerebral palsy by hamstring lengthening, posterior capsulotomy, and quadriceps mechanism shortening

Cited by 79 publications

References 7 publications

Single-stage multilevel soft-tissue surgery in the lower limbs with spastic cerebral palsy: Experience from a rehabilitation unit

Single-stage multilevel soft-tissue surgery in the lower limbs with spastic cerebral palsy: Experience from a rehabilitation unit

Influence of patellar position on the knee extensor mechanism in normal and crouched walking

Knee Moment-Angle Characteristics and Semitendinosus Muscle Morphology in Children with Spastic Paresis Selected for Medial Hamstring Lengthening

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