The Journal of Bone and Joint Surgery (American). 2008;90:2470-2484.
doi:10.2106/JBJS.G.00327
© 2008 The Journal of Bone and Joint Surgery, Inc.
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Distal Femoral Extension Osteotomy and Patellar Tendon Advancement to Treat Persistent Crouch Gait in Cerebral Palsy

Jean L. Stout, PT, MS1, James R. Gage, MD1, Michael H. Schwartz, PhD1 and Tom F. Novacheck, MD1

1 Center for Gait and Motion Analysis, Gillette Children's Specialty Healthcare, 200 East University Avenue, St. Paul, MN 55101. E-mail address for J.L. Stout: jstout{at}gillettechildrens.com. E-mail address for T.F. Novacheck: novac001{at}umn.edu
Investigation performed at the Center for Gait and Motion Analysis, Gillette Children's Specialty Healthcare, St. Paul, Minnesota

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Background: Hallmarks of a persistent crouched walking pattern exhibited by individuals with cerebral palsy usually include loss of an adequate plantar flexion/knee extension couple, hamstring and/or psoas tightness, or contracture in conjunction with quadriceps insufficiency. Traditional treatment addresses the muscle-tightness component, but not the contracture or the muscle insufficiency. This study was performed to evaluate the effectiveness of distal femoral extension osteotomy and/or patellar tendon advancement in the treatment of crouch gait in patients with cerebral palsy.

Methods: A retrospective, nonrandomized, repeated-measures design was used. Individuals with a diagnosis of cerebral palsy were included if they had had (1) a distal femoral extension osteotomy in combination with a distal patellar tendon advancement (thirty-three patients), (2) a distal femoral extension osteotomy without patellar tendon advancement (sixteen), or (3) a distal patellar tendon advancement only (twenty-four). All subjects were evaluated with preoperative and postoperative gait analysis. Gait, radiographic, strength, and functional measures were included in the analysis to assess changes in knee function.

Results: Seventy-three individuals met the criteria for inclusion. A single side was chosen for the analysis of each subject. Ninety percent of the subjects had additional, concurrent surgery. Improvements were noted in the index assessing the level of gait pathology and in functional variables across all groups, and pain was consistently decreased. All preoperative stress fractures healed. Strength levels were maintained across all groups. The Koshino index of patellar height improved from 1.4 to –2.3 in the group treated with patellar tendon advancement only and from 1.5 to –2.9 in the group treated with both osteotomy and tendon advancement. The range of knee flexion improved an average of 15° to 20°, and stance-phase knee flexion was restored to the typical range (9° to 10°) in the groups that had advancement of the patellar tendon as part of the procedure. Individuals who underwent a distal femoral osteotomy only were still in a crouch (a mean of 31° of knee flexion in midstance) at the final assessment.

Conclusions: Inclusion of patellar tendon advancement is necessary to achieve optimal results in the surgical management of a persistent crouch gait exhibited by adolescents and young adults with cerebral palsy. When this procedure is done alone or in combination with a distal femoral extension osteotomy (for the treatment of a knee flexion contracture), knee function in gait can be restored to values within typical limits, with gains in community function.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.


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Letters to the Editor:

Read all Letters to the Editor

The use of distal femur extension osteotomy in cerebral palsy
Mauro C Morais Filho
JBJS Online, 12 Nov 2008 [Full text]
Dr. Novacheck and colleagues respond to Dr. Morais Filho
Tom F. Novacheck, MD, et al.
JBJS Online, 1 Dec 2008 [Full text]