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Knee Flexion Deformity in Cerebral Palsy

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Cerebral Palsy

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Abstract

In children with cerebral palsy (CP), the most common problem at the knee is a flexion deformity or an alternative definition is limited knee extension. By far the most common problem occurring in the knee is contracture of the hamstring muscles, which, if left untreated in some patients, leads to fixed knee flexion contracture. For individuals who are ambulatory, Gross Motor Function Classification System (GMFCS) I–III, limited ability for full knee extension can lead to significant disability with a flexed knee gait posture called crouch gait. The increased knee flexion may increase the energy cost of walking and lead to high stress in the extensor mechanism. The etiology of this increased knee flexion or crouch gait posture is multifactorial and not entirely due to problems at the knee. Children with more limited motor ability at the GMFCS level IV–V also developed increased knee flexion contractures because of being in a seated position for most of their day. Additionally, many of these children like to sleep with their hips and knees flexed, further aggravating the flexion deformity. As the contractures and knee flexion deformity become severe in children who are constantly sitting, they develop posterior pelvic tilt, loss of lumbar lordosis, and increased kyphotic sitting posture. Children at GMFCS level IV–V also should be spending time weight-bearing in standers with knees and hips extend it. Progressive flexion deformities at the knees preclude comfortable standing or functional weight-bearing. The goal of this chapter is to address the problems caused by lack of knee extension, present treatment options, and expected outcomes.

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References

  • Al-Aubaidi Z, Lundgaard B, Pedersen NW (2012) Anterior distal femoral hemiepiphysiodesis in the treatment of fixed knee flexion contracture in neuromuscular patients. J Child Orthop 6:313–318

    Google Scholar 

  • Anderson JP, Snow B, Dorey FJ, Kabo JM (1988) Efficacy of soft splints in reducing severe knee-flexion contractures. Dev Med Child Neurol 30:502–508

    CAS  Google Scholar 

  • Atar D, Grant AD, Lehman WB (1990) New approach to limb deformities in neuromuscular patients. Bull Hosp Jt Dis Orthop Inst 50:99–106

    CAS  Google Scholar 

  • Atar D, Zilberberg L, Votemberg M, Norsy M, Galil A (1993) Effect of distal hamstring release on cerebral palsy patients. Bull Hosp Jt Dis 53:34–36

    CAS  Google Scholar 

  • Beals RK (2001) Treatment of knee contracture in cerebral palsy by hamstring lengthening, posterior capsulotomy, and quadriceps mechanism shortening. Dev Med Child Neurol 43:802–805

    CAS  Google Scholar 

  • Bleck E (1987) Orthopedic management in cerebral palsy. Mac Keith Press, Oxford, p 497

    Google Scholar 

  • Carney BT, Oeffinger D, Meo AM (2006) Sagittal knee kinematics following hamstring lengthening. Iowa Orthop J 26:41–44

    Google Scholar 

  • Chang WN, Tsirikos AI, Miller F, Lennon N, Schuyler J, Kerstetter L, Glutting J (2004) Distal hamstring lengthening in ambulatory children with cerebral palsy: primary versus revision procedures. Gait Posture 19:298–304

    Google Scholar 

  • Chang CH, Chen YY, Wang CJ, Lee ZL, Kao HK, Kuo KN (2010) Dynamic displacement of the femoral head by hamstring stretching in children with cerebral palsy. J Pediatr Orthop 30:475–478

    Google Scholar 

  • Damiano DL, Abel MF, Pannunzio M, Romano JP (1999) Interrelationships of strength and gait before and after hamstrings lengthening. J Pediatr Orthop 19:352–358

    CAS  Google Scholar 

  • Damron T, Breed AL, Roecker E (1991) Hamstring tenotomies in cerebral palsy: longterm retrospective analysis. J Pediatr Orthop 11:514–519

    CAS  Google Scholar 

  • Das SP, Pradhan S, Ganesh S, Sahu PK, Mohanty RN, Das SK (2012) Supracondylar femoral extension osteotomy and patellar tendon advancement in the management of persistent crouch gait in cerebral palsy. Indian J Orthop 46:221–228

    Google Scholar 

  • De Mattos C, Patrick Do K, Pierce R, Feng J, Aiona M, Sussman M (2014) Comparison of hamstring transfer with hamstring lengthening in ambulatory children with cerebral palsy: further follow-up. J Child Orthop 8:513–520

    Google Scholar 

  • 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 2:37–43

    Google Scholar 

  • de Windt FH, Spoor CW, Huson A, Duijfjes F (1984) A model for the study of hip dysplasia in the spastic child. Acta Orthop Belg 50:143–147

    Google Scholar 

  • Delp SL, Arnold AS, Speers RA, Moore CA (1996) Hamstrings and psoas lengths during normal and crouch gait: implications for muscle-tendon surgery. J Orthop Res 14:144–151

    CAS  Google Scholar 

  • DeLuca PA, Ounpuu S, Davis RB, Walsh JH (1998) Effect of hamstring and psoas lengthening on pelvic tilt in patients with spastic diplegic cerebral palsy. J Pediatr Orthop 18:712–718

    CAS  Google Scholar 

  • DeVries WH, Kruse RW (1998) Is there a relationship between hypertension and lower-extremity contracture release in cerebral palsy? Am J Orthop 27:421–422

    CAS  Google Scholar 

  • Dreher T, Vegvari D, Wolf SL, Klotz M, Muller S, Metaxiotis D, Wenz W, Doderlein L, Braatz F (2013) Long-term effects after conversion of biarticular to monoarticular muscles compared with musculotendinous lengthening in children with spastic diplegia. Gait Posture 37:430–435

    Google Scholar 

  • Drummond DS, Rogala E, Templeton J, Cruess R (1974) Proximal hamstring release for knee flexion and crouched posture in cerebral palsy. J Bone Joint Surg Am 56:1598–1602

    CAS  Google Scholar 

  • Eggers G (1952) Transplantation of the hamstring tendons to femoral condyles in order to improve hip extension and to decrease knee flexion in cerebral spastic paralysis. J Bone Joint Surg Am 34A:827–830

    Google Scholar 

  • Elmer EB, Wenger DR, Mubarak SJ, Sutherland DH (1992) Proximal hamstring lengthening in the sitting cerebral palsy patient. J Pediatr Orthop 12:329–336

    CAS  Google Scholar 

  • Gage JR (1990) Surgical treatment of knee dysfunction in cerebral palsy. Clin Orthop Relat Res (253):45–54

    Google Scholar 

  • Gavriliu S, Georgescu I, Ulici A, Ghita R, Japie EM, Pandea N, Parvan A, Burnei C, Tiripa IL, Martiniuc A, Hamei S, Draghici I (2013) Herbert capsuloplasty and Burnei tenomyoplasty for the correction of genu flexum in cerebral palsy, arthrogryposis and posttraumatic. Chirurgia (Bucur) 108:866–873

    CAS  Google Scholar 

  • Gordon AB, Baird GO, McMulkin ML, Caskey PM, Ferguson RL (2008) Gait analysis outcomes of percutaneous medial hamstring tenotomies in children with cerebral palsy. J Pediatr Orthop 28:324–329

    Google Scholar 

  • Granata KP, Abel MF, Damiano DL (2000) Joint angular velocity in spastic gait and the influence of muscle-tendon lengthening. J Bone Joint Surg Am 82:174–186

    CAS  Google Scholar 

  • Hennrikus WL, Rosenthal RK, Kasser JR (1993) Incidence of spondylolisthesis in ambulatory cerebral palsy patients. J Pediatr Orthop 13:37–40

    CAS  Google Scholar 

  • Hoffinger SA, Rab GT, Abou-Ghaida H (1993) Hamstrings in cerebral palsy crouch gait. J Pediatr Orthop 13: 722–726

    CAS  Google Scholar 

  • Inan M, Sarikaya IA, Yildirim E, Guven MF (2015) Neurological complications after supracondylar femoral osteotomy in cerebral palsy. J Pediatr Orthop 35:290–295

    Google Scholar 

  • Karol LA, Chambers C, Popejoy D, Birch JG (2008) Nerve palsy after hamstring lengthening in patients with cerebral palsy. J Pediatr Orthop 28:773–776

    Google Scholar 

  • Katz K, Rosenthal A, Yosipovitch Z (1992) Normal ranges of popliteal angle in children. J Pediatr Orthop 12: 229–231

    CAS  Google Scholar 

  • Kedem P, Scher DM (2016) Evaluation and management of crouch gait. Curr Opin Pediatr 28:55–59

    Google Scholar 

  • Lenhart RL, Brandon SC, Smith CR, Novacheck TF, Schwartz MH, Thelen DG (2016) Influence of patellar position on the knee extensor mechanism in normal and crouched walking. J Biomech 51:1

    Google Scholar 

  • Ma FY, Selber P, Nattrass GR, Harvey AR, Wolfe R, Graham HK (2006) Lengthening and transfer of hamstrings for a flexion deformity of the knee in children with bilateral cerebral palsy: technique and preliminary results. J Bone Joint Surg Br 88:248–254

    CAS  Google Scholar 

  • Macwilliams BA, Harjinder B, Stevens PM (2011) Guided growth for correction of knee flexion deformity: a series of four cases. Strategies Trauma Limb Reconstr 6:83–90

    CAS  Google Scholar 

  • Nene AV, Evans GA, Patrick JH (1993) ‘Simultaneous multiple operations for spastic diplegia’, Outcome and functional assessment of walking in 18 patients. J Bone Joint Surg Br 75:488–494

    CAS  Google Scholar 

  • 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

    Google Scholar 

  • Park MS, Chung CY, Lee SH, Choi IH, Cho TJ, Yoo WJ, Park BS, Lee KM (2009) Effects of distal hamstring lengthening on sagittal motion in patients with diplegia: hamstring length and its clinical use. Gait Posture 30:487–491

    Google Scholar 

  • Pascual-Pascual SI, de Muniain P, Roche MC, Pascual-Castroviejo I (1997) Sanchez Botulinum toxin as a treatment for infantile cerebral palsy. Rev Neurol 25:1369–1375

    CAS  Google Scholar 

  • Perry J, Thorofare NJ (1992) Gait analysis: normal and pathologic function. Slack, Thorofare

    Google Scholar 

  • Rethlefsen S, Tolo VT, Reynolds RA, Kay R, Orthop B (1999) Outcome of hamstring lengthening and distal rectus femoris transfer surgery. J Pediatr Orthop B 8:75–79

    CAS  Google Scholar 

  • Rethlefsen SA, Yasmeh S, Wren TA, Kay RM (2013) Repeat hamstring lengthening for crouch gait in children with cerebral palsy. J Pediatr Orthop 33:501–504

    Google Scholar 

  • Rose GE, Lightbody KA, Ferguson RG, Walsh JC, Robb JE (2010) Natural history of flexed knee gait in diplegic cerebral palsy evaluated by gait analysis in children who have not had surgery. Gait Posture 31:351–354

    CAS  Google Scholar 

  • Rutz E, Gaston MS, Camathias C, Brunner R (2012) Distal femoral osteotomy using the LCP pediatric condylar 90° plate in patients with neuromuscular disorders. J Pediatr Orthop 32:295–300

    Google Scholar 

  • Shah A, Asirvatham R (1994) Hypertension after surgical release for flexion contractures of the knee. J Bone Joint Surg Br 76:274–277

    CAS  Google Scholar 

  • Sharps CH, Clancy M, Steel HH (1984) A long-term retrospective study of proximal hamstring release for hamstring contracture in cerebral palsy. J Pediatr Orthop 4:443–447

    CAS  Google Scholar 

  • 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 90:2470–2484

    Google Scholar 

  • Taylor D, Connor J, Church C, Lennon N, Henley J, Niiler T, Miller F (2016) The effectiveness of posterior knee capsulotomies and knee extension osteotomies in crouched gait in children with cerebral palsy. J Pediatr Orthop B 25:543–550

    Google Scholar 

  • Thometz J, Simon S, Rosenthal R (1989) The effect on gait of lengthening of the medial hamstrings in cerebral palsy. J Bone Joint Surg Am 71:345–353

    CAS  Google Scholar 

  • Thompson NS, Baker RJ, Cosgrove AP, Corry IS, Graham HK (1998) Musculoskeletal modeling in determining the effect of botulinum toxin on the hamstrings of patients with crouch gait. Dev Med Child Neurol 40:622–625

    CAS  Google Scholar 

  • van der Houwen LE, Scholtes VA, Becher JG, Harlaar J (2011) Botulinum toxin A injections do not improve surface EMG patterns during gait in children with cerebral palsy – a randomized controlled study. Gait Posture 33:147–151

    Google Scholar 

  • 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 26:109–114

    Google Scholar 

  • Woratanarat P, Dabney KW, Miller F (2009) Knee capsulotomy for fixed knee flexion contracture. Acta Orthop Traumatol Turc 43:121–127

    Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA

    Freeman Miller

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  1. Freeman Miller
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Correspondence to Freeman Miller .

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Editors and Affiliations

  1. Department of Orthopaedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA

    Freeman Miller

  2. Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, USA

    Steven Bachrach

  3. Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA

    Nancy Lennon

  4. Columbia University, Irving Medical Center, Programs in Physical Therapy, New York, NY, USA

    Margaret E. O'Neil

Section Editor information

  1. Nemours Alfred I. duPont Hospital for Children, Wilmington, DE, USA

    Freeman Miller

  2. Department of Pediatrics (Emeritus), Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA

    Steven J. Bachrach

  3. Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA

    Steven J. Bachrach

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Miller, F. (2020). Knee Flexion Deformity in Cerebral Palsy. In: Miller, F., Bachrach, S., Lennon, N., O'Neil, M.E. (eds) Cerebral Palsy. Springer, Cham. https://doi.org/10.1007/978-3-319-74558-9_136

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  • DOI: https://doi.org/10.1007/978-3-319-74558-9_136

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-74557-2

  • Online ISBN: 978-3-319-74558-9

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