Atlas of Knee Operative Procedures in Cerebral Palsy

  • Freeman MillerEmail author
Living reference work entry


Knee problems are very common in children with cerebral palsy (CP). This includes increased knee flexion during stance phase, lack of knee flexion during swing phase, and torsional malalignment of the tibia. A very common problem is increasing muscle contracture as the child grows. The growth leads to hamstring contractures which are primarily treated with stretching exercises. However, for most children, it is not possible to maintain adequate length in hamstring muscles through the whole growth period, although it should be possible in most children to prevent the development of fixed knee flexion contractures. Many children will need to have a surgical procedure to address the problem of hamstring shortness usually by lengthening the tendons. Another common problem is spasticity and poor motor control of the rectus femoris muscle leading to poor knee flexion in swing phase. The treatment for this may involve rectus femoris transfer or distal resection. As the lack of knee extension becomes more severe and a fixed knee flexion contracture develops, the options for correction include posterior knee capsulotomy or distal femoral extension osteotomy. If an extension osteotomy is required, usually the patella needs to be brought more distal with either a plication or transfer of the origin of the patellar tendon. Another common problem which indirectly affects the knee is tibial torsion; both internal and external tibial torsion may occur in a child with CP. Correction of this usually requires an osteotomy of the tibia. The goal of this chapter is to provide a detailed surgical description of the indications, surgical technique, and postoperative management of these procedures around the knee joint in the child with CP.


Cerebral Palsy Hamstring lengthening Knee extension osteotomy Tibial osteotomy Knee capsulotomy Patellar tendon plication 


  1. Aiona M, Do KP, Feng J, Jabur M. (2017) Comparison of rectus femoris transfer surgery done concomitant with hamstring lengthening or delayed in patients with cerebral palsy. J Pediatr Orthop 37(2):107–110Google Scholar
  2. Bozinovski Z, Popovski N (2014) Operative treatment of the knee contractures in cerebral palsy patients. Med Arh 68:182–183CrossRefGoogle Scholar
  3. Dreher T, Vegvari D, Wolf SI, Geisbusch A, Gantz S, Wenz W, Braatz F (2012) Development of knee function after hamstring lengthening as a part of multilevel surgery in children with spastic diplegia: a long-term outcome study. J Bone Joint Surg Am 94:121–130CrossRefGoogle Scholar
  4. Ferri-de-Barros F, Inan M, Miller F (2006) Intramedullary nail fixation of femoral and tibial percutaneous rotational osteotomy in skeletally mature adolescents with cerebral palsy. J Pediatr Orthop 26:115–118CrossRefGoogle Scholar
  5. Galli M, Cimolin V, Vimercati S, Albertini G, Brunner R (2014) Quantification of patellar tendon shortening in a patient with cerebral palsy. J Appl Biomater Funct Mater 12:57–63PubMedGoogle Scholar
  6. Inan M, Ferri-de Baros F, Chan G, Dabney K, Miller F (2005) Correction of rotational deformity of the tibia in cerebral palsy by percutaneous supramalleolar osteotomy. J Bone Joint Surg (Br) 87:1411–1415CrossRefGoogle Scholar
  7. 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):271–286CrossRefGoogle Scholar
  8. Presedo A, Megrot F, Ilharreborde B, Mazda K, Pennecot GF (2012) Rectus femoris distal tendon resection improves knee motion in patients with spastic diplegia. Clin Orthop Relat Res 470:1312–1319CrossRefGoogle Scholar
  9. Woratanarat P, Dabney KW, Miller F (2009) Knee capsulotomy for fixed knee flexion contracture. Acta Orthop Traumatol Turc 43:121–127CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.AI DuPont Hospital for ChildrenWilmingtonUSA

Section editors and affiliations

  • Freeman Miller
    • 1
  • Steven J. Bachrach
    • 2
    • 3
  1. 1.Nemours Alfred I. duPont Hospital for ChildrenWilmingtonUSA
  2. 2.Department of Pediatrics (Emeritus)Nemours/Alfred I. duPont Hospital for ChildrenWilmingtonUSA
  3. 3.Sidney Kimmel Medical College of Thomas Jefferson UniversityPhiladelphiaUSA

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