How Quickly Should There Be A Change In Rom Of Rectus Femoris?

• Periodical Listing
• Clin Orthop Relat Res
• v.470(5); 2012 May
• PMC3314766

Clin Orthop Relat Res. 2012 May; 470(five): 1303–1311.

Rectus Femoris Transfer Improves Stiff Knee Gait in Children With Spastic Cerebral Palsy

Dinesh Thawrani, Md, Thierry Haumont, Medico, Chris Church, MS, PT, Larry Holmes, Jr, PhD, DrPH, Kirk West. Dabney, MD, and Freeman Miller, MD

Dinesh Thawrani

Department of Orthopaedics, Alfred I. duPont Hospital for Children, 1600 Rockland Route, Wilmington, DE 19803 USA

Thierry Haumont

Department of Orthopaedics, Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803 The states

Chris Church building

Section of Orthopaedics, Alfred I. duPont Hospital for Children, 1600 Rockland Route, Wilmington, DE 19803 USA

Larry Holmes, Jr

Section of Orthopaedics, Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803 The states

Kirk W. Dabney

Department of Orthopaedics, Alfred I. duPont Infirmary for Children, 1600 Rockland Road, Wilmington, DE 19803 The states

Freeman Miller

Section of Orthopaedics, Alfred I. duPont Hospital for Children, 1600 Rockland Route, Wilmington, DE 19803 U.s.

Abstract

Groundwork

Stiff genu gait is common among children with ambulatory cerebral palsy (CP). When surgery is indicated, rectus femoris transfer as a primary treatment enhances knee range of move, reduces time to elevation articulatio genus flexion, increases superlative knee flexion, and reduces toe drag.

Questions/purposes

Nosotros determined whether (1) distal rectus femoris transfer improved knee range of motion, time to peak genu flexion, peak human knee flexion, and toe elevate in children with CP diagnosed with stiff knee gait; and (ii) patients in some subgroups (eg, those with relatively loftier genu range of motility compared with those with low genu range of motion before rectus femoris transfer) had greater comeback in these parameters.

Methods

We retrospectively reviewed gait data from 56 patients (99 limbs) preoperatively, short-term, and long-term. Subgroup analyses were performed to determine whether patients with high knee range of motion relative to those with low or moderate knee range of motility improved differentially later rectus femoris transfer. The minimum followup was 7 years (mean ± SD, 10 ± 2 years; range, 7–13 years).

Results

The hateful height articulatio genus flexion increased from baseline to short-term and to long-term followup. Patients with low peak knee flexion had the greatest improvement of peak human knee flexion afterward rectus femoris transfer relative to the moderate and high peak articulatio genus flexion subgroups. Similarly, the greatest improvement after rectus femoris transfer for knee range of motion occurred in the depression genu range of motility subgroup relative to moderate and high subgroups. Rectus femoris transfer improved mean fourth dimension to summit knee flexion at brusk-term and long-term followup compared with baseline. Likewise, there was a decrease in toe drag at brusk- and long-term after rectus femoris transfer.

Conclusion

Distal rectus femoris transfer selectively improved peak knee flexion, toe drag, and reduced time to peak human knee flexion in convalescent children with CP with stiff human knee gait.

Level of Bear witness

Level 4, therapeutic written report. See guidelines for authors for a complete description of levels of evidence.

Keywords: Medicine & Public Health, Conservative Orthopedics, Orthopedics, Sports Medicine, Surgery, Surgical Orthopedics, Medicine/Public Health, full general

Introduction

Stiff knee gait (stiff knee gait) is relatively mutual in convalescent children with cerebral palsy (CP) [sixteen]. This most frequently results from increased activity of the rectus femoris muscle in the swing phase and is associated with reduced peak knee flexion (PKF) and full genu ROM as well equally delayed fourth dimension to the PKF [6]. Stiff knee joint gait also occurs every bit a result of poor ankle power in belatedly stance. Indeed, timing and magnitude of swing phase knee joint flexion are dependent on walking velocity, which accounts for the implication of poor ankle power in stiff genu gait [12]. Surgery remains an effective arroyo to improving motion and kinematics in spastic stiff human knee gait [4, vi].

Rectus femoris transfer in children with CP with potent genu gait is intended to increase human knee flexion during the swing phase and improve human foot clearance thereby reducing toe drag. Increased knee flexion at the swing phase is achieved past increasing human knee ROM, decreasing time to PKF, and increasing PKF in the swing phase, whereas foot clearance is enhanced past decreased toe drag. Rectus femoris transfer removes the action of this biarticular muscle from knee extension [i] and preserves its function every bit a hip flexor [6]. Usually the contraction pattern is appropriate for hip flexion, and for information technology to have an effect on the knee, it should piece of work as a genu flexor. This procedure provides a sure caste of knee flexion improvement in the early on swing phase that is adequate for basis clearance [half dozen, 14]. Neither proximal [6, 15] nor distal rectus release [3, 10] has demonstrated like improvements in PKF, time to PKF, knee ROM, and toe drag seen with distal rectus femoris transfer. The rectus femoris is removed from its insertion on the patella and transferred to some other muscle with sartorius and gracilis being the virtually common sites [half-dozen]. The specific site of transfer does not appear to bear on outcome [9].

Rectus femoris transfer is performed more frequently in children [16] in whom, with ensuing growth and maturation, the progressive impairment in stiff articulatio genus gait may influence the long-term improvement in PKF, fourth dimension to PKF, articulatio genus ROM, and toe drag [4, 13]. Furthermore, functional improvement after surgery may take more than ane year to develop [eight] and Saraph et al. [xiii] advocate 3 years of postoperative followup to determine its reward in enhancing kinematics. In two previously published series [7, 14], the maximum time to endpoint was four.5 years; the end points were not predictable.

Given the kinematic and clinical benefits of rectus femoris transfer may exist brusk-term and vary by preoperative kinematics, patients with high knee ROM for instance who had rectus femoris transfer might not have needed one in the first place. In this circumstance, the rectus femoris transfer may not bear witness prolonged increase in knee ROM, indicative of very little or relatively no long-term comeback in articulatio genus ROM in patients who might have had a relatively high preoperative knee joint ROM.

We therefore asked whether (1) rectus femoris transfer improves PKF, time to PKF, knee ROM, and toe elevate; (2) a subgroup of patients with low PKF (< 50°) and those with low articulatio genus ROM (< 36°) do good most from rectus femoris transfer; and (3) a combination of preoperative indicators of stiff knee gait improvement (knee ROM, fourth dimension to PKF, PKF, and toe drag) defines the subgroup of patients to whom rectus femoris transfer may meliorate potent knee gait the about.

Patients and Methods

From 1992 to 1999, 175 convalescent children with spastic CP underwent distal rectus femoris transfer for potent articulatio genus gait in our establishment. Stiff knee gait was divers past delayed and/or decreased PKF in the swing phase and reduced dynamic knee ROM during the gait bike. The inclusion criteria for rectus femoris transfer were (one) a history or ascertainment of toe drag; (ii) PKF < threescore°; (3) low total knee ROM < 50°; and (4) late PKF in swing. Although exclusion criteria were difficult to define, if the purpose of rectus femoris transfer was primarily to improve toe drag, so absenteeism of toe drag served every bit an exclusion. Similarly, if the primary purpose of surgery was to improve PKF or increment the genu ROM, then PKF > 60° and knee joint ROM > fifty° were considered exclusions. However, because patients who presented with either of these inclusion criteria were eligible for this study, inclusion criteria were relaxed to utilize to any of four inclusion criteria. In addition, we excluded (1) patients with previous surgery to the rectus femoris muscle and those who underwent surgery in other institutions; (2) patients who underwent gait assay in other gait laboratories; and (three) patients with missing information points. With these exclusions we were left with 56 patients (32%) with 99 operated limbs. There were 33 males and 23 females. All patients were functional ambulators and amid them, 50 had diplegia, five hemiplegia, and one quadriplegia. The mean age of participants at baseline was 8 ± 2 years (range, vii–xiii years). Patients who met the criteria for preoperative and short-term postoperative followup were called to return for the long-term minimum of 8 years after surgery. Nosotros cannot make whatsoever comment nigh the patients who did not return for long-term followup because only those who returned had data. This retrospective cohort study (case-only) received Institutional Review Board approval.

Nosotros performed post hoc power analysis to determine whether we had enough power to assess the differences between the preoperative and the followup PKF. In determining this, we used α = 0.05, an effect size of 9°, which is the difference between the mean preoperative and followup PKF (SD = 14.03, sample size north = 99), and repeated-measures analysis of variance (ANOVA). With these parameters, nosotros estimated the power to be 95.eight%, which is sufficient power. We applied the aforementioned procedure to knee ROM and used α = 0.05 (mean departure, 9°; SD, 16.15; n = 99) and computed a ability of 89.3%. For time to PKF, using similar parameters with a mean divergence of 5% change in time to PKF and SD = 7, nosotros estimated the ability to be 98%. Nosotros also estimated the post hoc statistical power for the subgroup (depression, moderate, and high human knee ROM, PKF, fourth dimension to PKF) assay using repeated-measure ANOVA and obtained sufficient power for PKF, knee ROM, and time to PKF (> 80%). The parameters used for these estimations were α = 0.05, upshot size, and sample size as demonstrated in the preoperative or baseline measures.

Miller et al. [6] described the mean age at surgery for the performance of rectus femoris transfer. The distal part of the rectus femoris was transferred to either sartorius or gracilis muscle at a mean age of seven.five years (± two.3). Other procedures were often performed meantime and are described elsewhere [5, 6].

Patients had three full gait analyses: preoperatively at an average of 6 months before surgery (mean, vi ± 5 months), postoperatively less than iii years later on surgery (hateful, two ± one years) (short-term), and at final followup 10 years subsequently surgery (mean, 10 ± 2 years) (long-term). A move assay system (Motion Assay Corp, Santa Rosa, CA, United states of america) with Orthotrac software was used to measure out and summate the kinematics of gait. The Cleveland Clinic mark set was used to measure upper extremity, torso, and lower extremity move. 10 to 20 gait cycles were recorded for each patient at a cocky-selected footstep. The post-obit kinematic outcome variables were selected: PKF in the swing stage, knee ROM measured between the maximum knee extension in the stance phase and PKF, and time to PKF in regard to the gait wheel (%) (Fig.1). We also measured the presence or absence of toe elevate from videotapes of the subject's gait. Toe drag was measured on a binary scale as either a "yes" or "no" and was scored as 0 (absent) or i (present). After initial analysis, three other possible predictors were discarded as a result of their skewed distribution (Ely test, electromyography, and rectus tone).

The 4 kinematic parameters selected to measure the upshot of stiff knee gait during a gait cycle: (1) peak genu flexion (PKF) in the swing phase; (2) knee ROM betwixt maximum extension at opinion and PKF at swing (knee ROM); (3) timing of PKF (TiPKF); and (iv) velocity of knee flexion (VKF).

To examine which patients benefited nearly from surgery, we created three subgroups (low, moderate, and high baseline or preoperative kinematics) to examine the consequence of rectus femoris transfer on these subgroups. In issue, to achieve these subgroups, nosotros used the mean baseline values of these parameters too as their 95% CI, minimum, and maximum values. Specifically, to obtain the low, moderate, and high knee ROM, time to PKF, PKF, and toe elevate, we obtained the summary statistic for the total sample. For human knee ROM, time to PKF, and PKF, we examined these data for normality and used the hateful, SD, and 95% CI to decide depression, moderate, and high knee ROM, fourth dimension to PKF, and PKF subgroups. The depression articulatio genus ROM for case represented the values below the lower 95% CI limit of mean, the moderate > 95% lower CI boundary to the mean, and high > mean to the upper 95% CI boundary. With these subgroups generated, we obtained the summary statistics (hateful, SD) and tested these subgroups for normality assumption earlier the hypothesis-driven analysis. A similar approach was applied to toe drag using median ranking and interquartile range to categorize the sample into depression, moderate, and loftier subgroups (Fig.2).

(A) Changes in PKF afterward surgery in the overall study population of children with CP with SKG. (B) Changes in PKF after surgery in the low PKF subgroup of children with CP with SKG. (C) Changes in PKF afterward surgery in the moderate PKF subgroup of children with CP children with SKG. (D) Changes in PKF subsequently surgery in the high PKF subgroup of children with CP with SKG. SKG = stiff knee gait.

We first examined the shape and distribution of the data using normality test for skewness likewise as for outliers. To appraise the relationship between rectus femoris transfer terminate point variables (PKF, knee ROM, fourth dimension to PKF, velocity of human knee flexion, toe drag) and the independent or predictor variables (age, gross motor function mensurate, gait velocity, popliteal angle), we used robust simple linear regression, which is not sensitive to normality supposition violation of this model. To exam for the chief composite hypothesis of the written report, rectus femoris transfer increases (1) PKF; (2) knee ROM; and (3) rectus femoris transfer decreases time to PKF; we used a repeated-measure out ANOVA. The subgroup hypothesis complex that (1) rectus femoris transfer increases PKF more in the subgroup with PKF < fifty° relative to those with PKF > 50° over time; (ii) rectus femoris transfer increases articulatio genus ROM in the subgroup with knee ROM < 36° compared with those with knee ROM > 36°; and (3) rectus femoris transfer decreases time to PKF in those with high fourth dimension to PKF relative to those with depression time to PKF was tested using repeated-measure ANOVA. This test statistic is adequate given a single sample (children with CP with stiff knee gait who underwent rectus femoris transfer) with more than than ane repeated measure of the response variable. In this analysis, a subject becomes its own command, which eliminates the between-subject variability, making this a very effective blueprint in measuring long-term impact of surgery or treatment. Because repeated-measure ANOVA generates an overall model F statistic and p value, which is pregnant whenever there is a significant mean difference betwixt any of the measures with the preoperative or baseline mensurate, a pairwise comparison using the Bonferroni method was performed. This method allows one to examine the significant difference for example in knee ROM, comparing preoperative articulatio genus ROM with curt-term knee ROM and preoperative knee ROM with long-term knee joint ROM. The Friedman test, which is a nonparametric culling to repeated-measure out ANOVA, was also used when data did not follow normal distribution. For example, to exam the hypothesis of a decrease in the proportion of toe drag over time comparison preoperative and postoperative toe drag (short-term and long-term), the Friedman exam and chi square with Fisher's exact were used. Furthermore, to determine the combination of preoperative result factors, mainly knee ROM, time to PKF, PKF, and toe drag, that may improve stiff knee gait in patients to whom rectus femoris transfer is indicated, we used the multiple linear regression model. Finally, to make up one's mind which combinations of kinematics will be almost adequate in assessing the rectus femoris transfer issue in improving stiff knee gait, nosotros performed a correlation coefficient analysis amid the PKF, knee ROM, and fourth dimension to PKF adjusting for multiple comparisons with the Bonferroni method with p < 0.01 resulting from the inclusion of three variables in the correlation matrix. The repeated-measure ANOVA was performed using SPSS software (Version 17.0; SPSS Inc, Chicago, IL, USA), whereas the summary statistic and linear regression model were done using STATA, Version 10.0 (Statacorp, College Station, TX, U.s.) (Fig.3).

(A) Changes in knee ROM subsequently surgery in overall sample of children with CP with SKG. (B) Changes in knee ROM afterward surgery in the low knee ROM subgroup of children with CP with SKG. (C) Changes in knee ROM later surgery in the moderate articulatio genus ROM subgroup of children with CP with SKG. (D) Changes in knee ROM afterward surgery in the loftier knee joint ROM subgroup of children with CP with SKG. SKG = stiff human knee gait.

Results

This report was conducted to assess whether or not (1) rectus femoris transfer improves PKF, time to PKF, knee joint ROM, and toe drag; (2) a subgroup of patients with low PKF (< 50°) and those with depression knee ROM (< 36°) benefit most from rectus femoris transfer; and (3) a combination of preoperative indicators of stiff knee gait comeback (human knee ROM, time to PKF, PKF, and toe drag) defines the subgroup of patients to whom rectus femoris transfer may meliorate stiff knee gait the most (Table ​ 1).

Table one

The relationship betwixt the outcome/dependent variables and potential predictors (simple linear regression assay model) at baseline (preoperative period)

Variable	β	t-value	95% CI	p value
Peak articulatio genus flexion
Historic period	−0.28	−0.45	−i.53–0.96	0.65
GMFM	0.03	0.56	−0.09–0.15	0.58
GV	0.04	0.99	−0.04–0.13	0.32
PA	−0.01	−0.09	−0.18–0.sixteen	0.93
Genu ROM
Age	−0.26	−0.37	−1.seventy–1.17	0.71
GMFM	−0.03	−0.41	−0.17–0.11	0.68
GV	0.01	0.28	−0.08–0.11	0.78
PA	0.02	0.17	−0.18–0.21	0.86
Timing of peak knee joint flexion
Age	−0.003	−1.01	−0.009–0.003	0.31
GMFM	< 0.0001	0	−0.0006–0.0006	0.99
GV	0.0001	0.49	−0.0003–0.0005	0.63
PA	0.0002	0.55	−0.0006–0.001	0.58
Velocity of genu flexion
Age	−0.15	−0.03	−9.91–9.62	0.98
GMFM	0.81	0.79	−one.24–2.88	0.43
GV	0.59	i.68	−0.xi–1.30	0.09
PA	0.44	0.65	−0.90–one.77	0.52
Toe drag
Age	−one.8	−2.21	−3.42 to −0.18	0.03
GMFM	6.21	0.72	−10.81–23.23	0.47
GV	0.001	ane.27	−0.0006–0.003	0.21
PA	0.004	8.7	0.57–0.91	0.007

GMFM = gross motor function measure; GV = gait velocity; PA = popliteal angle.

Compared with the baseline mean PKF (61 ± 14), in that location was an increase (p < 0.001) at short-term (68 ± 10) besides every bit long-term followup PKF (63 ± 11; F = 17; Table2). We observed an increase in knee ROM, comparing the baseline knee ROM (49° ± sixteen°) with genu ROM afterwards the brusque-term postoperative menses (52° ± 15°) but a subtract at the last followup (47° ± 14°; F = four, p = 0.02) (Table2). Also, compared with the baseline fourth dimension to PKF, in that location was a decrease at the short-term equally well equally long-term postoperative catamenia (F = four, p= 0.01). The baseline velocity of knee flexion (210 ± 108) increased (p < 0.001) at the curt-term (287 ± 136) likewise as long-term followup (239 ± 115; F = 20). Nosotros also assessed whether toe drag decreased afterward rectus femoris transfer in children with stiff human knee gait and found a decrease (p < 0.001) in toe drag. The preoperative toe elevate was 92% versus 8% (nontoe drag), whereas the proportion of toe drag during the followup menses < 3 years was 29% versus 71% (nontoe drag), indicative of postoperative decrease in toe drag, and this deviation was significant (chi square [df, 1] = 83, p < 0.001). Similarly, compared with the x-twelvemonth followup menses, the toe drag significantly decreased to 33% from 92% preoperative toe drag, and this departure was significant too (chi foursquare [df, 1] = 74.2, p < 0.001). Overall, nosotros observed a mean increase in articulatio genus ROM, PKF, and time to PKF over time as well as a decrease in the proportion of toe drag over time (Table3).

Table ii

Outcomes after rectus femoris transfer in children with stiff knee joint gait

	Preoperative baseline		Postoperative short-term		Postoperative long-term		F	df	p value
Kinematics	Mean	SD	Mean	SD	Hateful	SD
PKF	60.89	fourteen.03	68.23	x.08	62.6	10.78	xvi.78	i	< 0.001
KROM	49.26	sixteen.15	51.62	xiv.95	47.19	xiv.01	three.95	i	0.02
TiPKF	81	seven	lxxx	5	79	6	4.43	ane	0.01
VKF	210.19	108.16	286.74	135.54	238.74	115.34	20.45	ane	< 0.001

PKF = height genu flexion in degrees; KROM = knee ROM in degrees; TiPKF = time to tiptop articulatio genus flexion in percent of the gait cycle; VKF = knee flexion velocity in degrees/second; F is the ratio of the variances for the analysis of variance model, whereas df is the caste of freedom.

Table 3

Multiple comparisons between the intervention cycles with relation to the outcomes after rectus femoris transfer surgery in children with stiff knee gait

Variables	Intervention cycle: pre- and postoperative measures
	Preoperative versus short-term			Preoperative versus long-term			Short-term versus long-term
	Mean	SE	p value	Mean	SE	p value	Mean	SE	p value
PKF	7.33	ane.37	< 0.001	one.71	1.43	0.7	−5.62	1.16	< 0.001
KROM	2.36	1.67	0.483	−ii.08	one.58	0.57	−iv.43	ane.48	0.01
TiPKF	−one	0.006	0.19	−two	0.007	0.04	−1	0.005	0.53
VKF	76.55	xiii.6	< 0.001	28.55	11.78	0.05	−48	10.73	< 0.001

PKF = peak knee flexion in degrees; KROM = knee ROM in degrees; TiPKF = time to elevation human knee flexion in percent of the gait cycle; VKF = knee flexion velocity in degrees/2nd; the significance level is 0.01.

The low PKF grouping had the nearly increment (p < 0.001) in PKF after rectus femoris transfer at both brusk-term and long-term followup (Tabular arrayiv). The depression knee ROM grouping had a greater increase (p < 0.001) in PKF compared with the knee ROM between the baseline and short-term postoperative followup with no decrease in knee ROM at long-term followup. In the depression time to PKF group, defined by the least percentage of time to PKF (northward = 38, mean = 74 ± 5), there was an increase (p = 0.003) in the time to PKF at curt-term and long-term followup (Fig.four).

Table iv

Outcomes of rectus femoris transfer in patients with cerebral palsy with strong human knee gait comparing low, moderate, and high height genu flexion (PKF), knee ROM (KROM), and time to peak knee flexion (TiPKF)

Evaluation cycle	PKF (mean, SD)			KROM (mean, SD)			Ti PKF (mean, SD)
	Low	Moderate	High	Depression	Moderate	High	Low	Moderate	High
Baseline	49.69 ± 7.36	60.62 ± 1.46	73.54 ± vi.12	36.19 ± six.95	49.fourteen ± i.99	65.92 ± ix.35	74.19 ± 5.27	81.56 ± 0.xc	86.87 ± 3.42
< 3 years	63.43 ± 10.01	71.55 ± 10.98	72.04 ± 7.74	45.18 ± fifteen.50	54.97 ± 10.26	58.63 ± xi.ninety	77.22 ± iv.65	80.sixty ± 4.58	82.59 ± four.45
> vii years	threescore.77 ± 7.53	65.29 ± 7.32	64.37 ± 12.75	41.09 ± 12.04	46.41 ± 7.38	54.93 ± fourteen.ten	77.27 ± five.64	77.64 ± 4.79	81.98 ± iv.88

Low PKF grouping: F₍₂₎ = 44.49, p < 0.001, moderate PKF grouping: F₍₂₎ = seven.69, p = 0.002, loftier PKF grouping: F_(1.71) = xv.21, p < 0.001; low KROM group: F₍₂₎ = 7.five, p < 0.001, moderate KROM grouping: F₍₂₎ = 3.64, p = 0.05, high KROM group: F_(1.87) = fourteen.81, p < 0.001; low TiPKF grouping: F₍₂₎ = six.xv, p = 0.003, moderate Ti PKF grouping: F₍₂₎ = 3.43, p = 0.05, high Ti PKF group: F₍₂₎ = 36.06, p < 0.001; the F is the test statistic for the repeated measure analysis of variance model, whereas the value inside the parenthesis is the degree of liberty.

(A) Changes in fourth dimension to PKF after surgery in the overall sample of children with CP with SKG. (B) Changes in fourth dimension to PKF subsequently surgery in the low time to PKF of children with CP with SKG. (C) Changes in time to PKF afterwards surgery in the moderate fourth dimension to PKF subgroup of children with CP with SKG. (D) Changes in time to PKF after surgery in the high time to PKF subgroup of children with CP with SKG. SKG = strong knee gait.

We likewise attempted to accost the question as to whether or non a single or combined measure of rectus femoris transfer effectiveness was most appropriate or adequate to determine the indication for surgery. To answer this question, we performed a correlation coefficient analysis among the PKF, human knee ROM, and fourth dimension to PKF adjusting for multiple comparison with the Bonferroni method but institute no correlation (p > 0.05). Considering the fourth dimension to PKF correlated with toe drag in our model (Tabular array1), we performed a multivariable linear regression assay on the groups in which rectus femoris transfer showed the most improvement in increasing knee ROM and PKF and decreasing time to PKF likewise as reducing the proportion of toe elevate, which were the subgroups with low PKF, depression genu ROM, high time to PKF and a higher proportion of toe drag. We institute a negative linear human relationship between fourth dimension to PKF and articulatio genus ROM (p = 0.001) but not with PKF (p = 0.98).

Discussion

Children with CP often present with stiff knee gait; all the same, it is non fully understood if rectus femoris transfer improves kinematics and toe elevate equally amongst these patients. This study was therefore designed to reply the following questions: (1) Does rectus femoris transfer increase PKF and knee ROM and does information technology decrease time to PKF likewise equally toe elevate among children with CP diagnosed with stiff human knee gait? (2) Does a subgroup of patients with low PKF (< fifty°) and those with low knee ROM (< 36°) benefit near from rectus femoris transfer? (three) Does a combination of preoperative indicators of potent knee gait improvement (knee ROM, time to PKF, PKF, and toe drag) define the subgroup of patients to whom rectus femoris transfer may meliorate stiff knee gait the most?

First, the rectus femoris transfer data obtained in this report indicate that rectus femoris transfer increases mean knee ROM and PKF while decreasing mean fourth dimension to PKF and toe drag proportion. In fact, although the long-term mean PKF and knee ROM were slightly lower than the short-term means, both short-term and long-term means were college than the preoperative means. The previous reports have found improvements in PKF 1 to three years afterward the procedure varying from iii° to 17° [3, 7, 9, 14, fifteen]. This improvement with a range of variations was very similar to our current written report with the short-term followup improvement of 7° in PKF. Also, there are two longer-term studies, i reporting no change at four.6 years [14] and the other reporting 5° of loss of PKF [13], which is comparable to our 10-year followup that institute a mean vi° loss of PKF from the brusque followup time. The kinematic variables articulatio genus ROM and the time to PKF showed similar changes. There have been no previous attempts to correlate toe drag with kinematic improvements. Our findings propose that time to PKF is well-nigh sensitive to improvement in toe drag as assessed past videotape analysis.

Second, practice children with relatively high articulatio genus ROM, loftier PKF, low time to PKF, and less astringent toe drag experience the to the lowest degree improvement for stiff knee gait subsequently rectus femoris transfer? We demonstrated that children with CP with stiff knee gait who had loftier PKF, or high knee ROM, and or depression time to PKF were less likely to better in strong knee gait after rectus femoris transfer. Most of these were children with severe hunker whose surgical indication was related primarily to improving knee extension merely the goal of the rectus transfer was to preserve human knee flexion in swing, not to meliorate human knee flexion in swing. In fact, the high PKF group had a decrease of PKF subsequently the short-term followup and a further subtract 10 years thereafter. This is probable the result of the fact that high PKF was already in the normal or fifty-fifty in a higher place normal range. Whereas high knee ROM and depression fourth dimension to PKF groups showed no benefit of surgery, they also did not prove deterioration betwixt short-term and long-term followup. We also observed that patients with the least fourth dimension to PKF values may not benefit from rectus femoris transfer in improving toe elevate, which directly correlates with time to PKF. In our sample, rectus femoris transfer contrary to our expectations and the natural history [2, 11, 14] resulted in a decreased time to PKF at less than three years followup with like decrease at 10 years followup compared with baseline. Therefore, the indication for rectus femoris transfer should consider fourth dimension to PKF because it is the kinematic variable that all-time correlates with toe drag.

Tertiary, which combination of preoperative indicators of stiff knee joint gait defines the subgroup of patients to whom rectus femoris transfer may ameliorate stiff knee gait the virtually? Our data suggest that the patient who will do good most from both short- and longer-term improvement in toe drag, knee joint ROM, and PKF will be the child with tardily fourth dimension to PKF, a depression magnitude of PKF, and depression total articulatio genus ROM. Therefore, the patients who volition benefit the about from surgery are those with moderate to highest time to PKF (> or equal to 80%), and those with low PKF (30° to less than 59) or with moderate PKF (60° to less than 64°) equally characterized by our study. Consequently, patients with the highest PKF (64° to less than 86°) are less likely to benefit from rectus femoris transfer and therefore crave assessment of other factors such as time to PKF and knee ROM earlier surgical decision-making. Using our grouping, among those with whom surgery is indicated, low PKF, depression knee ROM, and high time to PKF, the about reliable kinematics for the indication of rectus femoris transfer remain knee joint ROM and time to PKF where there are inconsistent data on PKF.

In summary, despite the limitations of this study mainly a retrospective blueprint, distal rectus femoris transfer provides long-term improvement in strong knee gait with amend improvement observed if time to PKF is late and preoperative PKF and knee ROM are low.

Acknowledgments

We give thanks Dr Kenneth Rogers and Mr Dustin Sample for the coordination of the materials used in this enquiry and for editorial assistance, respectively. We also thank Ms Joyce Bright for her assistance in gathering the literature used in the preparation of this article.

Footnotes

Each author certifies that he or she, or a fellow member of their immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted commodity.

All ICMJE Conflict of Involvement Forms for authors and Clinical Orthopaedics and Related Research editors and lath members are on file with the publication and can exist viewed on asking.

Each author certifies that his or her establishment approved the human being protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3314766/

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