Long-Term Outcomes of Distal Femoral Extension Osteotomy and Patellar Tendon Advancement in Individuals with Cerebral Palsy.

BACKGROUND: We examined long-term outcomes across the domains of the International Classification of Functioning, Disability and Health for 2 groups of participants with cerebral palsy who demonstrated crouch gait at clinical gait analysis. One group underwent a distal femoral extension osteotomy with patellar tendon advancement (DFEO + PTA). The other group received other treatments (non-DFEO + PTA). METHODS: Fifty-one participants returned for a long-term gait analysis, physical examination, energy consumption test, knee radiographs, and questionnaires (median, 13 years post-DFEO + PTA or post-baseline [range, 8 to 21 years]). A subset of participants in the DFEO + PTA group also had a short-term analysis (9 to 24 months postoperatively). RESULTS: Participants were reasonably well-matched at baseline, although the DFEO + PTA group demonstrated greater crouch: minimum knee flexion, a median of 37° (width of the interquartile range, 12°) compared with 27° (9°); and knee flexion contracture, a median of 15° (10°) compared with 10° (5°). The gait deviation index (GDI) and sagittal plane knee kinematics were most improved at short term for the DFEO + PTA participants, with a subsequent slight decline at long-term analysis. Fewer DFEO + PTA participants were in crouch at long term (37% compared with 65%). At the long-term assessment, group scores for function, mobility, participation, quality of life, and most pain questionnaires were similar. Knee pain and osteoarthritis ratings did not differ between the groups. CONCLUSIONS: At long-term analysis, DFEO + PTA improves stance phase knee extension and knee flexion contracture compared with conventional treatment, but these benefits do not translate to improved activity, participation, or knee pain in early adulthood. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evidence of knee extensor dysfunction during sit-to-stand following distal femoral extension osteotomy and patellar tendon advancement in young adults with cerebral palsy: A pilot study.

A distal femoral extension osteotomy with patellar tendon advancement (DFEO+PTA) is a common treatment for individuals with cerebral palsy (CP) who walk in crouch. Musculoskeletal modeling suggests that the typical patella baja position post-DFEO+PTA may limit one's abilities to perform sit-to-stand (STS) tasks; however, STS function has not been assessed. Our purpose was to compare how well individuals who received a DFEO+PTA can perform a 5-times STS test (FTSST) eight or more years after surgery compared to their peers who did not receive a DFEO+PTA (non-DFEO+PTA group). Twenty-one participants completed the task (12 DFEO+PTA, 9 non-DFEO+PTA). Three-dimensional kinematics and kinetics were captured. Kinetics were non-dimensionalized to facilitate group comparisons. Non-DFEO+PTA participants performed the FTSST moderately faster than the DFEO+PTA group (median(IQR), 14.6(9.3) seconds vs. 20.3(10.1) seconds, non-parametric effect size É£=0.97, p=0.241). Peak negative knee power was larger for the non-DFEO+PTA group (Mean±SD, -0.063±0.025 vs. -0.048± 0.020, Cohen's d=0.66, p=0.165). A similar but weaker trend was observed for negative hip power (median(IQR) -0.120(0.066) vs. -0.105(0.044), É£=0.43, p=0.671). Both groups used their hips approximately twice as much as their knees to perform the task. The functional deficit among DFEO+PTA participants may be due to patella baja decreasing the knee extensor moment arm, which concurs with the modeling prediction. The group differences may also be due to the non-DFEO+PTA group being slightly higher functioning. Future research is warranted to determine if optimizing patella position during a DFEO+PTA may improve unaided STS function without compromising gait improvements.

Ambulatory children with cerebral palsy do not exhibit unhealthy weight gain following selective dorsal rhizotomy.

AIM: The aim of this study was to retrospectively analyze changes in age- and sex-adjusted body mass index (BMI) in ambulatory children with cerebral palsy (CP) who underwent selective dorsal rhizotomy (SDR). METHOD: Raw BMI, age- and sex-adjusted BMI z-scores, weight classification status, energy expenditure, and ambulation function were calculated before and after SDR at multiple post-SDR time points: 6 to <24 months, 24 to <48 months, 48 to <72, and 72 to <96 months. Linear mixed models were used to analyze changes in raw BMI, BMI z-scores, energy expenditure, and ambulation function. RESULTS: Pre- and post-surgical data were available for 363 children diagnosed with CP who underwent SDR (219 males, 144 females; mean age 6y [SD 2y 1mo]; mean BMI z-score 0.09 [SD 1.21]). Data from additional post-surgical time points were collected on subsamples. Although raw BMI significantly increased (p<0.01), these increases were consistent with anticipated growth. BMI z-scores did not significantly change over the 10-year study period. INTERPRETATION: Concerns of unhealthy weight gain following SDR are not supported by this study. Further work examining possible risk factors for BMI increase following SDR, as well as examining disparities in existing criteria for patient selection, is merited.