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Distal rectus femoris intramuscular lengthening for the correction of stiff knee gait in children with cerebral palsy


1. Center for Motion Analysis, Connecitcut Children’s Medical Center, Famington, CT;
2. School of Medicine, Yale University, New Haven, CT;
3. School of Medicine, University of Connecticut, Famington, USA

Background/Objectives: The rectus femoris transfer has been the traditional treatment for stiff knee gait patterns 1, 2. However, the distal rectus femoris intramuscular lengthening (DRFIL) is less invasive and may result in similar gait outcomes for patients with cerebral palsy (CP). Therefore, the purpose of this study was to assess the effect of the DRFIL, procedure on knee flexion during swing in children with CP.

Design: Nonrandomized retrospective study.

Participants and Setting: A total of 43 patients (72 sides) treated between 1991 and 2008 with pre-operative and post-operative gait analyses following DRFIL were analyzed. The DRFIL were performed at the junction between the proximal 2/3’s and distal 1/3 of the rectus femoris muscle. A 1.5-2cm section of the rectus femoris was removed at this site. The mean age at surgery was 9.0 ±4.3 years and the mean time of the post-operative gait analysis was 18.7 months (range 7-54 months) after surgery. GMFCS levels ranged from I through IV. The indications for DRFIL were identical to those for rectus femoris transfer. Simultaneous hamstring lengthenings were peformed in 55 of the 72 sides. This study took place in a tertiary referral center that specializes in the treatment of children with CP.

Materials/Methods: Each individual underwent a pre- and post-operative gait analysis including three-dimensional motion analysis, electromyography, and clinical exam. Pre- to post-operative differences for selected kinematic gait parameters were evaluated using a paired t-test (P<0.05).

Results: There was no change in the amplitude of peak knee flexion in swing post-operatively (P=0.50, pre=53 ± 11 deg, post=52 ± 9 deg). Peak knee flexion occurred 2% earlier in swing phase post-operatively (P=0.001), 82 ± 6% gait cycle (GC), post 80 ±5% GC). Overall sagittal plane knee excursion (P=0.042, pre=37 ± 12 deg, post=39 ± 14 deg) and mean knee flexion in stance (P=0.002, pre=26 ± 11 deg, post=21 ± 11 deg) improved post-operatively due to hamstring lengthenings.

Conclusions/Significance: When comparing preoperative and postoperative gait analysis data, our cohort showed maintenance of peak knee flexion in swing, improved timing of peak knee flexion in swing and increased knee sagittal plane range of motion. This is comparable to previously published results evaluating rectus femoris transfer for the treatment of stiff knee gait1. The DRFIL involves less surgical dissection and less operative time than the rectus femoris transfer and therefore is a less morbid surgical option in the treatment of stiff knee gait.

1. Adolfsen, SE et al. F Pediatr Orthbop 2007; 27 (6):658-67.
2. Gage, JR et al. Dev Med Child Neurol 1987; 29(2): 159-66.

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