Citation Information :
Carbonell PG, Valero JV, Fernández PD, Vicente-Franqueira JR. Monolateral external fixation for the progressive correction of neurological spastic knee flexion contracture in children. 2007; 2 (2-3):91-97.
The purpose of this study was to report the results of the surgical treatment of spastic knee flexion contracture using tenotomy and progressive correction by external fixator–distractor devices. The study design involved a prospective observational study of 16 knees in nine patients with spastic flexion contracture greater than 30°. Treatment was indicated for both ambulatory and nonambulatory patients; and, in the latter group when sitting or personal hygiene was compromised. The average age was 11.6 years (range 10–17). Five of the patients were male and four female. There was one case of hemiplegia (11.1%), two cases of paraplegia (22.2%), and six cases of quadriplegia (66.7%). Six patients retained some walking capacity, while three had none. In all cases, distal lengthening of the hamstrings was carried out. A monolateral fixator with a gradual correction device was applied for a period of 4.8 weeks. The average follow-up was 26.6 months. The preoperative straight-leg raise was 55°. The popliteal angle was 58° preoperatively (range 30–80°), 8.5° on removal of the fixator, and 20° at the end of the follow-up. Complications: There were no superficial or deep infections, and no fractures or distal sensory–motor alterations. There was one case of arthrodiatasis of the knee (6.3%) which was resolved when the fixator was removed, and 11 cases of pin-track infection (68.7%) which were resolved with local care and oral antibiotics. To conclude, spastic knee flexion contracture can be treated gradually with monolateral external fixator with distraction devices, and with distraction modules which prevent acute stretching of the posterior neurovascular structures of the knee.
Grant A, Joy M-T, Ó Brien N, Hennessy E, MacDonald D (1989) Cerebral palsy among children born during the Dublin randomised trial of intrapartum monitoring. Lancet 25:1233-1235
Herring JA (2002) Disorders of the brain. In: Herring JA (eds) Tachdjian's pediatric orthopaedics from the Texas Scottish Rite Hospital for children. WB Saunders, Philadelphia, pp 1121-1242
Stanley FJ, Watson L (1992) Trends in perinatal mortality and cerebral palsy in Western Australia, 1967 to 1985. BMJ 304:1658-1663
Abel MF, Damiano DL, Pannunzio M, Bush J (1999) Muscletendon surgery in diplegic cerebral palsy: functional and mechanical changes. J Pediatr Orthop 19:366-375
Alberman E, Benson J, McDonald A (1982) Cerebral palsy and severe educational subnormality in low-birthweight children: a comparison of births in 1951-53 and 1970-73. Lancet 1(8272):606-608
Murphy DJ, Sellers S, MacKenzie IZ, Yudkin PL, Johnson AM (1995) Case-control study of antenatal and intrapartum risk factors for cerebral palsy in very preterm singleton babies. Lancet 346:1449-1454
Damron TA, Breed AL, Cook T (1993) Diminished knee flexion after hamstring surgery in cerebral palsy patients: prevalence and severity. J Pediatr Orthop 13:188-191
Brouwer B, Davidson LK, Olney SJ (2000) Serial casting in idiophatic toewalkers and children with spastic cerebral palsy. J Pediatr Orthop 20:221-225
Dhawlikar SH, Root L, Mann RL (1992) Distal lengthening of the hamstrings in patients who have cerebral palsy. J Bone Joint Surg Am 74:1385-1391
Hoffinger SA, Rab GT, Abou-Ghaida H (1993) Hamstrings in cerebral palsy crouch gait. J Pediatr Orthop 13:722-726
Damron T, Breed AL, Roecker E (1991) Hamstring tenotomies in cerebral palsy: long-term retrospective analysis. J Pediatr Orthop 11:514-519
Gage JR (1990) Surgical treatment of knee dysfunction in cerebral palsy. Clin Orthop 253:45-54
Hadley N, Chambers C, Scarborough N, Cain T, Rossi D (1992) Knee motion following multiple soft-tissue releases in ambulatory patients with cerebral palsy. J Pediatr Orthop 13:324-328
Marshall PD, Broughton NS, Menelaus MB, Graham HK (1996) Surgical release of knee flexion contractures in myelomeningocele. J Bone Joint Surg Br 78:912-916
Perry J, Antonelli D, Ford W (1975) Analysis of knee-joint forces during flexed-knee stance. J Bone Joint Surg Am 57:961-967
Grujic H, Aparisi T (1982) Distal hamstring tendon release in knee flexion deformity. Int Orthop 6:103-106
Okawa A, Kajiura I, Hiroshima K (1990) Physical therapeutic and surgical management in spastic diplegia. A Japanese experience. Clin Orthop 253:38-44
Reimers J (1974) Contracture of the hamstrings in spastic cerebral palsy. A study of three methods of operative correction. J Bone Joint Surg Br 56:102-109
Sutherland DH, Santi M, Abel MF (1990) Treatment of stiff-knee gait in cerebral palsy: a comparison by gait analysis of distal rectus femoris transfer versus proximal rectus release. J Pediatr Orthop 10:433-441
Rodríguez-Merchán EC, Magallón M, Galindo E, López-Cabarcos C (1997) Hamstring release for fixed knee flexion contracture in hemophilia. Clin Orthop 343:63-67
Hoffer MM, Feiwell E, Perry R, Perry J, Bonnett C (1973) Functional ambulation in patients with myelomeningocele. J Bone Joint Surg Am 55A:137-148
Lieber RL (1994) Experimental design and statistical analysis. In: Simon SR (eds) Orthopaedic basic science. American Academy of Orthopaedic Surgeons, Columbus, pp 623-665
Reimers J (1990) Functional changes in the antagonists after lengthening the agonist in cerebral palsy. II. Quadriceps strength before and after distal hamstring lengthening. Clin Orthop 253:35-37
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
Herzenberg JE, Davis JR, Paley D, Bhave A (1994) Mechanical distraction for treatment of severe knee flexion contractures. Clin Orthop 301:80-88
Hollister AM, Jatana S, Singh AK, Sullivan WW, Lupichuk AG (1993) The axes of rotation of the knee. Clin Orthop 290:259-268
Huang SC (1996) Soft tissue contractures of the knee or ankle treated by the Ilizarov technique. Hugh recurrence rate in 26 patients followed for 3-6 years. Acta Orthop Scand 67:443- 449
Mooney JF 3rd, Koman LA (2001) Knee flexion contractures: soft tissue correction with monolateral external fixation. J South Orthop Assoc 10:32-36
Volkov MV, Oganesian OV (1975) Restoration of function of the knee and elbow with a hinge-distractor apparatus. J Bone Joint Surg Am 57:591-599
Gillen JA 2nd, Walker JL, Burgess RC, Stevens DB (1996) Use of Ilizarov external fixator to treat joint pterygia. J Pediatr Orthop 16:430-437
Herzenberg JE, Waanders NA (1991) Calculating rate and duration of distraction for deformity correction with the Ilizarov technique. Orthop Clin North Am 22:601-611
Damsin JP, Ghanem I (1996) Treatment of severe flexion deformity of the knee in children and adolescents using the Ilizarov technique. J Bone Joint Surg Br 78:140-144