Serebral palsili hastalarda suprakondiler femur ekstansiyon osteotomisi ve patellar tendon ilerletme sonuçları

Abstract

GİRİŞ ve AMAÇ: Diz fleksiyon kontraktürü ve patella alta serebral palsi (SP) hastalarında yaygın görülen ve yürüme fonksiyonunu önemli ölçüde bozan patolojilerdir. Suprakondiler femur ekstansiyon osteotomisi (SFEO) ve patellar tendon ilerletme (PTİ) ameliyatları SP kaynaklı diz fleksiyon kontraktürünün ve patella altanın tedavisinde uygulanan yöntemler arasındadır. Bu çalışmanın amacı SP kaynaklı diz fleksiyon kontraktürünün ve patella altanın tedavisinde uygulanan SFEO ve PTİ ameliyatlarının etkinliğinin incelenmesidir.
YÖNTEM ve GEREÇLER: Bu retrospektif çalışmaya 2013 ve 2015 yılları arasında SP tanısı olan ve diz fleksiyon kontraktürü için SFEO ve patella alta için PTİ ameliyatı yapılan on bir hasta (22 diz) dâhil edildi. Ameliyat edildiklerinde hastaların ortalama yaşı 13; ortalama takip süresi 31 aydı. Hastalar klinik olarak kaba motor fonksiyon sınıflama sistemi (KMFSS) ve diz fleksiyon kontraktürünün nüksü ile radyografik olarak ameliyat öncesi, ameliyat sonrası, takip anterior-posterior ve lateral diz grafileri ile değerlendirildi. Koshino-Sugimoto indeksi (KS), komplikasyonlar kaydedildi.
BULGULAR: KMFSS değerleri yedi hastada yükselmiştir. Takipler sırasında bir olguda diz fleksiyon deformitesinin nüksü saptandı ve SFEO ile tedavi edildi. Ameliyat öncesi KS indeksi ortalaması 1,37 iken ameliyat sonrasında 1,07 ve son takipte 1,24 ölçüldü (p=0.004). İki olguda takiplerde serklaj teli iritasyonu saptandı ve ilave cerrahi ile teller çıkarıldı.
TARTIŞMA ve SONUÇ: SP’ye bağlı diz fleksiyon kontraktürünün ve patella altanın SFEO ve PTİ ile başarılı radyolojik ve klinik sonuçlara ulaşılarak tedavi edildiği görülmüştür.

Keywords

• serebral palsi
• diz fleksiyon kontraktürü
• patella alta
• suprakondiler femur ekstansiyon osteotomisi
• patellar ilerletme

Results of supracondylar femoral extension osteotomy and patellar tendon advancement in patients with cerebral palsy

Abstract

INTRODUCTION: Knee flexion contracture and patella alta patella alta are common problems in cerebral palsy (CP) patients and disrupts gait function significantly. Supracondylar femur extension osteotomy (SFEO) and patellar tendon advancement (PTA) are among the leading treatment methods. We reviewed the efficacy of SFEO and PTA in the treatment of knee flexion contracture and patella alta of CP patients.
METHODS: In this retrospective study 22 hips of 11 CP patients who were operated between 2013 and 2015 were reviewed. The mean age was 13 years when the patients were operated and the mean follow-up period was 31 months. SFEO and PTA were peroformed in all cases. Patients were evaluated clinically with gross motor function classification system (GMFCS) and recurrence of knee flexion contracture and radiologically with knee radiograph. The Koshino-Sugimoto index (KS) was recorded.
RESULTS: GMFCS scores were improved in seven patients. Recurrence of knee flexion contracture was detected in one case who was treated with revision SFEO. The mean preoperatively KS was 1,37; postoperatively KS was 1,07 and follow-up 1,24 (p=0.004). Cerclage wire irritation was detected in two cases and extracted with additionally surgical procedures.
DISCUSSION AND CONCLUSION: Reconstruction of knee flexion contracture and patella alta in CP patients with SFEO and PTA provides successful clinical and radiological results.

Keywords

• cerebral palsy
• knee flexion contracture
• patella alta
• supracondylar femoral extension osteotomy
• patellar advancement

References

1. Kaynaklar 1. Lotman DB. Knee flexion deformity and patella alta in spastic cerebral palsy. Dev Med Child Neurol 1976;18:315-319.
2. 2. Beals RK. Treatment of knee contracture in cerebral palsy by hamstring lengthening, posterior capsulotomy, and quadriceps mechanism shortening. Dev Med Child Neurol 2001;43:802-805.
3. 3. Healy MT, Schwartz MH, Stout JL, Gage JR, Novacheck TF. Is simultaneous hamstring lengthening necessary when performing distal femoral extension osteotomy and patellar tendon advancement? Gait Posture 2011;33:1-5.
4. 4. Stout JL, Gage JR, Schwartz MH, Novacheck TF. Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy. J Bone Joint Surg Am 2008;90:2470-2484.
5. 5. Inan M, Sarikaya IA, Yildirim E, Guven MF. Neurological complications after supracondylar femoral osteotomy in cerebral palsy. J Pediatr Orthop 2015;35:290-295. 6. Osgood RB. A method of osteotomy of the lower end of the femur in cases of permanent flexion of the knee joint. Am J Orthop Surg 1913;2-11:336-346.
6. 7. Chandler FA. Re-establishment of normal leverage of the patella in knee flexion deformity in spastic paralysis. Surg Gynecol Obstet 1933;57:523-527.
7. 8. Narkbunnam R, Chareancholvanich K. Effect of patient position on measurement of patellar height ratio. Arch Orthop Trauma Surg 2015;135:1151-1156.
8. 9. Drummond DS, Rogala E, Templeton J, Cruess R. Proximal hamstring release for knee flexion and crouched posture in cerebral palsy. J Bone Joint Surg Am 1974;56:1598-1602.

9. 10. Frost HM. Cerebral palsy. The spastic crouch. Clin Orthop Relat Res 1971;80:2-8.
10. 11. Gage JR. Surgical treatment of knee dysfunction in cerebral palsy. Clin Orthop Relat Res 1990;253:45-54.
11. 12. Hoffinger SA, Rab GT, Abou-Ghaida H. Hamstrings in cerebral palsy crouch gait. J Pediatr Orthop 1993;13:722-726.
12. 13. Lin CJ, Guo LY, Su FC, Chou YL, Cherng RJ. Common abnormal kinetic patterns of the knee in gait in spastic diplegia of cerebral palsy. Gait Posture 2000;11:224-232.
13. 14. Miller F, Dabney KW, Rang M. Complications in cerebral palsy treatment. In: Epps CH Jr, Bowen RJ, editors. Complications in pediatric orthopaedic surgery. Philadelphia: Lippincott; 1995;477-544.
14. 15. Rab GT. Consensus on crouched gait. The diplegic child: evaluation and management. In: Sussman MD, editor. Park Ridge, Illinois: 1992;337-339.
15. 16. Rang M, Silver R, de la Garza J. Cerebral palsy. In: Lovell WW, Winter RB, editors. Pediatric orthopaedics. 2nd ed. Philadelphia: Lippincott, 1986;345-396.
16. 17. Anagnostakos K, Lorbach O, Reiter S, Kohn D. Comparison of five patellar height measurement methods in 90° knee flexion. Int Orthop 2011;35:1791-1797.
17. 18. Rodda JM, Graham HK, Nattrass GR, Galea MP, Baker R, Wolfe R. Correction of severe crouch gait in patients with spastic diplegia with use of multilevel orthopaedic surgery. J Bone Joint Surg Am 2006;88:2653-2664.
18. 19. Rosenthal RK, Levine DB. Fragmentation of the distal pole of the patella in spastic cerebral palsy. J Bone Joint Surg Am 1977;59:934-939.
19. 20. Perry J, Antonelli D, Ford W. Analysis of knee joint forces during flexed knee stance. J Bone Joint Surg Am 1975;57:961-967.
20. 21. Topoleski TA, Kurtz CA, Grogan DP. Radiographic abnormalities and clinical symptoms associated with patella alta in ambulatory children with cerebral palsy. J Pediatr Orthop 2000;20:636-639.
21. 22. Silver RL, de la Garza J, Rang M. The myth of muscle balance. A study of relative strengths and excursions of normal muscles about the foot and ankle. J Bone Joint Surg Br 1985;67:432-437.
22. 23. Rutz E, Baker R, Tirosh O, Brunner R. Are results after single-event multilevel surgery in cerebral palsy durable? Clin Orthop Relat Res 2013;471:1028-1038.
23. 24. Rutz E, Tirosh O, Thomason P, Barg A, Graham HK. Stability of the gross motor function classification system after single-event multilevel surgery in children with cerebral palsy. Dev Med Child Neurol 2012;54:1109-1113.
24. 25. Young JL, Rodda J, Selber P, Rutz E, Graham HK. Management of the knee in spastic diplegia: what is the dose? Orthop Clin North Am 2010;41:561-577.
25. 26. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol 1997;39:214-223.
26. 27. Palisano RJ, Rosenbaum P, Bartlett D, Livingston MH. Content validity of the expanded and revised Gross Motor Function Classification System. Dev Med Child Neurol 2008;50:744-750.
27. 28. Graham HK. Classifying cerebral palsy. J Pediatr Orthop 2005;25:127-128.
28. 29. Chandler FA. Patellar advancement operation: a revised technique. J Int Coll Surg 1940;3:433-437.