Anterior distal femoral hemiepiphysiodesis with and without patellar tendon shortening for fixed knee flexion contractures in children with cerebral palsy

Purpose Surgery is often required for fixed knee flexion contractures in patients with neuromuscular conditions. Anterior distal femoral hemiepiphysiodesis (ADFH) is an alternative to distal femoral extension osteotomy (DFEO) in skeletally immature patients. ADFH is typically not accompanied by patellar tendon shortening surgery (PTS). Our purpose was to compare ADFH alone versus ADFH with PTS for treatment of fixed knee flexion contractures and crouched gait in children with cerebral palsy (CP). Methods Retrospective review of pre- and postoperative gait analysis data for children with CP who underwent ADFH alone, or ADFH with PTS. Data were analysed using linear mixed models to control for covariates. Results In total, 25 participants (42 limbs) were included, 17 male and eight female, mean age at surgery 12.9 (sd 1.9) years. Both groups experienced significant improvement in popliteal angle, knee extension range of motion (ROM) and knee extension in stance phase. Greater improvement was seen for all variables in the ADFH/PTS group, mainly due to greater popliteal angle and knee flexion during gait preoperatively in that group (p ≤ 0.02) rather than the procedure performed (p ≥ 0.19). There was no difference between groups postoperatively. Rate of contracture resolution was 0.5° to 1.0° per month, faster in larger contractures (p = 0.02). Conclusions ADFH with and without PTS is effective in improving knee extension in skeletally immature patients with CP, correcting contractures at a rate of 0.5° to 1.0° per month. Combined ADFH and PTS surgery may be preferable in patients with larger contractures of up to 30° to 35°. Level of evidence III

Influence of prosthetic joint line position on outcome after total knee replacement

<p class="abstract"><strong>Background:</strong> The current study had been designed so as to assess whether joint line elevation and change in patellar tendon length influences knee flexion after primary cruciate retaining TKR.</p><p class="abstract"><strong>Methods:</strong> This prospective study involved patients with advanced degenerative joint disease involving one or both knees who presented to the outpatient department of a tertiary care hospital. Exclusion criteria were any prior knee surgery. Surgery was performed under tourniquet with standard medial para-patellar arthrotomy to expose all our knees. In the study radiological assessment was done by true lateral X-ray view of knee in 30 degree of flexion. We choose Caton-Deschamps indices (CI) for diagnosis of post TKR patella infera and joint line elevation. CI&lt;0.6 was defined as patella infera (normal range of CI 0.60-1.45). After all data collection comparison was done between joint line elevation versus without joint line elevation patients (with/without patellar tendon shortening) range of movement.<strong></strong></p><p class="abstract"><strong>Results:</strong> Total of 100 patients (72 females and 28 males) with 176 knees (bilateral=76, unilateral=24) who fulfilled the above said criteria involved in study. The mean age of the patients at the time of surgery was 64.4 years with range of 54 years to 80 years. The average follow up of 24 months, with minimum follow up of 18 months. Average range of motion (ROM) in NO Joint line elevation/patella tendon shortening patient measured 107.2^°, and joint line elevation with patellar tendon shortening (prior patella infera) and joint line elevation without patella tendon shortening(prior patella infera) patient average ROM was measured 86.7 and 87.8 degree respectively.</p><strong>Conclusions:</strong> In our study patellar tendon shortening and joint line elevation reduces ROM knee. Mechanical factors also explain the association between joint line elevation and patellar tendon length with range of motion. Reduction in length of extensor apparatus reduces the range of flexion.