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Rectus Femoris Transfer Surgery Worsens Crouch Gait in Children With Cerebral Palsy at GMFCS Levels III and IV

Sousa, Ted C. MD*; Nazareth, Alexander MS; Rethlefsen, Susan A. PT, DPT*; Mueske, Nicole M. MS*; Wren, Tishya A.L. PhD*,†,‡; Kay, Robert M. MD*,†

Journal of Pediatric Orthopaedics: October 2019 - Volume 39 - Issue 9 - p 466–471
doi: 10.1097/BPO.0000000000000988
Cerebral Palsy

Background: Previous study has shown that children with cerebral palsy (CP) functioning at Gross Motor Function Classification System (GMFCS) levels III and IV do not benefit from distal rectus femoris transfer (DRFT) due to lack of improvement in stance knee extension. The fate of knees in such subjects who do not undergo DRFT is unknown. The purpose of this study was to compare knee kinematic outcomes in patients with CP and stiff knee gait who underwent single-event multilevel surgery with and without DRFT.

Methods: Preoperative and postoperative gait analysis data were retrospectively reviewed for ambulatory (GMFCS levels I to IV) patients with CP with crouch and stiff knee gait whom underwent single-event multilevel surgery, including hamstring lengthening either with DRFT (N=34) or without DRFT (N=40). Statistical analyses included t tests and χ2 tests, and multiple regression analysis was performed to adjust for covariates. Data were stratified by GMFCS level groups I/II and III/IV.

Results: Improved maximum knee extension in stance was seen for both the DRFT (P=0.0002) and no DRFT groups (P≤0.0006) at GMFCS levels I/II, and the no DRFT group at GMFCS levels III/IV (P=0.02). Excessive stance knee flexion persisted for those at GMFCS level III/IV after DRFT. Maximum knee flexion in swing was maintained after DRFT, but significantly decreased in the no DRFT group (P<0.002) for both GMFCS groups. Change in total knee range of motion improved after DRFT only in the GMFCS I/II group subjects with unilateral involvement (P=0.01). Timing of maximum knee flexion in swing improved for all patients regardless of DRFT or GMFCS level group (P<0.0001).

Conclusions: In patients with CP functioning at GMFCS levels III and IV, DRFT results in persistent crouch postoperatively. Given the importance of maintaining upright posture in these patients, we do not recommend DRFT in patients functioning at GMFCS levels III and IV.

Level of Evidence: Level III—retrospective comparative study.

Keck School of Medicine, University of Southern California

*Children’s Orthopaedic Center, Children’s Hospital Los Angeles

Department of Biomedical Engineering, Viterbi School of Engineering, University of Southern California, Los Angeles, CA

No funding was received for any part of this study.

The authors declare no conflicts of interest.

Reprints: Susan A. Rethlefsen, PT, DPT, Children’s Orthopaedic Center, Children’s Hospital Los Angeles, 4650 Sunset Boulevard, M/S 69, Los Angeles, CA 90027. E-mail:

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