Stout Jean L, Gage James R, Schwartz Michael H, Novacheck Tom F
Center for Gait and Motion Analysis, Gillette Children's Specialty Healthcare, 200 East University Avenue, St. Paul, MN 55101, USA.
J Bone Joint Surg Am. 2008 Nov;90(11):2470-84. doi: 10.2106/JBJS.G.00327.
Hallmarks of a persistent crouched walking pattern exhibited by individuals with cerebral palsy usually include loss of an adequate plantar flexion/knee extension couple, hamstring and/or psoas tightness, or contracture in conjunction with quadriceps insufficiency. Traditional treatment addresses the muscle-tightness component, but not the contracture or the muscle insufficiency. This study was performed to evaluate the effectiveness of distal femoral extension osteotomy and/or patellar tendon advancement in the treatment of crouch gait in patients with cerebral palsy.
A retrospective, nonrandomized, repeated-measures design was used. Individuals with a diagnosis of cerebral palsy were included if they had had (1) a distal femoral extension osteotomy in combination with a distal patellar tendon advancement (thirty-three patients), (2) a distal femoral extension osteotomy without patellar tendon advancement (sixteen), or (3) a distal patellar tendon advancement only (twenty-four). All subjects were evaluated with preoperative and postoperative gait analysis. Gait, radiographic, strength, and functional measures were included in the analysis to assess changes in knee function.
Seventy-three individuals met the criteria for inclusion. A single side was chosen for the analysis of each subject. Ninety percent of the subjects had additional, concurrent surgery. Improvements were noted in the index assessing the level of gait pathology and in functional variables across all groups, and pain was consistently decreased. All preoperative stress fractures healed. Strength levels were maintained across all groups. The Koshino index of patellar height improved from 1.4 to -2.3 in the group treated with patellar tendon advancement only and from 1.5 to -2.9 in the group treated with both osteotomy and tendon advancement. The range of knee flexion improved an average of 15 degrees to 20 degrees, and stance-phase knee flexion was restored to the typical range (9 degrees to 10 degrees) in the groups that had advancement of the patellar tendon as part of the procedure. Individuals who underwent a distal femoral osteotomy only were still in a crouch (a mean of 31 degrees of knee flexion in midstance) at the final assessment.
Inclusion of patellar tendon advancement is necessary to achieve optimal results in the surgical management of a persistent crouch gait exhibited by adolescents and young adults with cerebral palsy. When this procedure is done alone or in combination with a distal femoral extension osteotomy (for the treatment of a knee flexion contracture), knee function in gait can be restored to values within typical limits, with gains in community function.
脑性瘫痪患者持续呈现的蹲伏步态特点通常包括缺乏足够的跖屈/膝关节伸展配合、腘绳肌和/或腰大肌紧张或挛缩，以及股四头肌功能不全。传统治疗针对肌肉紧张这一因素，但未涉及挛缩或肌肉功能不全问题。本研究旨在评估股骨远端伸展截骨术和/或髌腱前移术治疗脑性瘫痪患者蹲伏步态的有效性。
采用回顾性、非随机、重复测量设计。纳入诊断为脑性瘫痪且符合以下条件的个体：（1）接受股骨远端伸展截骨术联合髌腱远端前移术（33例患者）；（2）接受股骨远端伸展截骨术但未进行髌腱前移术（16例）；（3）仅接受髌腱远端前移术（24例）。所有受试者均在术前和术后进行步态分析评估。分析中纳入步态、影像学、力量和功能测量指标，以评估膝关节功能的变化。
73例个体符合纳入标准。对每个受试者选择一侧进行分析。90%的受试者还接受了其他同期手术。所有组在评估步态病理程度的指标以及功能变量方面均有改善，且疼痛持续减轻。所有术前应力性骨折均愈合。所有组的力量水平均得以维持。仅接受髌腱前移术的组中，髌腱高度的Koshino指数从1.4改善至 -2.3，接受截骨术和腱前移术的组中，该指数从1.5改善至 -2.9。膝关节屈曲范围平均改善了15度至20度，在将髌腱前移作为手术一部分的组中，站立相膝关节屈曲恢复至正常范围（9度至10度）。仅接受股骨远端截骨术的个体在最终评估时仍呈蹲伏状态（站立中期膝关节平均屈曲31度）。
对于患有脑性瘫痪的青少年和年轻人持续存在的蹲伏步态，在手术治疗中纳入髌腱前移术对于取得最佳效果是必要的。当单独进行该手术或与股骨远端伸展截骨术联合进行（用于治疗膝关节屈曲挛缩）时，步态中的膝关节功能可恢复至正常范围内的值，并改善其在社区中的功能。
