Management of the Knee Problems in Spastic Cerebral Palsy

Abstract

Two common knee problems in cerebral palsy are increased knee flexion during stance phase and reduced knee flexion during the swing phase of gait. We reviewed the recent literature and based on that, we formed this review. Hamstring spasticity, quadriceps weakness, soleus weakness, and lever-arm dysfunction are few factors which lead to increased knee flexion during stance phase. Rectus spasticity diminishes knee flexion in the swing. Resulting gait-stiff knee gait interferes with ground clearance. Both gait patterns result into esthetically poor gait and increased energy consumption. Knee flexion gait may lead to pain in the knee. Natural history of knee flexion gait suggests deterioration over time. In the early stage, these gait abnormalities are managed by nonoperative treatment. Cases in which nonoperative measures fail or advance cases need surgical treatment. Various variables which are taken into consideration before selecting a particular treatment option are described. We also present an algorithm for decision-making. Nonsurgical options and surgical procedures are discussed.

Keywords: Cerebral palsy; diplegia; knee flexion stiff knee.

Figure 1

(a) When knee can achieve full knee extension, ground reaction force passes anterior to knee joint. (b) When knee has fixed flexion deformity, ground reaction force passes posterior to center of knee joint. Quadriceps action is required to maintain upright posture

Figure 2

Lateral radiographs of the knee joint showing fragmentation of the lower pole of the patella (a) and the tibial tuberosity (b) in spastic diplegic walking with crouch gait

Figure 3

Schematic diagram of lateral radiograph of the knee joint showing the measurement of Koshino, Blackburne, and Caton index

Figure 4

Orthosis to stretch the hamstrings

Figure 5

Clinical photograph of the adolescent treated with femur extension osteotomy with patella tendon plication (a) preoperative (b) postoperative

Figure 6

Authors’ approach for the management of flexed knee gait in spastic diplegic child. DFEO = Distal femoral extension osteotomy, PTP = Patellar tendon plication

Figure 7

Authors’ approach for the management of stiff knee gait in spastic diplegic child