title: Long-term results after distal rectus femoris transfer as a part of multilevel surgery for the correction of stiff-knee gait in spastic diplegic cerebral palsy.
abstract: BACKGROUND
  The evidence for distal rectus femoris transfer as a part of multilevel surgery for the correction of stiff-knee gait in children with spastic diplegic cerebral palsy is limited because of inconsistent outcomes reported in various studies and the lack of long-term evaluations.
  
  
  METHODS
  This study investigated the long-term results (mean, nine years) for fifty-three ambulatory patients with spastic diplegic cerebral palsy and stiff-knee gait treated with standardized distal rectus femoris transfer as a part of multilevel surgery. Standardized three-dimensional gait analysis and clinical examination were carried out before surgery and at one year and nine years after surgery. Patients with decreased peak knee flexion in swing phase who had distal rectus femoris transfer to correct the decreased peak knee flexion in swing phase (C-DRFT) were evaluated separately from those with normal or increased peak knee flexion in swing phase who had distal rectus femoris transfer done as a prophylactic procedure (P-DRFT).
  
  
  RESULTS
  A significantly increased peak knee flexion in swing phase was found in the C-DRFT group one year after surgery, while a significant loss (15°) in peak knee flexion in swing phase was noted in the P-DRFT group. A slight but not significant increase in peak knee flexion in swing phase in both groups was noted at the time of the long-term follow-up. A significant improvement in timing of peak knee flexion in swing phase was only found for the C-DRFT group, and was maintained after nine years. Knee motion and knee flexion velocity were significantly increased in both groups and were maintained at long-term follow-up in the C-DRFT group, while the P-DRFT showed a deterioration of knee motion.
  
  
  CONCLUSIONS
  Distal rectus femoris transfer is an effective procedure to treat stiff-knee gait featuring decreased peak knee flexion in swing phase and leads to a long-lasting increase of peak knee flexion in swing phase nine years after surgery. Patients with more involvement showed a greater potential to benefit from distal rectus femoris transfer. However, 18% of the patients showed a permanently poor response and 15% developed recurrence. In patients with severe knee flexion who underwent a prophylactic distal rectus femoris transfer, a significant loss in peak knee flexion in swing phase was noted and thus a prophylactic distal rectus femoris transfer may not be indicated in these patients.
  
  
  METHODS
  Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Paediatric Orthopaedics and Foot Surgery, Department for Orthopaedic and Trauma Surgery, Heidelberg University Clinics, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany. thomas.dreher@med.uni-heidelberg.de
authors.forename: Thomas
authors.initials: T
authors.lastname: Dreher
authors.forename: Sebastian I
authors.initials: SI
authors.lastname: Wolf
authors.forename: Michael
authors.initials: M
authors.lastname: Maier
authors.forename: Sébastien
authors.initials: S
authors.lastname: Hagmann
authors.forename: Dóra
authors.initials: D
authors.lastname: Vegvari
authors.forename: Simone
authors.initials: S
authors.lastname: Gantz
authors.forename: Daniel
authors.initials: D
authors.lastname: Heitzmann
authors.forename: Wolfram
authors.initials: W
authors.lastname: Wenz
authors.forename: Frank
authors.initials: F
authors.lastname: Braatz
mesh_terms: D000293:Adolescent; D002547:Cerebral Palsy / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D002648:Child; D015331:Cohort Studies; D004185:Disability Evaluation; D005260:Female; D005500:Follow-Up Studies; D005684:Gait / Q000502:physiology; D020233:Gait Disorders, Neurologic / Q000209:etiology / Q000601:surgery*; D006801:Humans; D007719:Knee Joint / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D011182:Postoperative Care / Q000379:methods; D011446:Prospective Studies; D052097:Quadriceps Muscle / Q000601:surgery / Q000637:transplantation*; D016059:Range of Motion, Articular / Q000502:physiology*; D020127:Recovery of Function; D012008:Recurrence; D018570:Risk Assessment; D013997:Time Factors; D016896:Treatment Outcome