Abstract
Although the knee is the largest joint in the lower extremity, it creates fewer problems in children with cerebral palsy (CP) than the hip, foot, or ankle. It is not clear exactly why the knee joint is relatively immune to the pathomechanics that affect the hip and foot; however, because the muscles primarily control motion in a single plane, there is less opportunity to create severely mal-directed force vectors. Most of the stability of the knee is due to its inherent ligamentous stability, the strength of which is usually able to overcome the weak abnormal muscle forces in varus, valgus, or torsional malalignment planes. The high stress on the extensor side of the joint may lead to patella alta and stress reactions in the patella. Stiff knee and crouch gait patterns are most defined by the position of the knee; however, much of the etiology of these problems emanates from the foot as much as the knee. The primary focus of crouch gait which is increased knee flexion in stance phase is focused upon the knee. Often a major contributor to this position though is due to a foot deformity. The knees are very sensitive to change in muscle length especially hamstrings and knee extensors. Surgical procedures are frequently required to lengthen muscles and correct fixed flexion deformity of the knee. Patella alta and patellar subluxation are also relatively common problems in children with spasticity. This chapter provides an overview of the pathology which affects the knee joint in children with cerebral palsy.
References
Adolfsen SE, Ounpuu S, Bell KJ, DeLuca PA (2007) Kinematic and kinetic outcomes after identical multilevel soft tissue surgery in children with cerebral palsy. J Pediatr Orthop 27:658–667
Aiona M, Do KP, Feng J, Jabur M (2015) Comparison of rectus femoris transfer surgery done concomitant with hamstring lengthening or delayed in patients with cerebral palsy. J Pediatr Orthop. 2017 Mar;37(2):107–110
Andrisevic E, Westberry DE, Pugh LI, Bagley AM, Tanner S, Davids JR (2016) Correction of tibial torsion in children with cerebral palsy by isolated distal tibia rotation osteotomy: a short-term, in vivo anatomic study. J Pediatr Orthop 36:743–748
Beals RK (2001) Treatment of knee contracture in cerebral palsy by hamstring lengthening, posterior capsulotomy, and quadriceps mechanism shortening. Dev Med Child Neurol 43:802–805
Bozinovski Z, Popovski N (2014) Operative treatment of the knee contractures in cerebral palsy patients. Med Arch 68:182–183
Carney BT, Oeffinger D (2003) Sagittal knee kinematics following combined hamstring lengthening and rectus femoris transfer. J South Orthop Assoc 12:149–153
Chang WN, Tsirikos AI, Miller F, Lennon N, Schuyler J, Kerstetter L, Glutting J (2004) Distal hamstring lengthening in ambulatory children with cerebral palsy: primary versus revision procedures. Gait Posture 19:298–304
Chang CH, Chen YY, Wang CJ, Lee ZL, Kao HK, Kuo KN (2010) Dynamic displacement of the femoral head by hamstring stretching in children with cerebral palsy. J Pediatr Orthop 30:475–478
Choi Y, Lee SH, Chung CY, Park MS, Lee KM, Sung KH, Won SH, Lee IH, Choi IH, Cho TJ, Yoo WJ, Lee SY (2014) Anterior knee pain in patients with cerebral palsy. Clin Orthop Surg 6:426–431
Das SP, Pradhan S, Ganesh S, Sahu PK, Mohanty RN, Das SK (2012) Supracondylar femoral extension osteotomy and patellar tendon advancement in the management of persistent crouch gait in cerebral palsy. Indian J Orthop 46:221–228
de Morais Filho MC, Neves DL, Abreu FP, Juliano Y, Guimaraes L (2008) Treatment of fixed knee flexion deformity and crouch gait using distal femur extension osteotomy in cerebral palsy. J Child Orthop 2:37–43
Dodgin DA, De Swart RJ, Stefko RM, Wenger DR, Ko JY (1998) Distal tibial/fibular derotation osteotomy for correction of tibial torsion: review of technique and results in 63 cases. J Pediatr Orthop 18:95–101
Dreher T, Vegvari D, Wolf SI, Geisbusch A, Gantz S, Wenz W, Braatz F (2012a) Development of knee function after hamstring lengthening as a part of multilevel surgery in children with spastic diplegia: a long-term outcome study. J Bone Joint Surg Am 94:121–130
Dreher T, Wolf SI, Maier M, Hagmann S, Vegvari D, Gantz S, Heitzmann D, Wenz W, Braatz F (2012b) 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. J Bone Joint Surg Am 94:e142(1–10)
Elhassan Y, O’Sullivan R, Walsh M, O’Brien T (2013) Knee extensor disruption in mild diplegic cerebral palsy: a risk for adolescent athletes. BMJ Case Rep. 2013. pii: bcr2012008120. https://doi.org/10.1136/bcr-2012-008120
Er MS, Abousamra O, Rogers KJ, Bayhan IA, Church C, Henley J, Niiler T, Miller F (2017a) Long-term outcome of internal tibial derotation osteotomies in children with cerebral palsy. J Pediatr Orthop. 2017 Oct/Nov;37(7):454–459
Er MS, Bayhan IA, Rogers KJ, Abousamra O, Church C, Henley J, Miller F (2017b) Long-term outcome of external tibial derotation osteotomies in children with cerebral palsy. J Pediatr Orthop. 2017 Oct/Nov;37(7):460–465
Feldkamp M (1990) Patella fragmentation in cerebral palsy. Z Orthop Ihre Grenzgeb 128:160–164
Galli M, Cimolin V, Vimercati S, Albertini G, Brunner R (2014) Quantification of patellar tendon shortening in a patient with cerebral palsy. J Appl Biomater Funct Mater 12:57–63
Hagglund G, Wagner P (2008) Development of spasticity with age in a total population of children with cerebral palsy. BMC Musculoskelet Disord 9:150
Hagglund G, Wagner P (2011) Spasticity of the gastrosoleus muscle is related to the development of reduced passive dorsiflexion of the ankle in children with cerebral palsy: a registry analysis of 2,796 examinations in 355 children. Acta Orthop 82:744–748
Karol LA, Chambers C, Popejoy D, Birch JG (2008) Nerve palsy after hamstring lengthening in patients with cerebral palsy. J Pediatr Orthop 28:773–776
Klotz MC, Wolf SI, Heitzmann D, Krautwurst B, Braatz F, Dreher T (2013) Reduction in primary genu recurvatum gait after aponeurotic calf muscle lengthening during multilevel surgery. Res Dev Disabil 34:3773–3780
Klotz MC, Heitzmann DW, Wolf SI, Niklasch M, Maier MW, Dreher T (2016) The influence of timing of knee recurvatum on surgical outcome in cerebral palsy. Res Dev Disabil 48:186–192
Lee SY, Kwon SS, Chung CY, Lee KM, Choi Y, Kim TG, Shin WC, Choi IH, Cho TJ, Yoo WJ, Park MS (2014) Rectus femoris transfer in cerebral palsy patients with stiff knee gait. Gait Posture 40:76–81
Lloyd-Roberts GC, Jackson AM, Albert JS (1985) Avulsion of the distal pole of the patella in cerebral palsy. A cause of deteriorating gait. J Bone Joint Surg Br 67:252–254
Lotman DB (1976) Knee flexion deformity and patella alta in spastic cerebral palsy. Dev Med Child Neurol 18:315–319
Niiler TA, Richards JG, Miller F (2007) Concurrent surgeries are a factor in predicting success of rectus transfer outcomes. Gait Posture 26:76–81
Park MS, Chung CY, Lee SH, Choi IH, Cho TJ, Yoo WJ, Park BS, Lee KM (2009) Effects of distal hamstring lengthening on sagittal motion in patients with diplegia: hamstring length and its clinical use. Gait Posture 30:487–491
Presedo A, Megrot F, Ilharreborde B, Mazda K, Pennecot GF (2012) Rectus femoris distal tendon resection improves knee motion in patients with spastic diplegia. Clin Orthop Relat Res 470:1312–1319
Rethlefsen SA, Yasmeh S, Wren TA, Kay RM (2013) Repeat hamstring lengthening for crouch gait in children with cerebral palsy. J Pediatr Orthop 33:501–504
Rethlefsen SA, Nguyen DT, Wren TA, Milewski MD, Kay RM (2015) Knee pain and patellofemoral symptoms in patients with cerebral palsy. J Pediatr Orthop 35:519–522
Ryan DD, Rethlefsen SA, Skaggs DL, Kay RM (2005) Results of tibial rotational osteotomy without concomitant fibular osteotomy in children with cerebral palsy. J Pediatr Orthop 25:84–88
Senaran H, Holden C, Dabney KW, Miller F (2007) Anterior knee pain in children with cerebral palsy. J Pediatr Orthop 27:12–16
Sheehan FT, Babushkina A, Alter KE (2012) Kinematic determinants of anterior knee pain in cerebral palsy: a case-control study. Arch Phys Med Rehabil 93: 1431–1440
Siegel IM (1988) Historical vignette #9. Little big man: the life and genius of William John Little (1810–1894). Orthop Rev 17:1156, 1161–1166
Stout JL, Gage JR, Schwartz MH, Novacheck TF (2008) Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy. J Bone Joint Surg Am 90:2470–2484
Taylor D, Connor J, Church C, Lennon N, Henley J, Niiler T, Miller F (2016) The effectiveness of posterior knee capsulotomies and knee extension osteotomies in crouched gait in children with cerebral palsy. J Pediatr Orthop B 25:543–550
Temelli Y, Akalan NE (2009) Treatment approaches to flexion contractures of the knee. Acta Orthop Traumatol Turc 43:113–120
Topoleski TA, Kurtz CA, Grogan DP (2000) Radiographic abnormalities and clinical symptoms associated with patella alta in ambulatory children with cerebral palsy. J Pediatr Orthop 20:636–639
Tyler W, McCarthy EF (2002) Osteochondrosis of the superior pole of the patella: two cases with histologic correlation. Iowa Orthop J 22:86–89
Woratanarat P, Dabney KW, Miller F (2009) Knee capsulotomy for fixed knee flexion contracture. Acta Orthop Traumatol Turc 43:121–127
Zwick EB, Svehlik M, Steinwender G, Saraph V, Linhart WE (2010) Genu recurvatum in cerebral palsy – part B: hamstrings are abnormally long in children with cerebral palsy showing knee recurvatum. J Pediatr Orthop B 19:373–378
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Section Editor information
Rights and permissions
Copyright information
© 2019 Springer Nature Switzerland AG
About this entry
Cite this entry
Miller, F. (2019). Overview of Knee Problems in Cerebral Palsy. In: Miller, F., Bachrach, S., Lennon, N., O'Neil, M. (eds) Cerebral Palsy. Springer, Cham. https://doi.org/10.1007/978-3-319-50592-3_133-1
Download citation
DOI: https://doi.org/10.1007/978-3-319-50592-3_133-1
Received:
Accepted:
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-50592-3
Online ISBN: 978-3-319-50592-3
eBook Packages: Springer Reference MedicineReference Module Medicine