Short-term Hardware Short-term Hardware Outcomes Following Patellar Outcomes Following Patellar

Tendon Advancement in Tendon Advancement in Pediatric Patients with Pediatric Patients with

Crouch GaitCrouch Gait

AuthorsAuthorsInstitutionsInstitutions

IntroductionIntroduction

Cerebral Palsy: motor syndromesCerebral Palsy: motor syndromes- 2° to brain development- 2° to brain development

Crouch gait – spasticity/contractureCrouch gait – spasticity/contracture- Hamstring/psoas tightnessHamstring/psoas tightness- Lever-arm dysfunctionLever-arm dysfunction- WeaknessWeakness- Impaired balanceImpaired balance

Kliegman, Robert M., Richard E. Behrman, Hal B. Jenson, and Bonita F. Stanton. Nelson Textbook of Pediatrics. Philadelphia: Saunders, 2007.

Crouch GaitCrouch Gait

Body MechanicsBody Mechanics- Knee flexionKnee flexion- Hip flexionHip flexion- Ankle dorsiflexionAnkle dorsiflexion

Knee and back painKnee and back pain Quadriceps insufficiencyQuadriceps insufficiency Patella alta & Elongation of patellar Patella alta & Elongation of patellar

tendontendon 2° to achilles tendon lengthening2° to achilles tendon lengthening

Stout et al. JBJS 2008

Chambers Eur J Neur 2001

TreatmentTreatment

Gait analysis for evaluation (Pre-op Gait analysis for evaluation (Pre-op Mov?)Mov?)

ConservativeConservative- Occupational/Physical therapyOccupational/Physical therapy- Assistive devicesAssistive devices

MedicalMedical– Muscle relaxantsMuscle relaxants– BenzodiazepinesBenzodiazepines– Botulinum toxinBotulinum toxin

Kliegman, Robert M., Richard E. Behrman, Hal B. Jenson, and Bonita F. Stanton. Nelson Textbook of Pediatrics. Philadelphia: Saunders, 2007.

Surgical TreatmentSurgical Treatment

Procedures typically doneProcedures typically done– (Get from Halanski)(Get from Halanski)– (Preop and postop x-rays)(Preop and postop x-rays)– (Preop/postop gait analysis)(Preop/postop gait analysis)

Crouch GaitCrouch Gait

Surgical TreatmentSurgical Treatment

Distal femoral extension osteotomyDistal femoral extension osteotomy Patellar tendon advancementPatellar tendon advancement

- Patellar insertion freedPatellar insertion freed- Patellar tendon advanced distally along Patellar tendon advanced distally along

tibiatibia

- Cercalage wire from patella to insertion- Cercalage wire from patella to insertionStabilize new insertionStabilize new insertion

CombinationCombination

Stout et al JBJS 2008

ObjectiveObjective

To examine the short-term outcomes To examine the short-term outcomes of hardware failure following patellar of hardware failure following patellar tendon advancement in patients with tendon advancement in patients with crouch gaitcrouch gait

2 Hardware types2 Hardware types- Cercalage cable - Cercalage cable

- Cercalage wire- Cercalage wire

MethodsMethods

Retrospective cohort study Retrospective cohort study radiographsradiographs

Inclusion CriteriaInclusion Criteria- Billing codes: patellar advancementBilling codes: patellar advancement- Helen DeVos Children’s HospitalHelen DeVos Children’s Hospital- 1/1/03 to 11/2/081/1/03 to 11/2/08

Exclusion criteriaExclusion criteria– Different procedure performedDifferent procedure performed– Age > 17Age > 17

MethodsMethods

Patient radiographsPatient radiographs- Cercalage wire vs. cableCercalage wire vs. cable- Failure vs. IntactFailure vs. Intact

Patient recordsPatient records- Age at procedureAge at procedure- Time to post-op radiographTime to post-op radiograph- Time to failureTime to failure

Fisher’s exact testFisher’s exact test

RadiographsRadiographs

Cercalage wireCercalage wire Cercalage cableCercalage cable

Hardware FailureHardware Failure

ResultsResults

16 Patients with 16 Patients with 31 Patellar advancements31 Patellar advancements Fisher’s exact T-test (p < 0.001)Fisher’s exact T-test (p < 0.001)

Hardware Wire Cable

Age (years) 13 10

# Performed 11 20

# Failed 9 0

Failure Rate 89% 0%

Avg. Time F/U 258 90

DiscussionDiscussion

Statistically significant advantage to Statistically significant advantage to cablescables

Shorter follow-up timeShorter follow-up time Continued observation cablesContinued observation cables

- 1 year follow-up1 year follow-up

ConclusionConclusion

Cables show better outcomes than Cables show better outcomes than wireswires- 1 year follow-up for recommendations1 year follow-up for recommendations

Possible implicationsPossible implications– Decrease failed hardware removalDecrease failed hardware removal– More rapid mobilization post-opMore rapid mobilization post-op

Reference

Future WorkFuture Work

Continue follow-up for > 1 yearContinue follow-up for > 1 year Evaluation of long-term hardware Evaluation of long-term hardware

outcomesoutcomes Evaluation of patellar advancement Evaluation of patellar advancement

on growth plate mechanicson growth plate mechanics Evaluation of gait kinematicsEvaluation of gait kinematics

Reference

AcknowledgmentsAcknowledgments

AttendingAttending EditorEditor StatisticianStatistician InstitutionInstitution

Questions?Questions?