Rectus femoris surgery for the correction of stiff knee gait in cerebral palsy: a systematic review and meta-analysis
Description
Stiff Knee Gait (SKG) is very common in children with cerebral palsy (CP). It is characterized by decreased knee flexion during swing phase (SP). Source of this gait dysfunction is attributed to inappropriate rectus femoris activity during swing. The purpose of this systematic review was to determine outcomes of two surgical techniques: distal rectus femoris transfer (DRFT) and rectus intramuscular lengthening (RIL). In the last year, DRFT has been the accepted surgical procedure to treat stiff-knee gait. The concept of the transfer conversion from a knee extensor to a knee flexor has not been validated in the literature. That’s why there has been interest in a shorter operative technique as RIL. The meta-analysis was conducted in compliance with the PRISMA statement. It was prospectively registered in the PROSPERO registry. Medline, Science Direct, Cochrane registry, Scopus and Pascal were searched. Studies were collected up to March 2020. Patients were children with cerebral palsy. Interventions had to include DRFT or RIL. Outcomes measures had to include pre-and postoperative knee kinematics from gait analysis. Methodological Index for Non-Randomized Studies (MINORS) was used to assess the methodological quality of the included studies. Study selection was independently performed by 2 reviewers (AJ & MT). Pre-and 1 year postoperative motion analysis data were extracted. Effect size was estimated by the standardized mean difference (SMD). Of 695 studies identified, 16 were included in this review. Fifteen were retrospective and 1 was prospective. We analysed data from 1079 limbs and 768 patients. In DRFT studies, data pooling of Peak Knee Flexion (PKF), time to PKF (t-PKFGC), Knee range of motion (KROM) and Maximum knee extension in stance phase (MKEST) showed a significant improvement of 3.1° (SMD = 0.29), 2.3° (SMD = 0.43), 9.6° (SMD = 0.80) and 7.7° (SMD = 0.57) respectively. In RIL studies, data pooling of PKF and t-PKFGC were not significant. Whereas data pooling of KROM and MKEST showed a significant improvement of 7.3° (SMD = 0.57) and 11° (SMD = 0.83) respectively. Ours results showed that DRFT remain an effective surgery to treat stiff knee gait. However the effect size of DRFT remain low or moderate. In our study, the effect size of RIL was not interpretable because of outlier value. Indeed, the standard deviation of PKF value was abnormally low for Presedo et al. Moreover, heterogeneity of release technique is important. Indeed, term of “rectus intramuscular lengthening” could as well include a simple distal rectus tenotomy as a complete rectus femoris distal tendon resection. Heterogeneity of the studies included was too important because of different severity of lesions, different surgical procedures and many concomitant surgeries. Consequently, our results should be interpreted with caution. Annexe 1. Search Strategy on MEDLIN Annexe 2. TRANSFER Forest Plot Annexe 3. RELEASE Forest Plot
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Stiff Knee Gait (SKG) is very common in children with cerebral palsy (CP). It is characterized by decreased knee flexion during swing phase (SP). Source of this gait dysfunction is attributed to inappropriate rectus femoris activity during swing. The purpose of this systematic review was to determine outcomes of two surgical techniques: distal rectus femoris transfer (DRFT) and rectus intramuscular lengthening (RIL). The meta-analysis was conducted in compliance with the PRISMA statement. It was prospectively registered in the PROSPERO registry. Medline, Science Direct, Cochrane registry, Scopus and Pascal were searched. Studies were collected up to September 2018. Patients were children with cerebral palsy. Interventions had to include DRFT or RIL. Outcomes measures had to include pre-and postoperative knee kinematics from gait analysis. Methodological Index for Non-Randomized Studies (MINORS) was used to assess the methodological quality of the included studies. Study selection was independently performed by 2 reviewers (AJ & MT). Pre-and 1 year postoperative motion analysis data were extracted. Effect size was estimated by the standardized mean difference (SMD).