Distal Rectus Femoris Tendon Transfer for the Correction of Stiff-Knee Gait in Cerebral Palsy by T....

Distal Rectus Femoris Tendon Transfer for the Correction of Stiff-Knee Gait in Cerebral Palsy

by T. Dreher, F. Braatz, S.I. Wolf, V. Ewerbeck, D. Heitzmann, W. Wenz, and L. Döderlein

JBJS Essent Surg TechVolume 3(1):e5January 9, 2013

T. Dreher et al. JBJS Essent Surg Tech 2013;3:e5

The normal functional interaction between the rectus femoris muscle and the hamstrings during gait.

The Duncan-Ely test10.

The surgical approach (2 cm in length) for preparation of the rectus femoris tendon, which should be done 2 to 3 cm above the proximal patellar pole.

Illustration showing exposure of the fascia lata and tagging with two number-2-0 Vicryl sutures.

Photograph showing exposure and tagging of the fascia lata as illustrated in Fig. 4-A.

The rectus femoris tendon is separated from the underlying quadriceps tendon with a clamp.

Two anchoring sutures (number-1 Vicryl) are placed in the rectus femoris tendon.

The tagged rectus femoris tendon is released as distally as possible without injuring the underlying quadriceps tendon.

Illustration showing the rectus femoris muscle carefully mobilized from the underlying quadriceps by digital preparation.

Photograph showing the rectus femoris muscle mobilized from the underlying quadriceps, as illustrated in Fig. 7-A.

The rectus femoris tendon is freed from the encompassing tissue with use of the scissors.

It is very important to dissect the medial fascia lata enough to avoid a later angular deviation of the transferred rectus femoris tendon at the incision site.

The released rectus femoris tendon undersurface is shown.

The anatomy of the medial aspect of the thigh.

After incision of the fascia, the gracilis muscle belly can be exposed by the use of one finger or with a clamp.

Illustration showing how the intramuscular tendon of the gracilis is explored and separated from the underlying muscle belly with use of scissors.

Photograph showing exploration and separation of the intramuscular tendon of the gracilis, as illustrated in Fig. 11-A.

The tendon is then followed as proximally as possible to obtain an adequate tendon length for the transfer.

After separation of the tendon from its muscle belly, anchoring sutures (number-1 Vicryl) are placed in the tendon as proximally as possible.

After the gracilis tendon is released proximally to the tagging suture, the knee is fully flexed and the gracilis tendon is separated from the muscle belly as distally as possible.

The tendon is freed from all remaining muscle tissue in order to guarantee a smooth transfer.

The mini-incision for pulling out the gracilis tendon is made 1 to 2 cm above the pes anserinus (pink line).

After the incision, the tendon sheath of the gracilis tendon is opened and the gracilis tendon is exposed with a clamp.

Illustration showing how the gracilis tendon is pulled out with use of a moist sponge.

Photograph showing the gracilis tendon pulled out with a moist sponge, as illustrated in Fig. 16-B.

Through a distal medial incision above the palpable gracilis tendon, a small incision (standard approach for distal z-lengthening or sliding of medal hamstrings) is made and the tendon sheath

of the gracilis tendon is opened to expose the tendon.

A tendon harvest instrument is used, and the tendon is merged.

The tendon harvester is then driven proximally by palpating with the other hand.

A cutting mechanism is used, and the tendon is pulled out distally afterward.

Through the initial anterior approach, the transfer path is prepared by medial epifascial tunneling toward the approach in the popliteal fossa.

Photograph showing the technique illustrated in Fig. 18-A.

The tagging sutures of the released gracilis tendon are grasped, and the gracilis tendon is then transferred behind the knee axis of rotation to the anterior wound.

With the transfer clamp, the gracilis tendon is weaved in the released rectus femoris tendon with the interlacing technique described by Pulvertaft14 under moderate tension with use of number-

1 Vicryl suture, while the leg is positioned in 20° to 30° of kne...

Illustration showing the technique described in Fig. 19-A.

Alternative technique for transfer of the rectus femoris tendon to the iliotibial band, which is indicated when a hamstring lengthening was previously done.

Preoperative sagittal plane knee kinematics of a patient with stiff-knee gait, characterized by decreased peak knee flexion in swing, decreased knee flexion velocity, decreased knee flexion in

swing, and a delay in peak knee flexion in swing.

Preoperative sagittal plane knee kinematics of another patient with stiff-knee gait, characterized by decreased peak knee flexion in swing, decreased knee flexion velocity, decreased knee

flexion in swing, and a delay in peak knee flexion in swing.

Preoperative sagittal plane knee kinematics of a patient with severe flexed-knee gait throughout the stance and swing phases, reaching normal and even increased peak knee flexion in swing.

Preoperative sagittal plane knee kinematics of another patient with severe flexed-knee gait throughout the stance and swing phases, reaching normal and even increased peak knee flexion

in swing.

Preoperative sagittal plane knee kinematics of a patient with jump-knee gait11.

Distal Rectus Femoris Tendon Transfer for the Correction of Stiff-Knee Gait in Cerebral Palsy by T....

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