Knee
Hamstring contractures
Crouched gait in spastic diplegia
- hips and knees flexed throughout gait
- tight hamstring prevents knee extension with hip flexion
Options
Dynamic contractures
- distal hamstring lengthening (open versus percutaneous)
Fixed knee contractures
- guided growth / distal anterior femoral hemi-epiphysiodesis
- distal femoral extension osteotomy
Distal hamstring lengthening
Complications
- genu recurvatum / knee extension post hamstring release
- weakness hip extension / anterior pelvic tilt
- avoid by releasing medial hamstrings only
Technique
- semitendinosis release +/- transfer to maintain hip extension
- semimembranosus release
- leave biceps femoris intact
- postoperative casting
Sung et al J Neuroend Rehab 2017
- hamstring lengthening in 314 CP patients with CP and flexed knee
- semimembranosus lengthening
- semitendinosis release and transfer
- improvement in knee flexion and gait at 2 years
Guided growth / Anterior distal femoral hemi-epiphysiodesis
Indication
- fixed knee contracture
- skeletally immature
Tipping et al Gait Posture 2025
- systematic review of guided growth for knee flexion contracture
- improvement in knee flexion contracture 12o
- improvement in popliteal angle 16o
Distal femoral extension osteotomy + patella tendon advancement
Indication
- knee FFD > 20o
- skeletally mature
POSNA distal femoral extension osteotomy CP technique video
- 73 patients with CP treated with distal femoral extension osteotomy
- better outcomes when combined with patella tendon advancement
Quadriceps contractures
Issue
Tight rectus femoris
- stiff knee gait
- may be unmasked with hamstring lengthening
- limits knee flexion in gait / energy inefficient
Ely's test
- patient prone
- flex knee, will feel hip flex with tight rectus
Options
Rectus femoris release
Rectus femoris transfer to semitendinosus
Josse et al Orthop Traumatol Surg Res 2023
- systematic review of rectus femoris release versus transfer
- small to moderate improvement in knee kinematics with RF transfer
POSNA rectus femoris to semitendinosus transfer technique video
Excessive external rotation tibia
Supramalleolar tibial derotation osteotomy
Foot and ankle
Issues
| Equinus | Equinovarus | Planovalgus |
|---|---|---|
 |
 |
 |
Equinus
Definition
Most common foot and ankle defomrity
- fixed dorsiflexion of ankle / unable to reach plantigrade
- tight tendoachilles
Options
Tendoachilles lengthening +/- tibialis anterior shortening
Tendoachilles lengthening
Avoid overlengthening of tendoachilles which results in weakness / foot drop / slumping position
POSNA academy achilles tendon lengthening video
Hoke percutaneous slide technique
- mild contractures
- proximal and distal cuts medial, middle cut lateral
- cut half the tendon
Z lengthening of tendon
- severe contractures
- 186 tendoachilles release in CP
- overall recurrence 44%
- highest in hemiplegia and younger patients
Equinovarus
Cause
Contracture of tendoachilles and tibialis posterior
Most common in hemiplegia
Management
Flexible deformity
- tendoachilles release
- split tibialis posterior tendon transfer (SPLOTT)
- split tibialis anterior tendon transfer (SPLATT)
Fixed deformity - subtalar arthrodesis
- systematic review of split tibialis posterior transfer for equinovarus in CP
- recurrence hemiplegia 7%
- higher recurrence rate with increased age
- increased recurrence in quadriplegia 48%
Planovalgus
Options
Lateral calcaneal lengthening
Subtalar arthroesis
Subtalar arthrodesis
- systematic review of lateral calcaneal lengthening v arthoresis in CP planovalgus
- improved radiographic correction with calcaneal osteotomy
- increased complications with calcaneal osteotomy (recurrence / pain / ovecorrection / undercorrection)
