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      Reliability of patellar height indices in children with cerebral palsy and spina bifida

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          Abstract

          Background

          The Koshino (KI) and Caton-Deschamps (CDI) indices are used to measure patellar height in children, with the CDI showing excellent reliability in typically developing (TD) children. Reliability of such measures in children with cerebral palsy (CP) and spina bifida (SB) is unknown.

          Methods

          Lateral knee radiographs were reviewed retrospectively for children with TD (n = 49), CP (n = 48) and SB (n = 42). Five raters took measurements from radiographs twice, at least two weeks apart. Measurements included the CDI, Insall-Salvati Index (ISI) and KI. Systematic variability (bias) and random variability were examined using repeated measures ANOVA, 95% limits of agreement (LOA) and coefficients of variation (CV).

          Results

          Mean values of all three indices differed among raters (p < 0.0001). A significant difference was seen between the first and second measurements for CDI and KI indicating a learning effect. LOA ranges were large for the CDI (intra-rater: 0.37-0.95, inter-rater: 0.60-1.04) and ISI (intra-rater: 0.25-0.49, inter-rater: 0.51-0.57) for all patient groups. The KI showed a clinically acceptable range for TD participants (intra-rater: 0.14-0.16, inter-rater: 0.11-0.14) with larger ranges for CP (intra-rater: 0.26-0.33, inter-rater 0.0.2-0.35) and SB patients (intra-rater: 0.23-0.27, inter-rater: 0.19-0.25). CVs were lowest (best) for KI (3.8% to 7.4%) and highest (worst) for CDI (14.7% to 23.1%) for all three groups. Results were similar for patients with both open and closed physes.

          Conclusions

          The KI is the most reliable patellar height measure for paediatric patients with TD, CP and SB, with either open or closed physes. The KI is more complex and experience may be important for valid, reliable measurement.

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          Most cited references11

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          Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy.

          James R Gage, Theodore H. Schwartz, Robert Stout … (2008)
          Hallmarks of a persistent crouched walking pattern exhibited by individuals with cerebral palsy usually include loss of an adequate plantar flexion/knee extension couple, hamstring and/or psoas tightness, or contracture in conjunction with quadriceps insufficiency. Traditional treatment addresses the muscle-tightness component, but not the contracture or the muscle insufficiency. This study was performed to evaluate the effectiveness of distal femoral extension osteotomy and/or patellar tendon advancement in the treatment of crouch gait in patients with cerebral palsy. A retrospective, nonrandomized, repeated-measures design was used. Individuals with a diagnosis of cerebral palsy were included if they had had (1) a distal femoral extension osteotomy in combination with a distal patellar tendon advancement (thirty-three patients), (2) a distal femoral extension osteotomy without patellar tendon advancement (sixteen), or (3) a distal patellar tendon advancement only (twenty-four). All subjects were evaluated with preoperative and postoperative gait analysis. Gait, radiographic, strength, and functional measures were included in the analysis to assess changes in knee function. Seventy-three individuals met the criteria for inclusion. A single side was chosen for the analysis of each subject. Ninety percent of the subjects had additional, concurrent surgery. Improvements were noted in the index assessing the level of gait pathology and in functional variables across all groups, and pain was consistently decreased. All preoperative stress fractures healed. Strength levels were maintained across all groups. The Koshino index of patellar height improved from 1.4 to -2.3 in the group treated with patellar tendon advancement only and from 1.5 to -2.9 in the group treated with both osteotomy and tendon advancement. The range of knee flexion improved an average of 15 degrees to 20 degrees, and stance-phase knee flexion was restored to the typical range (9 degrees to 10 degrees) in the groups that had advancement of the patellar tendon as part of the procedure. Individuals who underwent a distal femoral osteotomy only were still in a crouch (a mean of 31 degrees of knee flexion in midstance) at the final assessment. Inclusion of patellar tendon advancement is necessary to achieve optimal results in the surgical management of a persistent crouch gait exhibited by adolescents and young adults with cerebral palsy. When this procedure is done alone or in combination with a distal femoral extension osteotomy (for the treatment of a knee flexion contracture), knee function in gait can be restored to values within typical limits, with gains in community function.
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            Is there a biomechanical explanation for anterior knee pain in patients with patella alta?: influence of patellar height on patellofemoral contact force, contact area and contact pressure.

            H Vandenneucker, B Innocenti, T Luyckx … (2009)
            The purpose of this study was to test the hypothesis that patella alta leads to a less favourable situation in terms of patellofemoral contact force, contact area and contact pressure than the normal patellar position, and thereby gives rise to anterior knee pain. A dynamic knee simulator system based on the Oxford rig and allowing six degrees of freedom was adapted in order to simulate and record the dynamic loads during a knee squat from 30 degrees to 120 degrees flexion under physiological conditions. Five different configurations were studied, with variable predetermined patellar heights. The patellofemoral contact force increased with increasing knee flexion until contact occurred between the quadriceps tendon and the femoral trochlea, inducing load sharing. Patella alta caused a delay of this contact until deeper flexion. As a consequence, the maximal patellofemoral contact force and contact pressure increased significantly with increasing patellar height (p < 0.01). Patella alta was associated with the highest maximal patellofemoral contact force and contact pressure. When averaged across all flexion angles, a normal patellar position was associated with the lowest contact pressures. Our results indicate that there is a biomechanical reason for anterior knee pain in patients with patella alta.
            Article 0 comments Cited 24 times – based on 0 reviews     Review now
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              Distal femoral extension osteotomy and patellar tendon advancement to treat persistent crouch gait in cerebral palsy. Surgical technique.

              James R Gage, Theodore H. Schwartz, Robert Stout … (2009)
              Hallmarks of a persistent crouched walking pattern exhibited by individuals with cerebral palsy usually include loss of an adequate plantar flexion/knee extension couple, hamstring and/or psoas tightness, or contracture in conjunction with quadriceps insufficiency. Traditional treatment addresses the muscle-tightness component, but not the contracture or the muscle insufficiency. This study was performed to evaluate the effectiveness of distal femoral extension osteotomy and/or patellar tendon advancement in the treatment of crouch gait in patients with cerebral palsy. A retrospective, nonrandomized, repeated-measures design was used. Individuals with a diagnosis of cerebral palsy were included if they had had (1) a distal femoral extension osteotomy in combination with a distal patellar tendon advancement (thirty-three patients), (2) a distal femoral extension osteotomy without patellar tendon advancement (sixteen), or (3) a distal patellar tendon advancement only (twenty-four). All subjects were evaluated with preoperative and postoperative gait analysis. Gait, radiographic, strength, and functional measures were included in the analysis to assess changes in knee function. Seventy-three individuals met the criteria for inclusion. A single side was chosen for the analysis of each subject. Ninety percent of the subjects had additional, concurrent surgery. Improvements were noted in the index assessing the level of gait pathology and in functional variables across all groups, and pain was consistently decreased. All preoperative stress fractures healed. Strength levels were maintained across all groups. The Koshino index of patellar height improved from 1.4 to -2.3 in the group treated with patellar tendon advancement only and from 1.5 to -2.9 in the group treated with both osteotomy and tendon advancement. The range of knee flexion improved an average of 15 degrees to 20 degrees , and stance-phase knee flexion was restored to the typical range (9 degrees to 10 degrees ) in the groups that had advancement of the patellar tendon as part of the procedure. Individuals who underwent a distal femoral osteotomy only were still in a crouch (a mean of 31 degrees of knee flexion in midstance) at the final assessment. Inclusion of patellar tendon advancement is necessary to achieve optimal results in the surgical management of a persistent crouch gait exhibited by adolescents and young adults with cerebral palsy. When this procedure is done alone or in combination with a distal femoral extension osteotomy (for the treatment of a knee flexion contracture), knee function in gait can be restored to values within typical limits, with gains in community function.
              Article 0 comments Cited 18 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Child Orthop
                Journal ID (iso-abbrev): J Child Orthop
                Journal ID (publisher-id): jco
                Title: Journal of Children's Orthopaedics
                Publisher: The British Editorial Society of Bone and Joint Surgery (London )
                ISSN (Print): 1863-2521
                ISSN (Electronic): 1863-2548
                Publication date (Print): 1 August 2017
                Volume: 11
                Issue: 4
                Pages: 249-255
                Affiliations
                [1 ]org-divisionChildren’s Orthopaedic Center , Children’s Hospital, Los Angeles, California, USA
                [2 ]org-divisionDepartment of Orthopaedic Surgery , Keck School of Medicine of USC, Los Angeles, California, USA
                [3 ]org-divisionChildren’s Orthopaedic Center, Children’s Hospital, and Department of Orthopaedic Surgery , Keck School of Medicine of USC, Los Angeles, California, USA
                [4 ]org-divisionChildren’s Hospital , New Orleans, Louisiana, USA
                Author notes
                [a ]Correspondence should be sent to: Susan A. Rethlefsen, org-divisionChildren’s Orthopaedic Center , Children’s Hospital Los Angeles, 4650 Sunset Blvd., M/S 69, Los Angeles, CA 90027, USA. srethlefsen@ 123456chla.usc.edu
                Article
                Publisher ID: jco-11-249
                DOI: 10.1302/1863-2548.11.170014
                PMC ID: 5584492
                SO-VID: 52929f87-b21b-45ba-8930-f2e6c3b85cc3
                Copyright © Copyright © 2017, The British Editorial Society of Bone and Joint Surgery: All rights reserved
                License:

                Open Access This article is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence ( http://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed.

                History
                Date received : 23 January 2017
                Date accepted : 6 June 2017
                Categories
                Subject: Original Clinical Article

                ScienceOpen disciplines: Orthopedics
                Keywords: patellar height index,cerebral palsy,spina bifida,reliability
                Data availability:
                ScienceOpen disciplines: Orthopedics
                Keywords: patellar height index, cerebral palsy, spina bifida, reliability

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