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Gait & Posture Jan 2022Post-stroke, patients exhibit considerable variations in gait patterns. One of the variations that can be present in post-stroke gait is knee hyperextension in the... (Review)
Review
BACKGROUND
Post-stroke, patients exhibit considerable variations in gait patterns. One of the variations that can be present in post-stroke gait is knee hyperextension in the stance phase.
RESEARCH QUESTION
What is the current evidence for the effectiveness of the treatment of knee hyperextension in post-stroke gait?
METHODS
MEDLINE, EMBASE, PEDro, CINAHL, and the Cochrane library were searched for relevant controlled trials. Two researchers independently extracted the data and assessed the methological quality. A best evidence synthesis was conducted to summarize the results.
RESULTS
Eight controlled trials (5 RCTs, 3 CCTs) were included. Three types of interventions were identified: proprioceptive training, orthotic treatment, and functional electrostimulation (FES). In the included studies, the time since the stroke occurrence varied from the (sub)acute phase to the chronic phase. Only short-term effects were investigated. The adjustment from a form of proprioceptive training to physiotherapy training programs seems to be effective (moderate evidence) for treating knee hyperextension in gait, as applied in the subacute phase post-stroke. Neither evidence for effects on gait speed nor gait symmetry were found as a result of proprioceptive training. Orthoses that cover the knee have some effects (limited evidence) on knee hyperextension and gait speed. No evidence was found for FES.
SIGNIFICANCE
This is the first systematic literature review on the effectiveness of interventions on knee hyperextension in post-stroke gait. We found promising results (moderate evidence) for some "proprioceptive approaches" as an add-on therapy to physiotherapy training programs for treating knee hyperextension during the subacute phase post-stroke, in the short-term. Therefore, initially, clinicians should implement a training program with a proprioceptive approach in order to restore knee control in these patients. Because only studies reporting short-term results were found, more high-quality RCTs and CCTs are needed that also study mid- and long-term effects.
Topics: Gait; Gait Disorders, Neurologic; Humans; Orthotic Devices; Stroke; Stroke Rehabilitation
PubMed: 34695721
DOI: 10.1016/j.gaitpost.2021.08.016 -
Orthopaedic Journal of Sports Medicine Aug 2020Symptomatic genu recurvatum is a challenging condition to treat. Both osseous and soft tissue treatment options have been reported to address symptomatic genu recurvatum. (Review)
Review
BACKGROUND
Symptomatic genu recurvatum is a challenging condition to treat. Both osseous and soft tissue treatment options have been reported to address symptomatic genu recurvatum.
PURPOSE/HYPOTHESIS
The purpose of this article was to review the current literature on surgical treatment options for symptomatic genu recurvatum and to describe the associated clinical outcomes. We hypothesized that anterior opening-wedge proximal tibial osteotomy (PTO) would be the most common surgical technique described in the literature and that this intervention would allow for successful long-term management of symptomatic genu recurvatum.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with the inclusion criterion of surgical treatment options for symptomatic genu recurvatum. Recurvatum secondary to polio, cerebrovascular accident, or cerebral palsy was excluded from this review.
RESULTS
A total of 311 studies were identified, of which 6 studies with a total of 80 patients met the inclusion criteria. Causes of genu recurvatum included physeal arrest; soft tissue laxity; and complications related to fractures, such as prolonged immobilization and malalignment. Mean follow-up times ranged from 1 to 14.5 years postoperatively. There were 5 studies that described anterior opening-wedge PTO, 2 of which used the Ilizarov distraction technique. All 3 studies that used PTO without the Ilizarov technique reported correction of recurvatum and increased posterior tibial slope; 2 of these studies also included subjective outcomes scores, reporting good or excellent outcomes in 70% (21/30) of patients. Of the studies that used the Ilizarov technique, both reported correction of recurvatum and increased posterior slope from preoperative to postoperative assessments. Both of these studies reported good or excellent subjective outcomes postoperatively in 89.5% (17/19) of patients. Additionally, 1 study successfully corrected recurvatum by performing a retensioning of the posterior capsule to address knee hyperextension, although follow-up was limited to 1 year postoperatively.
CONCLUSION
Anterior opening-wedge PTO, with or without postoperative external fixation with progressive distraction, was found to be a reliable surgical treatment for symptomatic genu recurvatum. After surgical management with PTO, patients can expect to achieve correction of knee hyperextension, restoration of a more posterior tibial slope, and increased subjective outcome scores.
PubMed: 32851107
DOI: 10.1177/2325967120944113 -
Strategies in Trauma and Limb... 2021Genu recurvatum is a rare deformity for which minimal literature exists. Non-operative management typically gives unsatisfactory results. This study aims to evaluate the...
AIM AND OBJECTIVE
Genu recurvatum is a rare deformity for which minimal literature exists. Non-operative management typically gives unsatisfactory results. This study aims to evaluate the treatment of genu recurvatum with a hexapod frame.
MATERIALS AND METHODS
A single-center retrospective chart review of genu recurvatum cases treated with a hexapod fixator application was performed. Radiographic parameters included the following: leg length discrepancy (LLD), angle of recurvatum, angle of tilt of the tibial plateau, patellar height and anatomic proximal posterior tibial angle (aPPTA). Radiographic and functional results were evaluated.
RESULTS
A total of five patients with six limbs corrected with a hexapod frame were found. Aetiology included post-traumatic (2), post-infectious (1) and idiopathic (3). The mean age at application was 13.36 (5.5-18.0) years. The total mean time in the fixator was 225 (160-412) days. The LLD decreased from a mean of 35.6 mm (0.7-50) preoperatively to a mean of 14.8 (1.0-39.3) postoperatively. The average patellar height remained similar 0.97 (0.69-1.2)-0.97 (0.51-1.6). The angle of the tilt of the tibial plateau improved from a preoperative mean of 66° (58.5-73.5°)-92.5° (80-98.5°). The angle of recurvatum improved from a preoperative mean of 26.4° (18.5-31°)-5.0° (0-9°). The aPTTA improved from (102-118°)-85.5° (77-96°).
CONCLUSION
Osteotomy distal to the tibial tuberosity and deformity correction using a hexapod frame allows for multiplanar correction. Throughout treatment, soft tissue management with physical therapy remained key to prevent knee contracture.
CLINICAL SIGNIFICANCE
A hexapod frame is a safe and accurate technique that allows correction of genu recurvatum along with concomitant deformities with low risk of complications.
HOW TO CITE THIS ARTICLE
Johnson L, McCammon J, Cooper A. Correction of Genu Recurvatum Deformity Using a Hexapod Frame: A Case Series and Review of the Literature. Strategies Trauma Limb Reconstr 2021;16(2):116-119.
PubMed: 34804228
DOI: 10.5005/jp-journals-10080-1528 -
Strategies in Trauma and Limb... 2021Sagittal guided growth of the distal anterior femur has been shown to be effective for the correction of fixed knee flexion deformity that is encountered in clinical...
AIM AND OBJECTIVE
Sagittal guided growth of the distal anterior femur has been shown to be effective for the correction of fixed knee flexion deformity that is encountered in clinical practice. The opposite deformity, namely genu recurvatum, is comparatively uncommon in children. The most common aetiology is post-traumatic. Acute correction by means of osteotomy has significant associated risks. Our objective was to determine whether a posterior 8-plate would suffice in correcting tibial recurvatum and obviate the need for an osteotomy.
MATERIALS AND METHODS
We included a total of five deformities, three boys (one bilateral) and one girl, managed by means of tethering of the posterior proximal tibial physis with a tension band plate. Standard radiographs obtained preoperatively and at follow-up included a standing anteroposterior (AP) of the legs noting limb lengths and the mechanical axis. We also obtained standing lateral views of each knee in maximal extension to measure and compare the posterior proximal tibial angle (PPTA).
RESULTS
The same-day surgery was well tolerated and there were no surgical or post-operative complications. The preoperative PPTA ranged from 106° to 117° and averaged 84° at follow-up. Correction occurred in an average of 20 months (range of 18-24 months). The patient with bilateral recurvatum due to Hurler's syndrome developed unilateral recurrent recurvatum culminating in percutaneous reinsertion of the metaphyseal screw. For each patient, knee hyperextension and associated pseudo-laxity resolved and limb lengths remained equal at follow-up.
CONCLUSION
Children with progressive genu recurvatum typically present with an insidious onset of symptoms. Guided growth of the posterior proximal tibia is a safe and effective means of correcting the deformity; osteotomy was avoided in this series.
LEVEL OF EVIDENCE
III - retrospective case series - no controls.
HOW TO CITE THIS ARTICLE
Stevens P, Stephens A, Rothberg D. Guided Growth for Tibial Recurvatum. Strategies Trauma Limb Reconstr 2021;16(3):172-175.
PubMed: 35111257
DOI: 10.5005/jp-journals-10080-1535 -
Cureus Apr 2021Recurvatum is defined as hyperextension of the knee in the stance phase of gait. Recurvatum knee is a naturally occurring common gait deviation in those with cerebral... (Review)
Review
Recurvatum is defined as hyperextension of the knee in the stance phase of gait. Recurvatum knee is a naturally occurring common gait deviation in those with cerebral palsy, along with crouch knee, jump knee, and stiff knee gaits. Early and late recurvatum occur in the first and second halves of stance. Early recurvatum is associated with dynamic calf contraction that raises the heel and pushes the knee into hyperextension as the forefoot contacts the floor. Late recurvatum occurs after the foot is already flat on the floor. As the body weight comes forward over the foot, the tibia stops its forward motion too early as the ankle comes to its range-of-motion limit. The advancing body then moves forward over a hyperextending knee. Surgical hamstring lengthening can have recurvatum as a side effect. There are several strategies to decrease this risk. Medial hamstring lengthening may be safer than combined medial and lateral lengthening. The concept here is that less lengthening or less aggressive lengthening means less recurvatum risk. However, combined medial and lateral lengthening can be reasonably safe from the risk of causing recurvatum if the knee is showing enough preoperative flexion in stance to warrant the increased surgery. More flexion in stance relates to less risk, while less flexion in stance relates to more risk. Knee flexion in stance can be measured. This is done by measuring knee flexion at initial contact and knee flexion in stance in a gait lab or with stop-action video. If there is minimal knee flexion in stance, hamstring lengthening might not be advisable, even if the hamstrings are tight on popliteal angle testing. There are other factors that contribute to recurvatum risk, such as knee hyperextension on static exam, equinus contracture, and jump knee gait. For treatment of recurvatum, the mainstay is the use of ankle foot orthoses set in dorsiflexion. Surgical equinus correction in those with early stance recurvatum can be effective but it is not likely to be effective in those with late stance recurvatum.
PubMed: 33859920
DOI: 10.7759/cureus.14408 -
Orthopedic Reviews 2022Back pain in young athletes is common. Adolescents are at an increased risk for back pain related to several factors including rapid growth. Traditionally, the... (Review)
Review
BACKGROUND
Back pain in young athletes is common. Adolescents are at an increased risk for back pain related to several factors including rapid growth. Traditionally, the conversation around back pain in the adolescent age group has been centered around diagnosis and treatment; however, there are emerging studies regarding prevention.
OBJECTIVE
The purpose of the present investigation is to summarize sport-specific risk factors, to describe the growing emphasis on prevention/screening, and report results on minimally invasive and surgical options.
METHODS
The literature search was performed in Mendeley. Search fields were varied until redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. The full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by at least 3 authors until an agreement was reached.
RESULTS
Adolescent athletes have a higher risk of developing spondylolysis and spondylolisthesis than their non-athletic counterparts. Participation in athletic activity alone, increased body mass index, varsity status, and nationally/internationally competitive status are identified are demographic risk factors. Weightlifters, gymnasts, football players, and combat athletes may be at higher risks. Increased lumbar lordosis, abdominal muscle weakness, hip flexor tightness, hamstring tightness, thoracolumbar fascia tightness, femoral anteversion, genu recurvatum, and thoracic kyphosis also predispose. Recent cadaveric and kinematic studies have furthered our understanding of pathoanatomic. There is some evidence to suggest that isokinetic testing and electromyographic data may be able to identify at-risk individuals. Perturbation-based exercise interventions can reduce the incidence of adolescent athletic back pain. There is a large body of evidence to support the efficacy of physical therapy. There is some data to support minimally invasive treatments including external bone growth simulators, steroid injections, and chemonucleolysis for specific pathologies. Endoscopic surgery results for a limited subset of patients with certain disease processes are good.
CONCLUSIONS
Back pain in adolescent athletes is common and may not lead to appropriate alterations in athletes' level of participation. Athletes with a higher body mass index should be counseled regarding the benefits of losing weight. Isokinetic testing and electromyographic data have the potential as diagnostic and screening tools. Strength deficits and postural control could be used to identify patients requiring early intervention and thus reduce the incidence. External bone growth simulators, steroid injections, and chemonucleolysis could potentially become conservative options in the future. When surgery is indicated, the endoscopic intervention has the potential to decrease operative time, decrease cost, and promote healing.
PubMed: 35936806
DOI: 10.52965/001c.37097 -
Annals of Physical and Rehabilitation... Apr 2010We carried out a systematic review of the literature on treatment of genu recurvatum in hemiparetic adult patients by searching the PubMed, Pedro, Trip Database and... (Review)
Review
INTRODUCTION AND METHODS
We carried out a systematic review of the literature on treatment of genu recurvatum in hemiparetic adult patients by searching the PubMed, Pedro, Trip Database and Science Direct databases. The following keywords were used: (recurvatum or hyperextension or knee) and (hemiplegia or hemiparesis).
RESULTS
Nine articles met our selection criteria. Four assessed retraining methods (functional electric stimulation or electrogoniometric feedback), two assessed orthopaedic or neurosurgical treatments and three articles focused on orthoses.
DISCUSSION AND CONCLUSION
Even though all the various treatments produced encouraging results, most of the reviewed studies presented methodological limitations. Moreover, none of the selected articles suggested a treatment strategy which takes account of the various aetiologies in genu recurvatum. On the basis of some of the reviewed articles and our own clinical experience, we propose an aetiology-specific treatment strategy for genu recurvatum patients. In a broad patient population, this categorization could form the basis for testing the specificity of each treatment method as a function of the cause of genu recurvatum. This approach could help confirm the clinical indications and identify the most appropriate treatment for each patient.
Topics: Humans; Joint Deformities, Acquired; Knee Joint; Paresis
PubMed: 20153279
DOI: 10.1016/j.rehab.2010.01.001 -
The Bone & Joint Journal Nov 2014Instability after total knee replacement (TKR) accounts for 10% to 22% of revision procedures. All patients who present for evaluation of instability require a thorough... (Review)
Review
Instability after total knee replacement (TKR) accounts for 10% to 22% of revision procedures. All patients who present for evaluation of instability require a thorough history to be taken and physical examination, as well as appropriate imaging. Deep periprosthetic infection must be ruled out by laboratory testing and an aspiration of the knee must be carried out. The three main categories of instability include flexion instability, extension instability (symmetric and asymmetric), and genu recurvatum. Most recently, the aetiologies contributing to, and surgical manoeuvres required to correct, flexion instability have been elucidated. While implant design and patient-related factors may certainly contribute to the aetiology, surgical technique is also a significant factor in all forms of post-operative instability.
Topics: Arthroplasty, Replacement, Knee; Humans; Joint Instability; Knee Joint; Knee Prosthesis; Range of Motion, Articular; Reoperation
PubMed: 25381421
DOI: 10.1302/0301-620X.96B11.34325 -
Arthroscopy Techniques May 2022A decreased posterior tibial slope has been associated with an increased risk of posterior cruciate ligament failure, anterior knee pain, and premature knee...
A decreased posterior tibial slope has been associated with an increased risk of posterior cruciate ligament failure, anterior knee pain, and premature knee osteoarthritis. Trauma is a common cause of osseous genu recurvatum. Surgical management is recommended to correct the tibial slope and prevent knee pain and osteoarthritis progression. This article discusses our preferred treatment using a proximal tibial opening-wedge osteotomy for surgical management of genu recurvatum secondary to significant anterior tibial slope.
PubMed: 35646563
DOI: 10.1016/j.eats.2022.01.007 -
Orthopaedics & Traumatology, Surgery &... Nov 2021Symptomatic Ligamentous Genu Recurvatum (SLGR) is characterized by an asymmetrical hyperextension of the knee associated with pain and a feeling of instability occurring...
INTRODUCTION
Symptomatic Ligamentous Genu Recurvatum (SLGR) is characterized by an asymmetrical hyperextension of the knee associated with pain and a feeling of instability occurring even during walking. The ligamentous origin of the recurvatum is linked to a sprain in hyperextension responsible for a rupture of the posterior structures that may be associated or not with a rupture of the cruciate ligaments.
HYPOTHESIS
Tibial Flexion Osteotomy (TFO) allows control of a SLGR without rupture of the cruciate ligaments secondary to a sprain in hyperextension.
MATERIAL AND METHODS
Ten patients (12 knees) including 8 women, aged 30.8 years on average (16-52) with asymmetrical SLGR secondary to a hyperextension sprain without rupture of the cruciate ligaments underwent TFO. An anterior tibial tuberosity (ATT) osteotomy was performed with an associated trans-tuberosity anterior opening wedge osteotomy of the tibia in the sagittal plane. The ATT was secured by two compression screws with lowering of the patella culminating from the opening wedge procedure. The genu recurvatum angle (GRA), tibial slope (TSangle) and patellar height according to the Caton-Deschamps index (CDI) were established. All patients were assessed using the IKDC and Lecuire scores (anatomical and functional scores).
RESULTS
The average follow-up was 4.2 years (12-106 months). The GR angle was 7.3±3.2° preoperatively versus 22.7±4.1° postoperatively (p<0.01). The TS angle averaged 95.5±2.3° preoperatively versus 104.0±3.7° postoperatively (p<0.01). The CDI decreased from 1.17±0.21 preoperatively to 0.83±0.11 postoperatively (p<0.01). The IKDC and Lecuire scores improved.
CONCLUSION
Trans-tuberosity high tibial flexion osteotomy is an effective strategy in cases of Symptomatic Ligamentous Genu Recurvatum without rupture of the cruciate ligaments secondary to a hyperextension sprain, and with constitutional hyperlaxity. This procedure allows significant clinical improvement and correction of the recurvatum deformity in the medium term.
LEVEL OF EVIDENCE
IV, retrospective descriptive study.
Topics: Adult; Female; Humans; Knee Joint; Ligaments, Articular; Osteotomy; Patella; Retrospective Studies; Tibia
PubMed: 34329759
DOI: 10.1016/j.otsr.2021.103025