1. Short-term Hardware Outcomes Following Patellar Tendon Advancement in Pediatric Patients with Crouch Gait AuthorsInstitutions

2. Introduction Cerebral Palsy: motor syndromes Cerebral Palsy: motor syndromes - 2° to brain development Crouch gait – spasticity/contracture Crouch gait – spasticity/contracture -Hamstring/psoas tightness -Lever-arm dysfunction -Weakness -Impaired balance Kliegman, Robert M., Richard E. Behrman, Hal B. Jenson, and Bonita F. Stanton. Nelson Textbook of Pediatrics. Philadelphia: Saunders, 2007.

3. Crouch Gait Body Mechanics Body Mechanics -Knee flexion -Hip flexion -Ankle dorsiflexion Knee and back pain Knee and back pain Quadriceps insufficiency Quadriceps insufficiency Patella alta & Elongation of patellar tendon Patella alta & Elongation of patellar tendon 2° to achilles tendon lengthening 2° to achilles tendon lengthening Stout et al. JBJS 2008 Chambers Eur J Neur 2001

4. Treatment Gait analysis for evaluation (Pre-op Mov?) Gait analysis for evaluation (Pre-op Mov?) Conservative Conservative -Occupational/Physical therapy -Assistive devices Medical Medical –Muscle relaxants –Benzodiazepines –Botulinum toxin Kliegman, Robert M., Richard E. Behrman, Hal B. Jenson, and Bonita F. Stanton. Nelson Textbook of Pediatrics. Philadelphia: Saunders, 2007.

5. Surgical Treatment Procedures typically done Procedures typically done –(Get from Halanski) –(Preop and postop x-rays) –(Preop/postop gait analysis)

6. Crouch Gait

7. Surgical Treatment Distal femoral extension osteotomy Distal femoral extension osteotomy Patellar tendon advancement Patellar tendon advancement -Patellar insertion freed -Patellar tendon advanced distally along tibia - Cercalage wire from patella to insertion Stabilize new insertion Combination Combination Stout et al JBJS 2008

8. Objective To examine the short-term outcomes of hardware failure following patellar tendon advancement in patients with crouch gait To examine the short-term outcomes of hardware failure following patellar tendon advancement in patients with crouch gait 2 Hardware types 2 Hardware types - Cercalage cable - Cercalage wire

9. Methods Retrospective cohort study radiographs Retrospective cohort study radiographs Inclusion Criteria Inclusion Criteria -Billing codes: patellar advancement -Helen DeVos Children’s Hospital -1/1/03 to 11/2/08 Exclusion criteria Exclusion criteria –Different procedure performed –Age > 17

10. Methods Patient radiographs Patient radiographs -Cercalage wire vs. cable -Failure vs. Intact Patient records Patient records -Age at procedure -Time to post-op radiograph -Time to failure Fisher’s exact test Fisher’s exact test

11. Radiographs Cercalage wire Cercalage wire Cercalage cable Cercalage cable

12. Hardware Failure

13. Results 16 Patients with 16 Patients with 31 Patellar advancements 31 Patellar advancements Fisher’s exact T-test (p < 0.001) Fisher’s exact T-test (p < 0.001) HardwareWireCable Age (years)1310 # Performed1120 # Failed90 Failure Rate89%0% Avg. Time F/U25890

14. Discussion Statistically significant advantage to cables Statistically significant advantage to cables Shorter follow-up time Shorter follow-up time Continued observation cables Continued observation cables -1 year follow-up

15. Conclusion Cables show better outcomes than wires Cables show better outcomes than wires -1 year follow-up for recommendations Possible implications Possible implications –Decrease failed hardware removal –More rapid mobilization post-op Reference

16. Future Work Continue follow-up for > 1 year Continue follow-up for > 1 year Evaluation of long-term hardware outcomes Evaluation of long-term hardware outcomes Evaluation of patellar advancement on growth plate mechanics Evaluation of patellar advancement on growth plate mechanics Evaluation of gait kinematics Evaluation of gait kinematics Reference

17. Acknowledgments Attending Attending Editor Editor Statistician Statistician Institution Institution

18. Questions?