Orthopaedic management of knee joint impairment in cerebral palsy: A systematic review and meta-analysis.

[BACKGROUND] The optimal management of impaired knee joint function in patients with cerebral palsy (CP) remains a significant and ongoing challenge in paediatric orthopaedic surgery.

[RESEARCH QUESTION] What are the clinical and functional outcomes after operative and non-operative orthopaedic interventions for knee joint impairment in patients with CP?

[METHODS] This systematic review and meta-analysis of orthopaedic interventions for the management of knee joint impairment in paediatric CP patients evaluated study-level data in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. We performed searches of the following electronic databases from their dates of inception to November 2019: Medline (Ovid), Embase (Ovid) and Pubmed. We extracted mean differences in pre-operative and post-operative measurements for the following outcomes: minimum knee flexion in stance; knee flexion at initial contact; maximum knee flexion in swing; range of motion; popliteal angle; fixed flexion deformity angle; and mean pelvic tilt.

[RESULTS] Sixty-nine retrospective cohort studies, prospective cohort studies and RCTs comprising 2991 patients were included with 4578 knees analysed. Included studies were of sufficient quality as assessed by the MOOSE checklist. Operative interventions showed significant improvement in knee flexion at initial contact, knee flexion in stance, range of motion, popliteal angle and fixed flexion deformity which were comparable when subgrouped according to operative technique. In contrast, non-operative techniques and botulinum toxin injection did not confer significant improvements. Operative interventions for knee joint impairment led to increased mean pelvic tilt and reduced maximum knee flexion in swing.

[SIGNIFICANCE] This review provides strong evidence that operative interventions for the management of knee joint impairment in cerebral palsy patients improve knee kinematics and clinical examination findings.