Sequence of flexion contracture development in the lower limb: a longitudinal analysis of 1,071 children with cerebral palsy

Background To prevent severe contractures and their impact on adjacent joints in children with cerebral palsy (CP), it is crucial to treat the reduced range of motion early and to understand the order by which contractures appear. The aim of this study was to determine how a hip-knee or ankle contracture are associated with the time to and sequence of contracture development in adjacent joints. Methods This was a longitudinal cohort study of 1,071 children (636 boys, 435 girls) with CP born 1990 to 2018 who were registered before 5 years of age in the Swedish surveillance program for CP and had a hip, knee or ankle flexion contracture of >= 10 degrees. The results were based on 1,636 legs followed for an average of 4.6 years (range 0-17 years). The Cox proportional-hazards model adjusted for Gross Motor Function Classification System (GMFCS) levels I-V was used to compare the percentage of legs with and without more than one contracture. Results A second contracture developed in 44% of the legs. The frequency of multiple contractures increased with higher GMFCS level. Children with a primary hip or foot contracture were more likely to develop a second knee contracture. Children with a primary knee contracture developed either a hip or ankle contracture as a second contracture. Conclusions Multiple contractures were associated with higher GMFCS level. Lower limb contractures appeared in specific patterns where the location of the primary contracture and GMFCS level were associated with contracture development in adjacent joints.