Updated: 10/4/2016

Rectus Femoris Transfer

Preoperative Patient Care


Intermediate Evaluation and Management


Obtains focused history and physical

  • history
  • signs and symptoms
  • stiff-knee gait and tripping in GMFCS I and II children may indicate that a rectus transfer could be considered.
  • physical exam
  • assesses range of motion and prone rectus (Ducan-Ely) test
  • performs a visual observation of the child's gait
  • recognizes factors that could predict complications or poor outcome


Orders and interprets required diagnostic studies

  • computerized gait analysis, when available, is reviewed
  • no radiographs or blood tests are indicated


Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention


Postop: 1-2 Week Postoperative Visit

  • physical therapy is started, if not contraindicated by other, simultaneous, procedures
  • diagnose and management of early complications

Advanced Evaluation and Management


Modifies post-operative plan based on response to treatment

  • increases frequency and intensity of physical therapy and home program if the child is slow to progress post-operatively

Preoperative H & P


Obtains history and performs basic physical exam

  • check range of motion
  • check prone rectus (Duncan-Ely) test for rectus spasticity
  • observe the patient's gait
  • identify medical co-morbidities that might impact surgical treatment


Screen studies (including gait study) to identify and contraindications for surgery

  • the indications for rectus transfer on the gait study: 1) stiff-knee gait and 2) an overactive rectus in swing phase
  • results of distal rectus femoris transfer are best in GMFCS I and II patients


Perform operative consent

  • Describe potential complications of surgery including
  • Crouch gait
  • Failure to improve knee flexion
  • Wound dehiscence, scar spreading or infection

Operative Techniques


Preoperative Plan


Execute a surgical walkthrough

  • describe steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them

Room Preparation


Surgical instrumentation

  • Army-Navy or Sofield retractors
  • a tonsil clamp (or similar, long clamp) to bring the semitendinosus into the anterior incision.


Room setup and equipment

  • standard OR table
  • radiolucent table is needed if bone surgery is being done as part of SEMLS


Patient positioning

  • supine

Skin Incision and superficial dissection


Make the longitudinal anterior incision

  • make a 4 to 5 cm longitudinal incision over the distal anterior thigh
  • the distal extent of the incision should at the proximal tip of the patella


Dissect down to expose the quadriceps tendon.

  • dissecting scissors and/or electrocautery are used to expose the quadriceps tendon
  • the medial and lateral borders of the tendon are exposed


Make the longitudinal posterior incision

  • make a 4-5 cm longitudinal incision in the distal third of the posterior thigh
  • identify the semitendinosus and incise the overlying fascia to expose the musculotendinous junction

Deep Dissection



Develop plane between the rectus femoris and vastus intermedius tendons

  • it is easiest to separate the rectus from the remainder of the quadriceps tendon proximally, usually 4-5 cm proximal to the patella
  • incise longitudinally for a length of 1-2 cm deep along the medial (or lateral) border of the quadriceps tendon 4 to 5 cm proximal to the patella
  • find the plane between the rectus femoris and the vastus intermedius
  • develop the interval with a freer elevator and/or manual dissection with a finger
  • The plane between the rectus and the vastus intermedius separates easily with blunt dissection.


Dissect and mobilize the rectus

  • use a freer elevator to penetrate the extensor mechanism immediately adjacent to the lateral border of the rectus femoris
  • use blunt dissection to free the lateral border of the rectus
  • the rectus should be separated from the vastus intermedius as distally as possible (to ~ 1 cm proximal to the patella) using blunt dissection
  • place a 2-0 nonabsorbable whipstitch in the rectus stump
  • Dissection should proceed from proximal to distal to ensure staying in the correct plane.

Transection of the Rectus and the Semitendinosus



Transect the rectus

  • transect the rectus 1 cm proximal to the patella while leaving the vastus intermedius below it intact
  • free the tendon from all underlying attachments after placement of a whip stitch using a size 2-0 nonabsorbable braided suture
  • pull the tendon distally and free the tendon from any soft tissue attachments proximally both medially and laterally.
  • after these soft tissue attachments are released, the rectus should have an excursion of at least 1.5 to 2 cm when manual traction is applied
  • To avoid entering the knee joint, make sure that the rectus tendon is easily visualized and separate from underlying tissue.


Transect the semitendinosus

  • place a right-angle retractor around the semitendinosus and transect the tendon proximal to the musculotendinous junction
  • place a non-absorbable 2-0 whipstitch in the tendon stump and free the tendon distally

Rectus Transfer



Identify and incise the intermuscular septum

  • use small rakes to retract the medial skin flap
  • dissection is deep to the fascia overlying the vastus medialis
  • retract the vastus medialis
  • identify and incise the intermuscular septum using cautery
  • make a large 3-4 cm window in the septum to keep the rectus transfer from becoming tethered.
  • the semitendinosus tendon stump is brought into the anterior compartment through this window
  • this is facilitated by use of a tonsil (or similar) clamp to grab the whip stitch in the semitendinosus stump
  • Right angle retractors (such as Sofield retractors) can facilitate blunt dissection of the vastus medialis off the septum.


Complete the transfer

  • complete the transfer under some tension, while still allowing full knee extension

Wound Closure


Deep closure

  • simple, interrupted 2-0 absorbable sutures are used in the subcutaneous tissue


Superficial closure

  • a running 3-0 nondyed absorbable monoftilament suture is used on the skin
  • a longer-lasting monofilament (e.g. PDS) is used for the anterior incision to minimize the risks of dehiscence and spreading of the scar

Postoperative Patient Care


Perioperative Inpatient Management


Write comprehensive admission orders if the rectus transfer is part of SEMLS

  • Advance diet as tolerated
  • IV fluids
  • Pain control
  • diazepam often helps significantly with spasms
  • physical therapy for gait training if not contraindicated by other, simultaneous, procedures
  • wound management
  • not typically needed in the hospital
  • dressings may be changed POD 2 if the patient has not been discharged


Discharges patient appropriately

  • pain control
  • diazepam is often helpful for spasms in the first 5-7 days post-op
  • schedule follow up in 1-2 weeks
  • wound care
  • dressings may be removed by family 7 days post-op

Complex Patient Care


Develop a comprehensive preoperative plan that includes options based on intraoperative findings

  • this typically only occurs in the child undergoing SEMLS.

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