Bruce R. Johnstone

Randomized trial of botulinum toxin injections into the salivary glands to reduce drooling in children with neurological disorders

The primary aim of this randomized, controlled trial was to assess the effectiveness of botulinum toxin A (BoNT‐A) injections into the submandibular and parotid glands on drooling in children with cerebral palsy (CP) and other neurological disorders. Secondary aims were to ascertain the duration of any such effect and the timing of maximal response. Of the 48 participants (27 males, 21 females; mean age 11y 4mo [SD 3y 3mo], range 6‐18y), 31 had a diagnosis of CP and 15 had a primary intellectual disability; 27 children were non‐ambulant. Twenty‐four children randomized to the treatment group received 25 units of BoNT‐A into each parotid and submandibular gland. Those randomized to the control group received no treatment. The degree and impact of drooling was assessed by carers using the Drooling Impact Scale questionnaire at baseline and at monthly intervals up to 6 months postinjection/baseline, and again at 1 year. Maximal response was at 1 month at which time there was a highly significant difference in the mean scores between the groups. This difference remained statistically significant at 6 months. Four children failed to respond to the injections, four had mediocre results, and 16 had good results. While the use of BoNT‐A can help to manage drooling in many children with neurological disorders, further research is needed to fully understand the range of responses.The primary aim of this randomized, controlled trial was to assess the effectiveness of botulinum toxin A (BoNT-A) injections into the submandibular and parotid glands on drooling in children with cerebral palsy (CP) and other neurological disorders. Secondary aims were to ascertain the duration of any such effect and the timing of maximal response. Of the 48 participants (27 males, 21 females; mean age 11y 4mo [SD 3y 3mo], range 6-18y), 31 had a diagnosis of CP and 15 had a primary intellectual disability; 27 children were non-ambulant. Twenty-four children randomized to the treatment group received 25 units of BoNT-A into each parotid and submandibular gland. Those randomized to the control group received no treatment. The degree and impact of drooling was assessed by carers using the Drooling Impact Scale questionnaire at baseline and at monthly intervals up to 6 months postinjection/baseline, and again at 1 year. Maximal response was at 1 month at which time there was a highly significant difference in the mean scores between the groups. This difference remained statistically significant at 6 months. Four children failed to respond to the injections, four had mediocre results, and 16 had good results. While the use of BoNT-A can help to manage drooling in many children with neurological disorders, further research is needed to fully understand the range of responses.

Cemented Versus Uncemented Surface Replacement Arthroplasty of the Proximal Interphalangeal Joint With a Mean 5-Year Follow-Up

PURPOSE To retrospectively compare the long-term results of cemented and uncemented surface replacement arthroplasties of the proximal interphalangeal (PIP) joint in a single surgeons experience. METHODS A cemented prosthesis was used on 18 patients for 27 PIP joints between February 1997 and September 2000. An uncemented prosthesis was used on 18 patients for 21 PIP joints between September 2000 and June 2003. The preoperative and postoperative pain score (0-10) during activities of daily living and the active range of motion for each digit as well as radiographs were assessed. Patients with less than 2 year of follow-up were excluded unless the short follow-up was due to prosthesis removal. Mean follow-up was 5 years. RESULTS Data were available for 28 patients who collectively received 24 cemented implants and 19 uncemented implants. The average length of follow-up was 4 years for the uncemented group and 6 years for the cemented group. The average pain score decreased by 5.5 units after the operation, and the average arc of motion increased by 13 degrees after the operation. No evidence was found for any association between implant type and postoperative pain and motion measurements. Very strong evidence was found for an association between implant type and subsidence, with 1 cemented implant subsiding compared with 13 uncemented implants. There was no evidence for an association between implant type and joint failure. CONCLUSIONS There was no difference in the postoperative pain scores or the postoperative arc of motion for the cemented versus the uncemented group. There were significantly more cases with radiologic evidence of loosening in the uncemented group (p < .001). Revision rate was higher in the uncemented group (26%) compared with that of the cemented group (8%), but this was not a significant difference (risk difference, -0.18; 95% confidence interval, -0.040 to 0.05).

Carpal tunnel syndrome in children with mucopolysaccaridoses

Carpal tunnel syndrome in children is uncommon. Mucopolysaccharidosis is the most common cause of carpal tunnel syndrome in this age group. With new treatment modalities available for mucopolysaccaridoses, the prognosis of the disease has greatly improved. The musculoskeletal manifestations including carpal tunnel syndrome now assume more importance. Early diagnosis and treatment of carpal tunnel syndrome in these children are important to achieve a good outcome. The authors present their experience in the management of children with mucopolysaccharidosis and carpal tunnel syndrome.

Prospective analysis of the outcome of surgical management of drooling in the pediatric population: a 10-year experience.

Background: Sialorrhea is a common problem in the neurologically impaired pediatric patient and surgery is the mainstay of treatment for severely affected patients refractory to conservative or medical treatment. Methods: The results of the surgical protocol used since 1993 at the Royal Children’s Hospital in Melbourne, Australia, are reported. Seventy-two patients underwent bilateral submandibular duct transposition combined with bilateral sublingual gland excision. Patients were analyzed prospectively and reviewed at 1, 6, and 12 months, then at 2 and 5 years postoperatively. Results: Of 67 patients with 2 years of complete follow-up, the median score for the frequency of drooling fell from 4.0 to 2.9 (p < 0.001) and the median severity-of-drooling score decreased from 4.8 to 3.0 (p < 0.001). There was a fall in the number of clothing/bib changes from a median of four per day to zero (p < 0.0001). Of 41 patients followed to 5 years, both the median frequency and severity of drooling scores remained at 3. Overall the majority of patients benefited from surgery. Thirteen patients (18 percent) experienced complications which were major in 9 percent. Conclusion: We have found bilateral sublingual gland excision in combination with bilateral submandibular duct transposition to be superior to bilateral submandibular duct transposition plus parotid duct ligation. The surgical treatment of sialorrhea continues to be a rewarding experience for our multidisciplinary team.

Lawn mower injuries in children: a 30-year experience.

Background:  Lawn mowers cause severe injuries that are particularly devastating to children. This study analyses the patterns and trends in lawn mower injuries involving children referred to Victoria’s principal children’s hospital.

Spinal accessory nerve transfer outperforms cervical root grafting for suprascapular nerve reconstruction in neonatal brachial plexus palsy.

Background: The authors evaluated long-term shoulder function in patients with neonatal brachial plexus palsy undergoing suprascapular nerve reconstruction with cervical root grafting or spinal accessory nerve transfer. Methods: A retrospective review was performed on all infants presenting with neonatal brachial plexus palsy between 1994 and 2010. Functional outcomes were compared by type of suprascapular nerve reconstruction. Results: Seventy-four patients met the inclusion criteria (46 transfers, 28 grafts). Both groups presented with an active movement scale score of 2.0 for shoulder abduction and 0.0 for external rotation. Postoperative follow-up was 9.0 years for the graft group and 6.7 years for the transfer group. Both groups achieved an active movement scale score of 5.0 for shoulder abduction at 12, 24, and 36 months postoperatively. Active movement scale scores for shoulder external rotation were 1.0, 2.0, and 2.5 for the graft group versus 2.0, 2.0, and 3.0 for the transfer group at 12, 24, and 36 months postoperatively. None of these differences reached statistical significance. Composite Mallet scores were 13.0 for the graft group versus 15.0 for the transfer group at 3 years (p = 0.06) and 13.0 for the graft group versus 16.0 for the transfer group at 5 years postoperatively (p = 0.07). Secondary shoulder surgery was performed on 57.1 percent (16 of 28) of patients with grafts compared with 26.1 percent (12 of 46) of patients with transfers (OR, 3.17; p = 0.02). Conclusion: Suprascapular nerve reconstruction by cervical root grafting results in poorer shoulder function and a two-fold increase in secondary shoulder surgery compared with spinal accessory nerve transfer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Functional and cosmetic outcome of surgery for cerebral palsy in the upper limb

Function, cosmesis, hygiene, and ability to dress can be improved by appropriate surgery. This frequently involves multiple simultaneous procedures and addresses the muscles, their tendons, and the joints they pass over. The improvement in cosmesis is most profound in hemiplegic patients. Overall, patients are satisfied with the results of surgery.

TOE-TO-HAND TRANSFER IN SYMBRACHYDACTYLY

Symbrachydactyly, or central atypical cleft, is classified as a failure of formation. For the adactylous or monodactylous forms, free toe transfer is the treatment of choice. We present 18 free toe transfers in 13 patients for symbrachydactyly. Despite abnormal anatomy, the functional building blocks have always been available and transfer technically possible. The result has been improved function and high levels of parental satisfaction.

Lipoblastoma: An important differential diagnosis of tumours of the hand in children

Abstract Lipoblastoma is a rare benign neoplasm of infancy and childhood with the potential for locally invasive, rapid growth. It has an excellent prognosis, and does not metastasise. An important differential diagnosis for these rapidly-enlarging tumours is liposarcoma. Ultrasound, magnetic resonance imaging, fine needle aspiration, and cytogenetics are important diagnostic tools for this rare tumour. We present two cases of lipoblastoma of the hand that were excised within a three month period with no evidence of recurrence at 14, and 12, months respectively.

Poly Implant Prothèse silicone breast implant rupture, gel bleed and fatigue in a ‘blinded’ patient

We read with interest and congratulate Miller et al. for successfully implementing remote telementoring for retroperitoneoscopic adrenalectomy (RA). However, their claim that this is locally a new surgical technique and adoption of RA has been slow is not entirely correct. The potential advantages of retroperitoneal over a transperitoneal approach for laparoscopic adrenalectomy has been well reported. This includes more direct access to the adrenal gland without the need to mobilize and retract intra-abdominal structures and possibly a shorter operative time and length of stay. Local Australasian urologists that perform laparoscopic retroperitoneal renal surgery (nephrectomy, partial nephrectomy, pyeloplasty) have been performing RA for a number of years and our senior urology registrars are trained in this procedure. The operative technique and outcomes for both retroperitoneal approaches (posterior or lateral) are very similar, except for patient positioning.Although Miller et al. performed RAin the prone jackknife position, we suggest that a lateral decubitus position is preferable as there is potentially less airway and respiratory risk in the lateral position, especially in the co-morbid obese patient. Also, in the unlikely event of open conversion, the patient is already in position for a flank incision.The only possible advantage with a posterior approach is the feasibility of bilateral adrenalectomies without patient repositioning.