Jeffrey D. Ackman

Comparing botulinum toxin A with casting for treatment of dynamic equinus in children with cerebral palsy

The purpose of this study was to compare the cumulative efficacy (three treatment sessions) of botulinum toxin A (BTX‐A) alone, casting alone, and the combination of BTX‐A and casting in the management of dynamic equinus in ambulatory children with spastic cerebral palsy (CP). Thirty‐nine children with spastic CP (mean age 5y 10mo, range 3 to 9y) were enrolled in the study. A multicenter, randomized, double blind, placebo‐controlled prospective study was used. Children were randomly assigned to one of three treatment groups: BTX‐A only (B), placebo injection plus casting (C), or BTX‐A plus casting (B+C). The dosage for the BTX‐A injections was 4U/kg per extremity. Assessments were performed at baseline, 3,6,7.5, and 12 months with a total of three treatments administered after the evaluations at baseline, 3, and 6 months. Primary outcome measures were ankle kinematics, velocity, and stride length. Secondary outcome measures were ankle spasticity, strength, range of motion, and ankle kinetics. Group B made no significant change in any variable at any time. Groups C and B+C demonstrated significant improvements in ankle kinematics, spasticity, passive range of motion, and dorsiflexor strength. Results of this 1‐year study indicate that BTX‐A alone provided no improvement in the parameters measured in this study, while casting and BTX‐A/casting were effective in the short‐ and long‐term management of dynamic equinus in children with spastic CP.

Comparison of upper extremity kinematics in children with spastic diplegic cerebral palsy using anterior and posterior walkers

This prospective study analyzes the upper extremity kinematics of 10 children with spastic diplegic cerebral palsy using anterior and posterior walkers. Although both types of walkers are commonly prescribed by clinicians, no quantitative data comparing the two in regards to upper extremity motion has been published. The study methodology included testing of each subject with both types of walkers in a motion analysis laboratory after an acclimation period of at least 1 month. Overall results showed that statistically, both walkers are relatively similar. With both anterior and posterior walkers, the shoulders were extended, elbows flexed, and wrists extended. Energy expenditure, walking speed and stride length was also similar with both walker types. Several differences were also noted although not statistically significant. Anterior torso tilt was reduced with the posterior walker and shoulder extension and elbow flexion were increased. Outcomes analysis indicated that differences in upper extremity torso and joint motion were not dependent on spasticity or hand dominance. These findings may help to build an understanding of upper extremity motion in walker-assisted gait and potentially to improve walker prescription.

A biomechanical analysis of upper extremity kinetics in children with cerebral palsy using anterior and posterior walkers

Upper extremity (UE) joint kinetics during aided ambulation is an area of research that is not well characterized in the current literature. Biped UE joints are not anatomically designed to be weight bearing, therefore it is important to quantify UE kinetics during assisted gait. This will help to better understand the biomechanical implications of UE weight bearing, and enable physicians to prescribe more effective methods for treatment and therapy, perhaps minimizing excessive loads and torques. To address this challenge, an UE model that incorporates both kinematics and kinetics has been developed for use with walkers instrumented with load cells. In this study, the UE joint kinetics are calculated for 10 children with cerebral palsy using both anterior and posterior walkers. Three-dimensional joint reaction forces and moments are fully characterized for the wrist, elbow, and shoulder (glenohumeral) joints for both walker types. Statistical analysis methods are used to quantify the differences in forces or moments between the two walker types. Comparisons showed no significant differences in kinetic joint parameters between walker types. Results from a power analysis of the current data are provided which may be useful for planning longer term clinical studies. If risk factors for UE joint pathology can be identified early, perhaps a change in gait training routine, walker prescription, or walker design could prevent further harm.

Limb lengthening in pediatric patients with ollier's disease

Background: Olliers disease is a non-hereditary skeletal disorder. Orthopedic management of limb length discrepancy could be complex given the nature of bone pathology, the significant amount of length discrepancy and the difficulty to predict it. The goal of the study is to identify the outcomes and complications associated with surgical management of limb length discrepancy. Methods: This is an IRB approved, retrospective review of patients with Olliers disease who had limb lengthening. The age at the time of surgery, amount of total length discrepancy and discrepancy for each individual bone, amount of lengthening and as a ratio to the length of the bone itself, type of fixator, duration of the fixator, complications are recorded. Unpaired T-tests evaluated the effect of simultaneous versus single-bone lengthening and tibia vs. femur being lengthened on the external fixator index. One-way ANOVA test was used to evaluate the effect of osteotomy location on mean External Fixator Index (EFI). Results: 14 patients with 40 segmental limb lengthening procedures are identified. The mean LLD was 7.1 cm and mean amount of length gained was 7.8 cm. Follow up was minimum 2 years and maximum 18 years 2 months. The average fixator duration was 178.6 days. The average percent of lengthening through each bone was 19.2. The average EFI was 36.5 days/cm. There was no difference between tibia vs. femur and between simultaneous vs. single bone on EFI. There was no difference among osteotomy type. There were 3 cases of nonunion, one delayed union, 5 cases of premature consolidation. One case had fixation failure. There were 7 cases of knee stiffness of which 3 cases required surgery. Conclusions: Our study shows that Enchondromal bone appears to respond to lengthening with a structurally proper regenerate. Premature consolidation needs to be always kept in mind and appropriate adjustment should be made in the rate of lengthening.