Kerr Graham

The effect of botulinum toxin A on gastrocnemius length : magnitude and duration of response

Thirty‐nine ambulant children (22 with hemiplegia, 17 with diplegia) with spastic cerebral palsy receiving isolated gastrocnemius muscle injection with botulinum toxin A were studied prospectively. The children had a mean age of 6 years (range 3 to 13 years). Measurement of gastrocnemius muscle length was used to estimate the dynamic component of each childs spasticity and to quantify the response. There was a strong correlation between the dynamic component of spasticity before injection and the corresponding magnitude of the response after injection. Children undergoing repeated injections showed similar correlations. A strong correlation was found between the duration of response and the dynamic component. Children with hemiplegia showed twice the duration for a given dynamic component compared with those with diplegia when injected with the same total dose per unit body weight. Long‐term lengthening did not occur for the cohort, although some patients showed a response at a 12‐month follow‐up. By delaying shortening, the injections may have a role in delaying the need for surgery. Injections were well tolerated with few side effects.

High- or low-technology measurements of energy expenditure in clinical gait analysis?

The repeatability of energy‐expenditure measurements were studied in five children and four adults without disabilities using the Cosmed K4 (high technology). The ability to detect change in measurements was compared between this instrument and the Physiological Cost Index (PCI; low technology). The results of repeatability (95% range) for oxygen cost were 13.1% in children and 13% in adults. In contrast, the SD of PCI was 6 to 72% of the mean in adults and wider in children (91%; 95% range). The validity of PCI as an outcome measure was questioned. In addition, 177 children with motor disability were prospectively studied using the Cosmed K4. Previous experience with the Cosmed K2 (intermediate technology) helped to develop a practical and repeatable protocol for testing children with disability using the Cosmed K4. The protocol commenced with 5 minutes of rest to achieve baseline values of heart rate and oxygen consumption, followed by 10 minutes of continuous walking at a self‐selected speed on a 10–metre level oval walking track. The test concluded with 5 minutes of rest to monitor the return to baseline values. Ninety‐one percent of the children with disability quickly reached a steady‐state of oxygen consumption and carbon‐dioxide production. The carbon‐dioxide sensor in the Cosmed K4 has enabled a new group of severely involved children with cerebral palsy (9%) to be defined. These children have been termed ‘physiologically marginal ambulators’.

Prospective evaluation of a shortened regimen of treatment for acute osteomyelitis and septic arthritis in children.

Background We present the findings of a prospective, bi-center study to establish the appropriate duration of antibiotic therapy for acute, uncomplicated bone and joint infections in children. Historically, patients have been treated with prolonged courses of intravenous and oral therapy. Our hypothesis was that children could be safely treated with 3 days of high-dose intravenous therapy followed by 3 weeks of oral therapy. Methods We prospectively collected data from children presenting to Birmingham Childrens Hospital and The Royal Childrens Hospital, Melbourne who fitted our diagnostic criteria for septic arthritis and osteomyelitis over a 52-month period. Inclusion criteria for entry into the database were children ≤16 years of age who had no underlying disease or medical therapy predisposing to infection, and who had symptoms for less than 14 days before presentation. They were all started on intravenous antibiotics and a predetermined treatment algorithm was followed. All patients with septic arthritis also underwent joint washout. The patients were converted to oral antibiotics once they improved clinically and hematologically. Regular outpatient follow-up continued for 1 year with blood tests and x-rays. Results Our database included 70 consecutive, eligible children aged 2 weeks to 14 years. Staphylococci were the only organisms isolated in cases of osteomyelitis, whereas Streptococcal infection was more prevalent in patients with septic arthritis. Using our treatment protocol, we found that 59% of children could be converted to oral therapy after 3 days of intravenous therapy and 86% after 5 days. The median duration of inpatient stay was 5 days. We established that 3 weeks of oral therapy was appropriate for those patients who received 5 days or less intravenous treatment. We have identified temperature and C-reactive protein as the best quantitative means of monitoring response to therapy. All patients were clinically, hematologically, and radiologically normal before discharge 1 year post-presentation. Conclusions We have found that a shortened course of intravenous and oral antibiotic therapy is effective in the management of acute uncomplicated bone and joint sepsis in children. Level of Evidence II Prospective cohort study investigating diagnostic tests and the results of treatment.

Management of children with ambulatory cerebral palsy: an evidence-based review. Commentary by Hugh Williamson Gait Laboratory staff.

The evaluation of complex interventions, such as Single Event Multilevel Surgery (SEMLS) requires more than randomized controlled trials. Rehabilitation following SEMLS is prolonged and the outcomes of interest may not be apparent for 5 years or more after the surgery. We suggest long term, prospective cohort studies with objective outcome measures be recognized as of equal importance to randomized controlled trials. The evidence in support of instrumented gait analysis (IGA) is also reviewed. We suggest that clinical levels of evidence are not an appropriate method to evaluate a measurement tool. Specifically, IGA should be evaluated in terms of validity, reliability and cost effectiveness. We demonstrate that the use of IGA has improved medium and long term outcomes in ambulant children with cerebral palsy in a center where IGA has been used routinely both for planning SEMLS and for monitoring outcomes.

Injection frequency of botulinum toxin A for spastic equinus: a randomized clinical trial.

We compared two botulinum toxin A (BoNT‐A) injection frequency regimens, 12‐monthly versus 4‐monthly, for spastic equinus in a randomized clinical trial. The primary outcome measure was passive ankle dorsiflexion.

Quality of Life in Children With Cerebral Palsy Implications for Practice

The ability to assess the quality of life of children with cerebral palsy to inform and evaluate individual care plans, service planning, interventions, and policies is crucial. In this article, the recent evidence on quality of life in children with cerebral palsy is reviewed, with attention to the determinants of quality of life and role of this construct as a practical outcome indicator in clinical trials. Quality of life measurement advances for children with cerebral palsy are discussed with a focus on condition-specific quality of life measures, particularly, the Cerebral Palsy Quality of Life–Child, which is the first condition-specific quality of life measure for children with cerebral palsy. The article presents an overview for clinicians and researchers intending to use quality of life measures on children with cerebral palsy and provides recommendations for future research that will better inform practice in the field.

Subtalar fusion for pes valgus in cerebral palsy: results of a modified technique in the setting of single event multilevel surgery.

Background: We studied the use of cortico-cancellous circular allograft combined with cannulated screw fixation for the correction of dorsolateral peritalar subluxation in a series of children with bilateral spastic cerebral palsy undergoing single event multilevel surgery. Methods: Forty-six children who underwent bilateral subtalar fusion between January 1999 and December 2004 were retrospectively reviewed. Gait laboratory records, Gross Motor Function Classification System (GMFCS) levels, Functional Mobility Scale (FMS) scores, and radiographs were reviewed. The surgical technique used an Ollier type incision with a precut cortico-cancellous allograft press-fit into the prepared sinus tarsi. One or two 7.3 mm fully threaded cancellous screws were used to fix the subtalar joint. Radiographic analysis included preoperative and postoperative standing lateral radiographs measuring the lateral talocalcaneal angle, lateral talo-first metatarsal angle, and navicular cuboid overlap. Fusion rate was assessed with radiographs >12 months after surgery. Results: The mean patient age was 12.9 years (range, 7.8 to 18.4 y) with an average follow-up of 55 months. Statistically significant improvement postoperatively was found for all 3 radiographic indices: lateral talocalcaneal angle, mean improvement 20 degrees (95% CI, 17.5-22.1; P<0.001); lateral talo-first metatarsal angle, mean improvement 21 degrees (95% CI, 19.2-23.4; P<0.001); and navicular cuboid overlap, mean improvement 29% (95% CI, 25.7%-32.6%; P<0.001). FMS improved across all patients, with Gross Motor Function Classification System III children experiencing a 70% improvement across all 3 FMS distances (5, 50, and 500 m). All 3 radiographic measures improved significantly (P<0.001). Fusion was achieved in 45 patients and there were no wound complications. Conclusions: With this study, we demonstrate significant improvement in radiographic segmental alignment and overall function outcome with this modified subtalar fusion technique. We conclude that this technique is an effective complement for children with dorsolateral peritalar subluxation undergoing single event multilevel surgery. Level of Evidence Level IV.

Cross-sectional study to investigate the health-related quality of life in children with severe lower limb trauma in Victoria

The aim of this study is to investigate the health‐related quality of life in children with severe lower limb trauma after at least 12 months post‐injury and to assess patient and injury characteristics in association with the health‐related quality of life scores.

Functional decline in children undergoing selective dorsal rhizotomy after age 10

Selective dorsal rhizotomy (SDR) is now a well accepted option for spasticity management in children with cerebral palsy. The evidence base for this is provided by three classic randomized controlled trials and a subsequent meta-analysis. Less formal experience of the technique in routine clinical practice at a small number of specialist centres reinforces its efficacy in reducing spasticity and improving gross motor function in children for whom it is indicated. SDR only acts to reduce spasticity – so spasticity must be the primary impairment. It runs a risk of weakening muscles so functional muscle strength must be good. This requires adequate strength in the muscles themselves, but also that neither joint contractures nor lever arm dysfunction compromise functional strength. Single event multi-level surgery (SEMLS) is an equally well accepted option which has also been established to improve gross motor function. It, however, has different indications. Its primary aim is to correct muscle and joint contractures, and lever arm dysfunction. Effects on spasticity are not well understood though the effect of spasticity on individual muscles will be reduced when those muscles or their tendons are lengthened. SDR and SEMLS are thus different management options with different indications. If the study by MacWilliams et al. had been a prospective randomized controlled trial then it would have been rejected at ethical review on the grounds that deciding a child is suitable for one option would, by definition, make them unsuited to receive the other. This is not, however, a randomized controlled trial conducted under idealized conditions, but an observational analysis of what happens in the real world. The authors are to be complimented that they have identified two apparently similar groups of adolescents (judged on the basis of pre-operative gait variable scores) who have been subject to interventions that are mutually exclusive. Such cohorts are extremely useful for examining the comparative effects of interventions, but are likely to become less common as the differential indications for SDR and SEMLS become clearer. Spasticity is the main factor compromising gait and motor function in children with cerebral palsy in early and middle childhood. In later childhood and adolescence muscle and joint contractures, bony abnormalities, and muscle weakness become more important. It is thus clear that SDR is much more likely to be appropriate in early childhood. Two of the classic studies of the efficacy of SDR were limited to children below 7 years old and showed improvement in gross motor function whereas a third study which extended to 18 years showed only marginal improvement. The current study by MacWilliams et al. would appear to confirm that SDR is generally inappropriate in later childhood and adolescence when other factors are more important than spasticity. Not only is it unlikely to lead to improvements but it is now clear that there is a risk of deterioration compared with more appropriate interventions or, indeed, doing nothing.

Obituary: Ian Torode.

27 July 2015 and soon after developed major medical complications related to a pre-existing cardiac condition. He coped with the initial setbacks with humour and stoicism and made quite good progress. Regrettably, a fresh round of complications led to his passing on 9 August 2015. Ian is survived by his wife Lyn and his 2 sons Robbie and Tim. To them we extend our condolences. Ian was born on 31 October 1949 in the town of Colac, Victoria, Australia. He grew up in a family of 5 siblings, the son of the well-known and highly respected Dr Keith Torode, the local family doctor. He attended Geelong College and studied medicine at the University of Melbourne. He undertook residency in orthopaedic surgery at the University of Connecticut, Hartford, Connecticut, USA, followed by fellowship training in paediatric orthopaedics at The Hospital for Sick Children, Toronto, Canada from 1980 to 1981. He was influenced by Drs Robert Gillespie, Mercer Rang, Robert Salter, Colin Moseley, and Norris Carroll, and inspired by the late Robert Gillespie and developed an interest in congenital limb abnormalities. Ian was appointed as a consultant orthopaedic surgeon at The Obituary: Ian Torode