Michael D. Aiona

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.

Congenital longitudinal deficiency of the tibia.

Fifty-seven patients (seventy-one limbs) who had congenital longitudinal deficiency of the tibia (tibial hemimelia) were retrospectively categorized according to radiographic type (Types 1 through 4, as described by Jones et al.). At an average follow-up of nine years, fifty-six of fifty-seven patients walked independently. An ablative surgical procedure was performed on sixty-one of the seventy-one lower extremities. According to the classification of Jones et al., fifty-four limbs had a Type-1 (a or b) or Type-2 deficiency. In twenty-two of these extremities, disarticulation of the knee was performed; in twenty-five, a Syme amputation; and in one, a Chopart amputation. The ipsilateral foot was retained in six extremities that had a severe Type-1 or Type-2 deficiency. Medial transfer of the fibula (the Brown procedure) generally yielded less than satisfactory results; in ten of fourteen extremities, one or more additional operations were needed. Seventeen extremities were classified as having a Type-3 or Type-4 deficiency; Syme amputation was done in nine and Chopart amputation, in four. Despite satisfactory reconstruction of the ankle, a Syme amputation was necessary in most extremities that had a Type-4 deficiency because a major leg-length discrepancy was projected. In four limbs that had a Type-3 or Type-4 deficiency, the foot was retained.

Deficiencies of current methods for the timing of epiphysiodesis

A review of 71 epiphysiodeses with adequate orthoroentgenographic and skeletal-age data was carried out to compare the accuracy of predicting outcome among the methods of Anderson and Green, Menelaus, and Moseley. Differing the methodology did not have a meaningful effect on their similar but limited accuracy. We advocate the use of the Menelaus method, which is simple and based on chronologic age, as it proved as accurate as any other method. The routine use of serial Gruelich and Pyle skeletal-age data could not be shown to increase the accuracy in predicting outcome over serial chronologic-age data, and thus its value in limb-length inequality is limited. Regardless of the method used, unpredictable results occur in a proportion of patients. The patient and parents should be advised of this when planning strategies for limb-length discrepancy.

Evaluation of rotational gait abnormality in the patients cerebral palsy.

Internal rotation of hip is commonly seen in children with cerebral palsy. Existing muscle imbalance causes persistence of femoral deformity, which may contribute to rotational asymmetry. In cerebral palsy, gait deviations are the result of dynamic and static components, both caused by muscle imbalance. In this study we investigated the predictability of hip rotation in gait from the measurement of anatomic deformity. Computed tomography (CT) measurements of femoral anteversion and physical examination data failed to predict the hip rotation in gait. However, tibial (CT) measurements and physical examination data highly correlated with tibial rotation in gait. We conclude the dynamic component of hip rotation during gait is significant, as anatomic deformity did not predict gait deviations.

Length and force of the gastrocnemius and soleus during gait following tendo Achilles lengthenings in children with equinus

Nine subjects (12 sides) with cerebral palsy who walked in equnius were evaluated prior to and 1 year after surgical tendo Achilles lengthening. Gastrocnemius and soleus length [Gait Posture, 6 (1997) 9] and plantarflexor force [Gait Posture, 6 (1997) 9; J Biomech, 23 (1990) 495] were calculated. The length of the gastrocnemius and soleus increased significantly (P<0.01) following the intervention. Force output of the triceps surae during push-off increased significantly (13.95 N/kg body weight (BW) preop to 30.31 N/kg BW postop; P<0.01). Assessment of the force-length capacity of the triceps surae in candidates for tendo Achilles lengthenings may identify individuals at risk of residual weakness and iatrogenic crouch.

Recurrence after femoral derotational osteotomy in cerebral palsy.

The authors studied the long-term results of femoral derotational osteotomy (FDO) for medial femoral torsion in ambulatory children with cerebral palsy. Thirty children with 45 femurs that underwent distal FDO were followed for a mean of 6.5 years. Although correction was achieved after surgery, recurrence occurred during follow-up in 15 femurs. Preoperative mean external hip rotation of 10.7 ± 7.2 degrees increased to 41.3 ± 16.6 degrees 1 year after surgery and decreased to 28.2 ± 14.7 degrees 5 years after surgery. On kinematic data, maximum hip rotation in stance of 30 degrees before surgery decreased to 8.7 degrees 1 year after surgery and increased to 16.1 degrees 5 years after surgery. Minimum hip rotation of 10.4 degrees before surgery was corrected to -4.3 degrees 1 year after surgery and was 0.8 degrees 5 years after surgery. Passive hip external rotation and kinematic hip rotation showed progressive deterioration of the initial correction. Patients having surgery prior to age 10 were more likely to show deterioration.

Spinal deformity after selective dorsal rhizotomy in ambulatory patients with cerebral palsy.

Thirty-four patients with ambulatory spastic diplegia (ages 10–19.8 years) who were part of a prospective study of selective dorsal rhizotomy (SDR) had standardized radiographs before and after SDR. Follow-up ranged from 5 to 11.6 years after surgery. Two different surgical approaches were used: laminectomy (14 patients) and laminoplasty (20 patients). Radiographs were measured for coronal and sagittal balance. Thirty patients had a spinal deformity at long-term follow-up compared with 10 patients before surgery. Seventeen patients (50%) developed lumbar hyperlordosis greater than 60°. Six patients (18%) developed grade 1 spondylolisthesis, Scoliosis occurred de novo in eight patients (24%) and progressed by greater than 5° in two patients with preoperative scoliosis. No significant differences were found between laminoplasty and laminectomy patients. None of the patients have undergone any surgical intervention for spinal deformity. There was a higher incidence of spinal deformity after SDR than in normals and an historical control population, which warrants clinical and radiographic long-term follow-up.

Gait Changes in Children with Spastic Diplegia After Selective Dorsal Rhizotomy

Twenty-six ambulatory children underwent preoperative and 1-year postoperative assessments after selective dorsal rhizotomy. These included spasticity, passive range of motion, tone, three-dimensional motion analysis, and electromyography. Independent and dependent ambulators were evaluated separately. A decrease in spasticity was found in all lower extremity muscle groups. An increase in passive range of motion was found only at the hip for both independent and dependent ambulators. Gait changes included increases in velocity and stride length in the independent ambulators. An improvement in hip extension during stance was found in the dependent ambulators only; however, an increase in knee extension and dorsiflexion in stance were seen in both groups. Selective dorsal rhizotomy improves both passive and dynamic range of motion in children with spastic diplegia.

Outcome of patients after Achilles tendon lengthening for treatment of idiopathic toe walking.

Abstract: Fifteen children who were diagnosed with idiopathic toe walking that cannot be corrected by nonoperative treatment were assessed by clinical examination and computer-based gait analysis preoperatively and approximately 1 year after Achilles tendon lengthening. Passive dorsiflexion improved from a mean plantarflexion contracture of 8 degrees to dorsiflexion of 12 degrees after surgery. Ankle kinematics normalized, with mean ankle dorsiflexion in stance improving from −8 to 12 degrees and maximum swing phase dorsiflexion improving from −20 to 2 degrees. Peak ankle power generation increased from 2.05 to 2.37 W/kg but did not reach values of population norms. No patient demonstrated clinically relevant triceps surae weakness or a calcaneal gait pattern. Seven patients had a stance phase knee hyperextension preoperatively, and 6 of these corrected after surgery. Achilles tendon lengthening improves ankle kinematics without compromising triceps surae strength; however, plantarflexion power does not reach normal levels at 1 year after surgery.

Stair locomotion in children with spastic hemiplegia: the impact of three different ankle foot orthosis (AFOs) configurations.

The purpose of this study was to investigate the impact of three different ankle foot orthoses (AFO) configurations on the function and kinematics of stair locomotion in children with spastic hemiplegia. Nineteen children were evaluated barefoot and with a hinged, posterior leaf spring (PLS) and solid AFO during stair ascent and descent. Stair specific items from the Pediatric Evaluation of Disability Inventory (PEDI) were used to evaluate function, while a motion measurement system was used to evaluate kinematics. The PEDI revealed no significant differences between AFOs and barefoot, although a greater percentage of children were able to keep up with their peers while wearing a hinged AFO. At the ankle, the hinged AFO provided the greatest amount of dorsiflexion during stance. All AFOs reduced plantarflexion in comparison to barefoot. The results of this study indicate that for children with spastic hemiplegia the use of an AFO did not impair stair ambulation.