Thirty-one severe, symptomatic valgus deformities of the hindfoot in twenty children who had flatfoot (twenty-five feet) or skewfoot (six feet) were corrected with a modification of the calcaneal lengthening osteotomy described by Evans. Despite prolonged non-operative treatment, all patients had pain, a callus, ulceration, or a combination of these signs and symptoms under the head of the plantar flexed talus; they could not tolerate a brace, and shoe wear was excessive. Twenty-six of the deformities were secondary to an underlying neuromuscular disorder. The calcaneal lengthening was combined with an opening-wedge osteotomy of the medial cuneiform to correct the deformities of both the hindfoot and the forefoot in the patients who had a skewfoot. Other concurrent osseous and soft-tissue procedures were frequently performed in the flatfeet and skewfeet to correct adjacent deformities or to balance the muscle forces. Allograft bone was used in twenty-four feet and autogenous bone, in seven. The patients ranged in age from four years and seven months to sixteen years at the time of the operation. The duration of follow-up ranged from two years to three years and seven months after the operation. Satisfactory clinical and radiographic correction of all components of the deformity of the hindfoot was achieved in all but the two most severely deformed feet. These two feet had sufficient correction to eliminate the symptoms despite a small persistent callus under the head of the talus. The pain and callus were eliminated in all of the other feet, the patients were able to tolerate a brace, and shoe wear was improved. Subtalar motion was preserved in all feet except for the four that had had a limited joint arthrodesis performed previously or simultaneously for pre-existing degenerative osteoarthrosis. Calcaneal lengthening is effective for the correction of severe, intractably symptomatic valgus deformities of the hindfoot in children. My patients had resolution of the signs and symptoms associated with the deformity while avoiding the need for an arthrodesis and the many short and long-term complications associated with it.

Calcaneal lengthening for valgus deformity of the hindfoot. Results in children who had severe, symptomatic flatfoot and skewfoot.

The role of intramuscular botulinum toxin A in the treatment of 26 children with cerebral palsy was evaluated. The indication for injection was the presence of a dynamic contracture of lower-limb muscles interfering with positioning or walking. Spastic target muscles were identified by clinical examination and, in ambulant children, by gait analysis. Between 50 and 320 units of botulinum toxin were injected into each muscle group to a total dose of 100 to 400 units per child. The effects of injection were monitored by repeated clinical examination and gait analysis. There were no clinically detectable systemic side-effects, and all but one patient had a reduction in tone, which occurred within three days and persisted for two to four months. There were significant improvements in ambulatory status and in sagittal-plane kinematics. In some cases these gains persisted after the tone-reducing effects of the toxin had worn off.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1469-8749.1994.tb11864.x

Botulinum toxin in the management of the lower limb in cerebral palsy

Increased gastrocnemius/soleus muscle tone in children with cerebral palsy may cause an equinus of the ankle. Botulinum toxin type A (BTX), a neuromuscular blocking agent, reduces muscle tone in various neuromuscular disorders. The safety and short-term efficacy of BTX injections were evaluated in a prospective, 3-month, double-blind, randomized clinical trial involving 114 children with cerebral palsy and dynamic equinus foot deformity. Outcome was determined by observational gait analysis, ankle range-of-motion measurements, and quantification of muscle denervation by nerve conduction. Patients in the BTX group demonstrated improved gait function and partial denervation of the injected muscle. No serious adverse events were reported.

Botulinum toxin type A neuromuscular blockade in the treatment of lower extremity spasticity in cerebral palsy: a randomized, double-blind, placebo-controlled trial. BOTOX Study Group.

Summary Increased gastrocnemius/soleus muscle tone in children with cerebral palsy may cause an equinus of the ankle. Botulinum toxin type A (BTX), a neuromuscular blocking agent, reduces muscle tone in various neuromuscular disorders. The safety and short-term efficacy of BTX injections were evaluated in a prospective, 3-month, double-blind, randomized clinical trial involving 114 children with cerebral palsy and dynamic equinus foot deformity. Outcome was determined by observational gait analysis, ankle range-of-motion measurements, and quantification of muscle denervation by nerve conduction. Patients in the BTX group demonstrated improved gait function and partial denervation of the injected muscle. No serious adverse events were reported.

Botulinum Toxin Type A Neuromuscular Blockade in the Treatment of Lower Extremity Spasticity in Cerebral Palsy: A Randomized, Double-blind, Placebo-controlled Trial

Background: To analyze the effects of multiple preoperative, intraoperative, and postoperative factors on the intermediate results of triple arthrodesis, we focused on preoperative deformity, preoperative diagnosis, degree of clinical and radiographic correction, and arthritis of the ankle. Methods: Between 1987 and 1995, 160 patients were managed with a total of 183 triple arthrodeses. Patients who had an infection or neuroarthropathy or who were managed with a revision arthrodesis were excluded from our study. Of the 160 patients, 111 (132 feet) who had been followed for a minimum of two years formed our study group. Each patient had an arthrodesis with rigid screw fixation and realignment of the joint surfaces without resection of wedges. The average duration of follow-up was 5.7 years (range, 2.0 to 10.8 years). Results: As seen radiographically, arthritis of the ankle was significantly more severe postoperatively than preoperatively (p < 0.01), although patient satisfaction was not associated with the presence of arthritis. On a scale (not a visual analog) of 0 (not satisfied) to 10 (completely satisfied), overall satisfaction averaged 8.3 points (range, 0 to 10 points). The postoperative modified ankle-hindfoot score of the American Orthopaedic Foot and Ankle Society averaged 60.7 points (range, 0 to 94 points). There was a significant association (p = 0.001) between satisfaction of the patient and postoperative alignment. Ten patients had a total of eleven complications: four superficial wound problems, three nonunions, one case of superficial peroneal neuritis, one case of Charcot-like neuroarthropathy of the foot (in a patient in whom diabetes developed during the followup period), one rupture of the Achilles tendon, and one case of peroneal tenosynovitis. Of the 111 patients, 101 (91 percent) stated that they would have the procedure again under similar circumstances, and this response was independent of the preoperative diagnostic or deformity group. Conclusions: Triple arthrodesis for the treatment of various deformities and etiologies is effective in relieving pain and improving functional deficits. Although a high prevalence of subsequent arthritis of the ankle was noted clinically and radiographically, we could detect no association between satisfaction of the patient and arthritis.

Clinical outcome after primary triple arthrodesis.

SUMMARY

The use of intramuscular alcohol in treating cerebral-palsied children has led to reduced spasticity for varying periods of time, although the periods diminish with each subsequent injection. During the period of reduced spasticity there is an opportunity for therapists and orthopaedic surgeons to determine whether corrective surgery is indicated. The injections have produced no adverse effects.



RESUME

L'utilisation de l'alcool intramusculaire dans le traitement des enfants IMC a permis de reduire la spasticite durant des periodes variees, quoique la duree d'action ait diminue apres chaque nouvelle injection. Durant la periode de spasticite reduite, il y a possibilite pour les reeducateurs et les chirurgiens orthopediques de rechercher si la chirurgie corrective est indiquee. Les injections n'ont pas produit d'effets nocifs.



ZUSAMMENFASSUNG

Die Anwendung von intramuskuldren Alkoholinjektionen bei der Behandlung der spastischen Cerebralparese



Durch intramuskulare Alkoholinjektionen bei cerebralparetischen Kindern konnte eine verminderte Spastizitat von unterschiedlicher Zeitdauer erreicht werden. Die Zeitspannen werden allerdings mit jeder weiteren Injektion kiirzer. In der Phase der verminderten Spastizitat haben Therapeuten und Orthopaden Gelegenheit festzustellen, ob eine operative Korrektur angezeigt ist. Die Injektionen hatten keine schadlichen Nebenwirkungen.



RESUMEN

La utilization de alcohol intramuscular como ayuda en el tratamiento de la paralisis cerebral espastica



La utilization de alcohol intramuscular en el tratamiento de ninos con paralisis cerebral ha conducido a la reduccion de la espasticidad por periodos de tiempo variables, aunque estos periodos disminuyen con cada inyeccion subsiguiente. Durante el periodo de espasticidad reducida el terapeuta y el cirujano ortopedico tienen la oportunidad para determinar si esta indicada una cirugia correctiva. Las inyecciones no han producido ningun efecto adverso.

Intramuscular alcohol as an aid in management of spastic cerebral palsy.

:Review of 66 triple arthrodeses in 47 children (average age at operation, 12.1 years) with a minimal follow-up of two years provides a study of contemporary experience with this surgical procedure. Over 90% of patients had no or negligible pain; 79% considered their feet to be satisfactory

Donald G. Seitz

Papers

Intramuscular alcohol as an aid in management of spastic cerebral palsy.

Triple arthrodesis in children: a ten-year review.