Transcript Botulinum Toxin in Pediatric Stiff Hips

3rd International Conference on
Pediatrics
May 18-20, 2015 Texas, San Antonio,
USA
Dr. Tamer Rizk
Consultant Pediatric Neurologist
Al-Takhassusi Hospital, Habib Medical Group
Riyadh, Saudi Arabia
Background
Objective
Methods
Results
Discussion
• Conclusion
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Botulinum toxin has been used in various indications in pediatric
age group, with promising results in relieving pain and spasticity
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Childhood is the optimal time to intervene to maximize the
motor function of pediatric patients with cerebral palsy
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Botulinum toxin is a well-tolerated anti-spasticity treatment
that is effective for the hip adductors providing an important
contribution to the management of non-ambulatory cerebral
palsy children and improves their quality of life
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Targeted Botulinum toxin injections reduced pain in children
with significant spasticity and pain at the hip level
The aim of this study is
to show the
Functional & Orthopedic
Contributions of
Botulinum Toxin
in the
Treatment of Pediatric Stiff Hips
4 pediatric patients with Post-Operative Stiff
Hips were included
3 patients with
complicated
developmental dysplasia
of the hip post multiple
revision surgeries
1 case of spastic CP after hip
surgery was injected by botulinum
toxin in selected muscles as an
adjunctive modality to the
standard orthopedic and
rehabilitation managements
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3 years old girl with bilateral DDH.
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One stage bilateral open reduction
without acetapuloplasty was performed
at the age of 26 months.
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Follow up X-ray after 4 weeks showed
dislocated right hip in the spica cast.
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Revision surgery was done twice for redislocation, including acetabuloplasty
and femoral osteotomy.
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She had a fracture distal femur in
between, the total casting was around
28 weeks.
Pelvic X-ray showing dislocation of
the right hip in hip spica cast, 4
weeks postoperatively.
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A significant decrease in range of motion was noticed in both
hips and she was walking with a limp & hyperlordosis.
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Hip flexion was only from 40- 90 degrees. Abduction, adduction,
and rotation were < 20 degrees each.
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Extensive physiotherapy didn’t show a significant improvement.
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Decision to admit her for rehabilitation and botulinum toxin
injection in the quadriceps, hip adductors and Sartorius muscle
(100 units in each muscle).
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She showed a marked improvement with her range of
movements, spasm, pain and limping that started at two weeks
post injection and continued till in her last follow up.
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4 yr old girl was diagnosed with
bilateral DDH at 16 months.
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At the age of 2 years she had bilateral
hip surgery (anterior open reduction&
Pemberton’s acetabuloplasty).
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She had two revision hip surgeries for
re-dislocation of both hips at 2 settings
with a total casting time of 24 weeks.
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With the removal of the last cast, both
hips were manipulated under
anaesthesia and the patient was
referred for an extensive PT.
Postoperative pelvic X-ray
showing both hips after
bilateral open reduction
and Pemberton’s
acetabuloplasty.
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Right hip flexion was from 30 to 90 and in
the left 10–90 degrees with very limited
rotation and abduction.
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At 3 months she was re-assessed for hip
ROM; she had only gained 110 degrees of
flexion, and around 20 degrees of
abduction and rotation on either side.
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Botulinum toxin injection (100 units in
the quadriceps, 100 units in the hip
adductors and 100 units in the Sartorius
muscle)  decreased stiffness in both
hips; facilitated physiotherapy and
rehabilitation measures that improved
her range of motion to near normal in the
last follow up at the age of 4 years
Pelvic X-ray six weeks post cast
removal showing
bilateral concentric reduction of
both hips but hips were stiff.
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7 yr old female with left DDH at an early age; parents refused intervention.
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At 5 years of age parents agreed for surgical treatment (open reduction,
acetabuloplasty and femoral shortening osteotomy).
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3 months post operation the hip spica cast was removed.
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Left hip was found in fixed flexion (80 degrees), abduction and external
rotation deformity.
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She started to walk with a clear limp and a lordotic gait.
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She was subjected to extensive in-patient followed by outpatient PT.
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Due to failure in gaining significant range of motion, the left hip flexors and
adductors were released surgically.
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However optimum results were not achieved.
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Botulinum toxin injection (100 units in the quadriceps, 100
units in the hip adductors and 100 units in the Sartorius
muscle).
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This was followed by extensive physical therapy that
resulted in an improvement in range of motion.
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Botulinum toxin injection was also beneficial in decreasing
the limp, pelvic obliquity and spinal deviation .
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Slight limitation of flexion and internal rotation (10–15
degrees) was observed at the left hip in her last follow up.
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A 17-year-old female; known to have diplegic CP presented
with right hip pain and limping.
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She was seen at the movement disorders clinic for spasticity
management, she had leg length discrepancy and pain in her
right hip.
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She was diagnosed with right hip severe subluxation, for
which she had right hip Chiari osteotomy.
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After surgery she developed severe muscle spam, pain and
spasticity in the right lower extremity much more than the
left side and more than before surgery.
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Botulinum toxin injection was given twice, six months apart
(100 units in the quadriceps,100 units in the adductors, and
100 units in the hamstring muscles).
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She had an improvement in spasticity, pain and in her gait.
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In the last follow up visit she was using a cane to assist her in
long distance walking but she was pain free with equal hip
range of motion
Mutlu A, Livanelioglu A, Gunel KM. Reliability of ashworth and modified ashworth scales in children with spastic cerebral palsy. BMC Musculoskelet Disord 2008; 9: 44. http://dx.doi.org/10.1186/
1471-2474-9-44.
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All patients experienced:
• Significant reduction in pain
• Significant improvement in posture, range of motion & mobility.
• Improvement at 2 weeks period (max effect of the Botulinum toxin).
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No serious complications were reported that were directly
related to the use of Botulinum toxin treatment.
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3 DDH cases needed single injection to get the desired outcome;
Fourth CP patient:
• Needed 2 injections (2 doses) to get the desired outcome, probably
due to her original spasticity.
• Showed initial improvement after 2 weeks, but she has to be injected
after 6 months (wearing off of the effect of the Botlinum toxin)
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All muscles injected matched the clinical presentation
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Options for treatment of a postoperative stiffness:
▪ Physiotherapy
▪ Manipulation under anaesthesia
▪ Surgical debridement or releases
 the gain in the range of motion with physiotherapy is often modest
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Surgeon can forcefully overcome adhesions with manipulation
under anaesthesia, while moving the joint through the desired
range of motion paying attention to exert enough force to move
the joint and not enough to fracture the already weakened bone
“by long immobilization and reduced mobility”.
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In refractory cases, surgical release of adhesions often is used.
Fitzsimmons SE, Vazquez EA, Bronson MJ. How to treat the stiff total knee arthroplasty?: a systematic review.
Clin Orthop Relat Res 2010; 468(4): 1096–1106.
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Multiple disciplinary team in spasticity clinic, including:
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Pediatric neurologist
Pediatric orthopaedic surgeon,
Pediatric rehabilitation medicine,
Pediatric physical therapist
As the experience with Botulinum toxin injection is well
established in our centre; the idea of using Botulinum toxin
injection came out, knowing its safety and effectiveness even
after repeated injections.
Mannava S, Callahan MF, Trach SM, Wiggins WF, Smith BP, Koman LA, et al. Chemical denervation with botulinum neurotoxin a improves the
surgical manipulation of the muscle-tendon unit: an experimental study in an animal model. J Hand Surg Am 2011; 36(2): 222–231.
Lowe K, Novak I, Cusick A. Repeat injection of botulinum toxin A is safe and effective for upper limb movement and function in children with
cerebral palsy. Dev Med Child Neurol 2007; 49(11): 823–829.
Seyler TM, Jinnah RH, Koman LA, Marker DR, Mont MA, Ulrich SD, Bhave A. Botulinum toxin type A injections for the management of flexion
contractures following total knee arthroplasty. J Surg Orthop Adv 2008; 17(4): 231–238.
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Botulinum toxin has been used to decrease postoperative
spasticity-related pain and in postoperative contractures in
cases post total knee and total hip arthroplasty.
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It has been shown that the chemical denervation effect of
Botulinum toxin leads to temporary paralysis that relieves
muscle over activity, which is a direct cause of muscle
shortening and the decrease in range of motion.
Seyler TM, Jinnah RH, Koman LA, Marker DR, Mont MA, Ulrich SD, Bhave A. Botulinum toxin type A injections for the management of flexion contractures
following total knee arthroplasty. J Surg Orthop Adv 2008; 17(4): 231–238.
Ramachandran M, Eastwood DM. Botulinum toxin and its orthopaedic applications. J Bone Joint Surg Br 2006; 88(8): 981–987.
Bhave A, Zywiel MG, Ulrich SD, McGrath MS, Seyler TM, Marker DR, Delanois RE, Mont MA. Botulinum toxin type A injections for the management of muscle
tightness following total hip arthroplasty: a case series. J Orthop Surg Res 2009; 26(4): 34. http://dx.doi.org/10.1186/1749-799X-4-34.
Huet de la Tour E, Tardieu C, Tabary JC, Tabary C. Decrease of muscle extensibility and reduction of sarcomere number in soleus muscle following a local
injection of tetanus toxin. J Neurol Sci 1979; 40(2-3): 123–131.
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The presented cases showed that botulinum toxin injection
helped to:
• Reduce pain
• Increase range of motion in:
 Young patients with pain and stiffness after surgery for
difficult and complex complicated DDH cases
 CP patients post hip surgery.
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These findings confirm previous reports of the role of botulinum
toxin as a potentially effective adjunct therapy, which stabilize
the condition and improve the quality of life in CP cases, Even
complete recovery can be anticipated in older children.
Cullen DM, Boyle JJW, Silbert PL, Singer BJ, Singer KP. Botulinum toxin injection to facilitate rehabilitation of muscle imbalance syndromes in sport medicine. Disabil Rehabil 2007; 29
(23): 1832–1839.
Lundy CT, Doherty GM, Fairhurst CB. Botulinum toxin type A injections can be an effective treatment for pain in children with hip spasms and cerebral palsy. Dev Med Child Neurol 2009;
51(9): 705–710.
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The presented cases demonstrate that
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Preliminary results of using Botulinum toxin are promising
• It is a potentially rewarding management option
• It could be considered in the management of postoperative stiff hips in
the pediatric age group, especially in difficult cases that are refractory to
standard treatment.
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It is recommended to recruit more patients to establish this
line of treating postoperative hip stiffness in children.
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Muscle selection, injection techniques and participation of all
concerned subspecialties utilizing appropriate modalities of
treatment will result in well-defined treatment goals and
outcome.
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Choice of muscles for Botulinum toxin administration
necessitates:
• Clinical examination looking for
• painful muscles /spastic/ with decreased range of motion.
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To increase the effectiveness of Botulinum toxin :
• Inject inside the fascial compartment
• Appropriate dose so the diffusion occurs with minimizing
unwanted spread.
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Post injection, a measurable goal should be set to reach
through MDT; (PT, neurology & orthopedic surgery).
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Tight soft tissue stretching, activation of weak muscles and
re-educating the affected muscles through functional
exercises that leads to regaining of normal function.
Cullen DM, Boyle JJW, Silbert PL, Singer BJ, Singer KP. Botulinum toxin injection to facilitate rehabilitation of muscle imbalance es in sport medicine. Disabil Rehabil 2007; 29 (23):
1832–1839.
Ramachandran M, Eastwood DM. Botulinum toxin and its orthopaedic applications. J Bone Joint Surg Br 2006; 88(8): 981–987.
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These preliminary results of botulinum toxin injection when
given to selected muscle groups seem to be promising in
relieving pain, improving range of motion and function in
pediatric patients with postoperative stiff hips.
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It should be considered as a treatment option in the
management of difficult cases of postoperative stiff hips
refractory to physiotherapy.
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To our knowledge, no previous study has shown the results of
Botulinum toxin in postoperative stiff hips in children.
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Limitations of this study are the small number of the patients
and the lack of a control group.
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Botulinum toxin injection when given to selected muscles
appears effective in:
• Relieving pain
• Improving range of mobility
 in patients with complicated DDH and CP
• Botulinum toxin is a potentially rewarding management
option that should be considered in the management of stiff
complicated DDH post surgical intervention.
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Muscle selection and participation of all concerned subspecialties will improve the outcome.
Thanks