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Adductor release and chemodenervation in children with cerebral palsy: a pilot study in 16 children
Abhay Khot1, Samuel Sloan, Sameer Desai
1The Royal Children's Hospital, Flemington Road, Parkville, VIC, 3052, Australia, abhay.khot@gmail.com.
Insights
This study shows a combined surgery and Botulinum neurotoxin A injection effectively reduced hip subluxation and improved mobility in children with cerebral palsy. The intervention offers a valuable temporary solution for managing spasticity and contractures.
Area of Science:
- Pediatric Orthopedics
- Neurology
- Rehabilitation Medicine
Background:
- Bilateral spastic cerebral palsy (CP) often leads to lower limb spasticity, hip displacement, and adductor contractures.
- These conditions significantly impair gross motor function and mobility in affected children.
- Management strategies aim to improve range of motion, reduce spasticity, and enhance functional outcomes.
Purpose of the Study:
- To evaluate the short-term outcomes of a combined surgical and medical intervention for children with bilateral spastic CP.
- To assess the intervention's effectiveness in managing lower limb spasticity, hip displacement, and adductor contractures.
- To determine the impact on joint range of motion, hip migration, and gross motor function.
Main Methods:
- A prospective cohort study involving 16 children (aged 2-6 years) with bilateral spastic CP (GMFCS levels III-IV).
- Intervention included surgical adductor lengthening, obturator nerve phenolization, and Botulinum neurotoxin A injections in hamstrings and calves.
- Clinical, radiographic, and functional data were collected at 3, 6, 12, and 24 months post-intervention.
Main Results:
- Significant improvements in hip abduction, knee extension, and ankle dorsiflexion were maintained for 24 months.
- Mean hip migration percentage decreased significantly from 29% to 21% (P < 0.001).
- Gross motor function showed significant improvement based on a validated mobility scale, with no reported complications.
Conclusions:
- The combined surgical-medical approach effectively reduced hip subluxation and improved gross motor function in children with bilateral spastic CP.
- This intervention serves as a valuable temporizing measure prior to considering more definitive treatments.
- The findings support the use of this combined strategy for improving functional outcomes in pediatric CP management.
Purpose:
A pilot study with short-term outcomes of a combined surgical and medical intervention for management of generalized lower limb spasticity, hip displacement and contractures of adductors in children with bilateral spastic cerebral palsy.
Methods:
A prospective cohort study of 16 children (9 boys and 7 girls) aged 2-6 years with bilateral spastic cerebral palsy was performed. At entry, 5 were classified as level III and 11 as level IV, according to the Gross Motor Function Classification System (GMFCS). The intervention consisted of surgical lengthening of adductor longus and gracilis combined with the phenolization of the anterior branch of the obturator nerve, using 1 ml of 6% phenol, applied under direct vision at the time of lengthening of adductor longus. The hamstring and calf muscles were each injected with Botulinum neurotoxin A at a dose of 4 U/kg/muscle. Serial clinical (hip, knee, ankle joint range of motion), radiographic (migration percentage) and functional data-taken from a functional mobility scale (FMS) or GMFCS-were collected at 3, 6, 12 and 24 months post-operatively.
Results:
There was a significant increase in hip abduction, knee extension (popliteal angle) and ankle dorsiflexion, maintained for 24 months; mean hip migration percentage decreased from 29 to 21% (P < 0.001). Using a validated mobility scale, significant improvements were noted in gross motor function. There were no complications related to the intervention.
Conclusions:
The combined surgical-medical intervention resulted in a reduction of spastic hip subluxation and improvements in gross motor function, as determined by the FMS. The combined intervention is, thus, useful as a temporizing measure, before definitive decisions are made considering such interventions as dorsal rhizotomy, intrathecal baclofen and single-event, multilevel surgery.
