The Influence of Botulinum Toxin A Injections into the Calf Muscles on Genu Recurvatum in Children with Cerebral Palsy

Overview

Journal Clin Orthop Relat Res

Publisher Wolters Kluwer

Specialty Orthopedics

Date 2013 Mar 7

PMID 23463290

Citations 5

Authors

Matthias C M Klotz

Sebastian I Wolf

Daniel Heitzmann

Simone Gantz

Frank Braatz

Thomas Dreher

Affiliations

Soon will be listed here.

Abstract

Background: With cerebral palsy (CP), an equinus deformity may lead to genu recurvatum. Botulinum toxin A (BtA) injection into the calf muscles is a well-accepted treatment for dynamic equinus deformity.

Questions/purposes: The purpose of this study was to determine whether BtA injections into the calf muscles to decrease equinus would decrease coexisting genu recurvatum in children with diplegic CP.

Methods: In a retrospective study, 13 children (mean age, 5 years) with spastic diplegic CP showing equinus and coexisting primary genu recurvatum, who were treated with BtA injections into the calf muscles, were included. Evaluations were done before and 6 and 18 weeks after intervention using three-dimensional gait analysis and clinical examinations according to a standardized protocol. Basic statistical analyses (power analysis, ANOVA) were performed to compare genu recurvatum before treatment and at 6 and 18 weeks after injection with BtA.

Results: During stance phase, maximum ankle dorsiflexion was increased substantially from -3.0° ± 14.3° before to 6.2° ± 14.2° 6 weeks after the injections. Despite this, with the numbers available, the amount of recurvatum in stance did not improve with treatment at either 6 or 18 weeks. There was significant improvement of knee hyperextension during stance phase of 6.2° between baseline and 18 weeks after BtA injection, but a genu recurvatum was still present in most patients.

Conclusions: Despite improvement of ankle dorsiflexion after injection with BtA, genu recurvatum did not show relevant improvement at 6 or 18 weeks after injection with the numbers available. Because knee hyperextension remained in most patients, other factors leading to genu recurvatum should be taken into consideration. In addition, a botulinum toxin-induced weakness of the gastrocnemius may explain why recurvatum gait was not significantly reduced.

Level Of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Citing Articles

A New Method for Postural Misalignment of a 6-Year-Old Girl With Cerebral Palsy: A Case Report.

Hou Y, Zheng H, Li J, Wang S, Zhang D, Tang T Arch Rehabil Res Clin Transl. 2021; 3(2):100116.

PMID: 34179752 PMC: 8212001. DOI: 10.1016/j.arrct.2021.100116.

Recurvatum of the Knee in Cerebral Palsy: A Review.

Yngve D Cureus. 2021; 13(4):e14408.

PMID: 33859920 PMC: 8038913. DOI: 10.7759/cureus.14408.

Calf lengthening may improve knee recurvatum in specific children with spastic diplegic cerebral palsy.

Bauer J, Patrick Do K, Feng J, Aiona M J Child Orthop. 2020; 14(4):353-357.

PMID: 32874371 PMC: 7453170. DOI: 10.1302/1863-2548.14.200092.

Literature Review and Comparison of Two Statistical Methods to Evaluate the Effect of Botulinum Toxin Treatment on Gait in Children with Cerebral Palsy.

Nieuwenhuys A, Papageorgiou E, Pataky T, De Laet T, Molenaers G, Desloovere K PLoS One. 2016; 11(3):e0152697.

PMID: 27030973 PMC: 4816309. DOI: 10.1371/journal.pone.0152697.

Botulinum Toxin Type A Injection for Spastic Equinovarus Foot in Children with Spastic Cerebral Palsy: Effects on Gait and Foot Pressure Distribution.

Choi J, Jung S, Rha D, Park E Yonsei Med J. 2016; 57(2):496-504.

PMID: 26847306 PMC: 4740546. DOI: 10.3349/ymj.2016.57.2.496.

References

BANKS H . The management of spastic deformities of the foot and ankle. Clin Orthop Relat Res. 1977; (122):70-6. View

Bang M, Chung S, Kim S, Kim S . Change of dynamic gastrocnemius and soleus muscle length after block of spastic calf muscle in cerebral palsy. Am J Phys Med Rehabil. 2002; 81(10):760-4. DOI: 10.1097/00002060-200210000-00007. View

Aiona M, Sussman M . Treatment of spastic diplegia in patients with cerebral palsy: Part II. J Pediatr Orthop B. 2004; 13(3):S13-38. DOI: 10.1097/00009957-200405000-00016. View

SUTHERLAND D, Kaufman K, Wyatt M, Chambers H, Mubarak S . Double-blind study of botulinum A toxin injections into the gastrocnemius muscle in patients with cerebral palsy. Gait Posture. 1999; 10(1):1-9. DOI: 10.1016/s0966-6362(99)00012-0. View

SUTHERLAND D, Davids J . Common gait abnormalities of the knee in cerebral palsy. Clin Orthop Relat Res. 1993; (288):139-47. View

Steele K, Seth A, Hicks J, Schwartz M, Delp S . Muscle contributions to support and progression during single-limb stance in crouch gait. J Biomech. 2010; 43(11):2099-105. PMC: 2914221. DOI: 10.1016/j.jbiomech.2010.04.003. View

Wren T, Rethlefsen S, Kay R . Prevalence of specific gait abnormalities in children with cerebral palsy: influence of cerebral palsy subtype, age, and previous surgery. J Pediatr Orthop. 2004; 25(1):79-83. DOI: 10.1097/00004694-200501000-00018. View

SUTHERLAND D, Cooper L, Daniel D . The role of the ankle plantar flexors in normal walking. J Bone Joint Surg Am. 1980; 62(3):354-63. View

Baddar A, Granata K, Damiano D, Carmines D, Blanco J, Abel M . Ankle and knee coupling in patients with spastic diplegia: effects of gastrocnemius-soleus lengthening. J Bone Joint Surg Am. 2002; 84(5):736-44. DOI: 10.2106/00004623-200205000-00006. View

10.

Perry J, Hoffer M, Giovan P, Antonelli D, Greenberg R . Gait analysis of the triceps surae in cerebral palsy. A preoperative and postoperative clinical and electromyographic study. J Bone Joint Surg Am. 1974; 56(3):511-20. View

11.

Metaxiotis D, Siebel A, Doederlein L . Repeated botulinum toxin A injections in the treatment of spastic equinus foot. Clin Orthop Relat Res. 2002; (394):177-85. DOI: 10.1097/00003086-200201000-00021. View

12.

Lee C, BLECK E . Surgical correction of equinus deformity in cerebral palsy. Dev Med Child Neurol. 1980; 22(3):287-92. DOI: 10.1111/j.1469-8749.1980.tb03707.x. View

13.

Hayek S, Gershon A, Wientroub S, Yizhar Z . The effect of injections of botulinum toxin type A combined with casting on the equinus gait of children with cerebral palsy. J Bone Joint Surg Br. 2010; 92(8):1152-9. DOI: 10.1302/0301-620X.92B8.23086. View

14.

Koog Y, Min B . Effects of botulinum toxin A on calf muscles in children with cerebral palsy: a systematic review. Clin Rehabil. 2010; 24(8):685-700. DOI: 10.1177/0269215510367557. View

15.

Houltram J, Noble I, Boyd R, Corry I, Flett P, Graham H . Botulinum toxin type A in the management of equinus in children with cerebral palsy: an evidence-based economic evaluation. Eur J Neurol. 2002; 8 Suppl 5:194-202. DOI: 10.1046/j.1468-1331.2001.00052.x. View

16.

Liu M, Anderson F, Schwartz M, Delp S . Muscle contributions to support and progression over a range of walking speeds. J Biomech. 2008; 41(15):3243-52. PMC: 4423744. DOI: 10.1016/j.jbiomech.2008.07.031. View

17.

Rodda J, Graham H, Carson L, Galea M, Wolfe R . Sagittal gait patterns in spastic diplegia. J Bone Joint Surg Br. 2004; 86(2):251-8. DOI: 10.1302/0301-620x.86b2.13878. View

18.

Maanum G, Jahnsen R, Stanghelle J, Sandvik L, Keller A . Effects of botulinum toxin A in ambulant adults with spastic cerebral palsy: a randomized double-blind placebo controlled-trial. J Rehabil Med. 2011; 43(4):338-47. DOI: 10.2340/16501977-0672. View

19.

Olney B, Williams P, MENELAUS M . Treatment of spastic equinus by aponeurosis lengthening. J Pediatr Orthop. 1988; 8(4):422-5. DOI: 10.1097/01241398-198807000-00008. View

20.

Cosgrove A, Corry I, Graham H . Botulinum toxin in the management of the lower limb in cerebral palsy. Dev Med Child Neurol. 1994; 36(5):386-96. DOI: 10.1111/j.1469-8749.1994.tb11864.x. View