1. Botulinum Toxin in Pediatric Stiff Hips
3rd International Conference on Pediatrics May 18-20, 2015 Texas, San Antonio, USA
Botulinum Toxin in Pediatric Stiff Hips
Dr. Tamer Rizk  
Consultant Pediatric Neurologist
Al-Takhassusi Hospital, Habib Medical Group
Riyadh, Saudi Arabia

2. Overview
Background
Objective
Methods
Results
Discussion
Conclusion

3. Background
Botulinum toxin has been used in various indications in pediatric age group, with promising results in relieving pain and spasticity
Childhood is the optimal time to intervene to maximize the motor function of pediatric patients with cerebral palsy
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
Targeted Botulinum toxin injections reduced pain in children with significant spasticity and pain at the hip level

4. Objective The aim of this study is to show the Functional & Orthopedic
Contributions of
Botulinum Toxin
in the
Treatment of Pediatric Stiff Hips

5. 4 pediatric patients with Post-Operative Stiff Hips were included
Methods
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

6. Case 1 3 years old girl with bilateral DDH.
One stage bilateral open reduction without acetapuloplasty was performed at the age of 26 months.
Follow up X-ray after 4 weeks showed dislocated right hip in the spica cast.
Revision surgery was done twice for re-dislocation, including acetabuloplasty and femoral osteotomy.
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.

7. Case 1 (Cont.)
A significant decrease in range of motion was noticed in both hips and she was walking with a limp & hyperlordosis.
Hip flexion was only from degrees. Abduction, adduction, and rotation were < 20 degrees each.
Extensive physiotherapy didn’t show a significant improvement.
Decision to admit her for rehabilitation and botulinum toxin injection in the quadriceps, hip adductors and Sartorius muscle (100 units in each muscle).
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.

8. Case 2
4 yr old girl was diagnosed with bilateral DDH at 16 months.
At the age of 2 years she had bilateral hip surgery (anterior open reduction& Pemberton’s acetabuloplasty).
She had two revision hip surgeries for re-dislocation of both hips at 2 settings with a total casting time of 24 weeks.
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.

9. Case 2 (Cont.)
Right hip flexion was from 30 to 90 and in the left 10–90 degrees with very limited rotation and abduction.
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.
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.

10. Case 3
7 yr old female with left DDH at an early age; parents refused intervention.
At 5 years of age parents agreed for surgical treatment (open reduction, acetabuloplasty and femoral shortening osteotomy).
3 months post operation the hip spica cast was removed.
Left hip was found in fixed flexion (80 degrees), abduction and external rotation deformity.
She started to walk with a clear limp and a lordotic gait.
She was subjected to extensive in-patient followed by outpatient PT.
Due to failure in gaining significant range of motion, the left hip flexors and adductors were released surgically.
However optimum results were not achieved.

11. Case 3 (Cont.)
Botulinum toxin injection (100 units in the quadriceps, 100 units in the hip adductors and 100 units in the Sartorius muscle).
This was followed by extensive physical therapy that resulted in an improvement in range of motion.
Botulinum toxin injection was also beneficial in decreasing the limp, pelvic obliquity and spinal deviation .
Slight limitation of flexion and internal rotation (10–15 degrees) was observed at the left hip in her last follow up.

12. Case 4
A 17-year-old female; known to have diplegic CP presented with right hip pain and limping.
She was seen at the movement disorders clinic for spasticity management, she had leg length discrepancy and pain in her right hip.
She was diagnosed with right hip severe subluxation, for which she had right hip Chiari osteotomy.
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.

13. Case 4 (Cont.)
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).
She had an improvement in spasticity, pain and in her gait.
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

14. Mutlu A, Livanelioglu A, Gunel KM
Mutlu A, Livanelioglu A, Gunel KM. Reliability of ashworth and modified ashworth scales in children with spastic cerebral palsy. BMC Musculoskelet Disord 2008; 9:

15. Results 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).
No serious complications were reported that were directly related to the use of Botulinum toxin treatment.
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)
All muscles injected matched the clinical presentation

16. Clin Orthop Relat Res 2010; 468(4): 1096–1106.
Discussion
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
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”.
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.

17. Discussion (Cont.)
Multiple disciplinary team in spasticity clinic, including:
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.

18. Discussion (Cont.)
Botulinum toxin has been used to decrease postoperative spasticity-related pain and in postoperative contractures in cases post total knee and total hip arthroplasty.
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.
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.

19. Discussion (Cont.)
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.
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.

20. Conclusion The presented cases demonstrate that
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.
It is recommended to recruit more patients to establish this line of treating postoperative hip stiffness in children.
Muscle selection, injection techniques and participation of all concerned subspecialties utilizing appropriate modalities of treatment will result in well-defined treatment goals and outcome.

21. Conclusion (Cont.)
Choice of muscles for Botulinum toxin administration necessitates:
Clinical examination looking for
painful muscles /spastic/ with decreased range of motion.
To increase the effectiveness of Botulinum toxin :
Inject inside the fascial compartment
Appropriate dose so the diffusion occurs with minimizing unwanted spread.
Post injection, a measurable goal should be set to reach through MDT; (PT, neurology & orthopedic surgery).
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.

22. Conclusion (Cont.)
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.
It should be considered as a treatment option in the management of difficult cases of postoperative stiff hips refractory to physiotherapy.
To our knowledge, no previous study has shown the results of Botulinum toxin in postoperative stiff hips in children.
Limitations of this study are the small number of the patients and the lack of a control group.

23. Take home message
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.
Muscle selection and participation of all concerned sub-specialties will improve the outcome.

24. Thanks