Tendon transfer surgery in upper-extremity cerebral palsy is more effective than botulinum toxin injections or regular, ongoing therapy

Combined Wrist Extensor Tenodesis and Tendon Transfers for Severe Spastic Flexed Wrist Deformity: Surgical Technique and Case Series

Spastic wrist flexion deformities both limit the functional use of the hand for grasp and pinch producing a stigmatizing appearance. Tendon transfers and total wrist arthrodesis are treatment options for this condition depending on the patient's characteristics, the latter the most commonly used in patients with severe wrist flexion deformities. Tendon transfers alone in this scenario have the tendency for recurrent deformity due to tenorrhaphy failure or soft tissue creep and resultant loss of tension. Total wrist arthrodesis is a more invasive procedure, which can have hardware or fusion problems and that is irreversible. We propose a novel technique that incorporates a distally based wrist extensor tendon slip and suture tape tenodesis to the distal radius. The rationale of this technique is to act as a protective, internal splint to prevent recurrent deformity after primary or revision tendon transfer for moderate to severe spastic flexed wrist deformities, avoiding the need to perform a total wrist arthrodesis.

Tendon transfer in spastic cerebral palsy upper limb

Cerebral palsy (CP) in upper limb produces functional, aesthetic and hygienic issues, and is not always amenable to surgical procedures. We are reporting a single-center, long follow-up experience with tendon transfer in wrist and forearm CP. The CP cases who had undergone tendon transfer in hand, wrist and forearm in a 14-year period were evaluated for change in motion, function and cosmetic appearance and also assessed by Manual Ability Classification System (MACS), and Dash (Disability of Arm, Shoulder, Hand) scores. Forty-two spastic CP patients with a mean age of 19.81 (10-34 years, SD: 5.36) years with a mean follow-up of 5.5 (2-14) years, entered the study. 24 cases were GMFCS I or II and 18 were III or IV. Supination beyond neutral was seen in 48.5%, and improvement in MACS scores in all the cases. Improved 'grasp' and 'release' and keyboard use was seen in 50%, 71% and 87% respectively. The satisfaction from appearance and improved function of 83-96% correlated positively with GMFSC, MACS and DASH scores. Noticeable improvement in personal hygienic care was seen in only 52% of cases. Tendon transfer in well-selected spastic upper extremity CP cases results in long-time improved function, and limb appearance - correlating with initial GMFCS and MACS scores.

Short- medium- and long-term effects of botulinum toxin on upper limb spasticity in children with cerebral palsy: A meta-analysis of randomized controlled trials

BACKGROUND

Botulinum toxin (BTX) is an effective management method for spasticity in children with cerebral palsy (CP), but the short- medium- and long-term effects remain unclear.

OBJECTIVE

The primary objective was to quantify the effects of BTX injections on upper limb spasticity over time in children with CP. The secondary objective was to evaluate efficacy according to the International Classification of Functioning, Disability, and Health-Children & Youth version framework.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials that included control/comparison groups treated with a placebo or other treatments. We searched CINAHL, Embase, PubMed, Scopus, Web of Science, and PsycINFO from their inception to April 2024. The pooled mean difference (MD) or standard mean difference (SMD) with 95 % CI was calculated using a random effects model at the short-term (up to 3 months), medium-term (3 to 6 months), and long-term (over 6 months).

RESULTS

A total of 658 children with CP aged 1.8 to 19 years old in 12 eligible trials were involved. The primary outcome of the Melbourne Assessment percentile showed a significant increase in the medium- (MD = 2.63, 95 % CI 0.22 to 5.04, I² = 0 %) and long-term (MD = 4.72, 95 % CI 0.93 to 8.51, I² = 0 %) in favor of BTX. Pooled effects also showed that BTX significantly improved Modified Ashworth Scale scores in the short- (MD = -0.44, 95 % CI -0.88 to -0.01, I² = 88 %) and medium-term (MD = -0.20, 95 % CI -0.28 to -0.13, I² = 0 %), and individual goals and bimanual performance up to 6-months. No significantly higher risk of adverse events was observed with BTX.

CONCLUSIONS AND IMPLICATIONS

BTX injections sustainably improved the quality of affected upper limb function and temporarily improved individual goals and bimanual performance in children with CP. Our findings cautiously support a time interval of 3 to 6 months between BTX injections in the upper limbs of children with CP.

TRIAL REGISTRATION

This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (Registration ID: CRD42022323672).

Kinematic upper limb analysis outperforms electromyography at grading the severity of dystonia in children with cerebral palsy

BACKGROUND

Severity of dyskinesia in children with cerebral palsy is often assessed using observation-based clinical tools. Instrumented methods to objectively measure dyskinesia have been proposed to improve assessment accuracy and reliability. Here, we investigated the technique and movement features that were most suitable to objectively measure the severity of dystonia in children with cerebral palsy.

METHODS

A prospective observational study was conducted with 12 participants with cerebral palsy with a predominant motor type of dyskinesia, spasticity, or mixed dyskinesia/spasticity who had upper limb involvement (mean age: 12.6 years, range: 6.7-18.2 years). Kinematic and electromyography data were collected bilaterally during three upper limb tasks. Spearman rank correlations of kinematic or electromyography features were calculated against dystonia severity, quantified by the Dyskinesia Impairment Scale.

FINDINGS

Kinematic features were more influential compared to electromyography features at grading the severity of dystonia in children with cerebral palsy. Kinematic measures quantifying jerkiness of volitional movement during an upper limb task with a reaching component performed best (|rs| = 0.78-0.9, p < 0.001).

INTERPRETATION

This study provides guidance on the types of data, features of movement, and activity protocols that instrumented methods should focus on when objectively measuring the severity of dystonia in children with cerebral palsy.

Effects of botulinum toxin injections in the upper limbs of children with cerebral palsy: A systematic review of the literature

BACKGROUND

Spasticity is a common motor disorder in children with cerebral palsy (CP). Upper limb CP impairment has a significant negative impact on daily activities. Botulinum toxin (BTX-A) injections are widely used to reduce spasticity, but their effectiveness is not well-defined. We performed a systematic review of literature to answer questions about the effectiveness of BTX-A injections in the upper limb in children with CP.

METHODS

A systematic review of literature was conducted according to PRISMA guidelines. Eligible studies were randomized controlled trials with a high level of evidence on BTX-A upper limb injections in children. The outcomes analyzed included the study population, spasticity, quality of movement, activity limitations, quality of life, pain, appearance and side effects.

RESULTS

A total of 24 studies were included. The number of patients included was 1358 with a mean age between 3 and 11years. Improvement after BTX-A injection compared to the control group was observed for spasticity (n=10/19 studies), bimanual activities (Assisting Hand Assessment) (n=3/7), activity limitations (n=6/11), pain (n=2/2) and appearance (n=2/2). No study found an improvement in quality of life. Side effects were described in 16 studies and were moderate in all cases.

CONCLUSION

This review of literature showed that BTX-A injections can improve spasticity and particularly activity limitations when reasonable objectives are established.

LEVEL OF EVIDENCE

IV, systematic review.

The Green Transfer-Long-Term Results

PURPOSE

The purpose of this study was to determine the long-term results of the Green transfer (flexor carpi ulnaris to extensor carpi radialis brevis) for patient-reported outcomes, wrist position, and range of motion.

METHODS

We re-examined 13 patients from a previous prospective study involving surgery for hemiplegia that included a Green transfer. The average follow-up was 8 years with the range from 5 to 11 years. The wrist range of motion and the postoperative position of the wrists were measured. The surgical outcomes were measured via the Pediatric Orthopedic Data Collection Instrument, the Shriner's Hospital Upper Extremity Evaluation, Pediatric Quality of Life, and visual analog score for appearance from the patient and the parent.

RESULTS

At this follow-up, only 7 of the 13 patients had a wrist position near neutral with the ability to flex and extend the wrist. Wrist range of motion was improved in four, decreased in four, and stayed the same in five patients. In contrast to these positional wrist results, statistically significant improvements were noted in several aspects of the Pediatric Orthopedic Data Collection Instrument, visual analog scores, and Shriner's Hospital Upper Extremity Evaluation scores.

CONCLUSIONS

Long-term follow-up of the flexor carpi ulnaris to extensor carpi radialis brevis tendon transfer in hemiplegic patients reveals the results to be variable but favorable from a patient-reported outcome standpoint.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Expert consensus on the surgical evaluation and management of upper extremity spasticity in adults

In the last decade there has been incredible interest and advancement in the surgical care of adult patients with upper motor neuron (UMN) injuries. Spasticity represents a prevalent and debilitating feature of UMN syndrome, which can result from cerebral palsy, spinal cord injury, cerebrovascular accident and traumatic or anoxic brain injury. While several diagnostic tools and management strategies have been described for upper limb spasticity, evidence-based practice guidelines do not currently exist due to low patient volume and a paucity of surgeons routinely performing surgeries in UMN syndrome patients. As such, expert consensus may help provide guidance for patients, therapists and clinicians alike. In this article an expert panel was assembled, and the Delphi method was utilized to present diagnostic considerations, define operative indications, discuss surgical treatment modalities and encourage a standard set of outcome measures for patients with upper extremity spasticity.

Surgical Treatment of Thumb-in-Palm Deformity: A Case Report

CASE

A 13-year-old adolescent boy with spastic triplegia was referred to our institution with a thumb-in-palm deformity. An intramuscular slide of the flexor pollicis longus and augmentation of the weak abductor pollicis longus, extensor pollicis longus, and extensor pollicis brevis by tendon transfer were performed. Two years later, the result of the surgery was evaluated as excellent.

CONCLUSION

There are several factors that will play a decisive role in the final outcome and effectiveness of hand surgery, such as the severity of the neuromuscular disorder, the extent of the deformity, the quality of voluntary muscle control, hand sensibility, and the age and intelligence of the patient.

Can the Shriners Hospital Upper Extremity Evaluation (SHUEE) Detect Change in Dynamic Position and Spontaneous Function of the Upper Limb in People With Hemiplegic Cerebral Palsy?

BACKGROUND

The Shriners Hospital Upper Extremity Evaluation (SHUEE) is a video-based measure designed to assess upper extremity function in people with cerebral palsy (CP). The SHUEE completes both dynamic positional analysis (DPA; position during functional activities) and spontaneous functional analysis (spontaneous use of the involved limb). Although the SHUEE has been suggested as a measure for planning upper limb interventions and evaluating outcomes, limited evidence of its ability to detect change exists. Thus, this study aimed to describe responsiveness of the SHUEE to detect change after orthopaedic surgery.

METHODS

In this Institutional Review Board-approved retrospective cohort study, we identified children with CP who were administered SHUEE on≥2 encounters. We formed pairs of initial and follow-up visits between temporally adjacent visits. Pairs were assigned to a surgery or non-surgery group based on intervening upper limb orthopaedic surgery. We compared differences in baseline SHUEE scores between groups and differences in temporally adjacent SHUEE scores within groups using Welch unequal variances t tests and paired t tests, respectively.

RESULTS

Nineteen people (7 female) with hemiplegic CP had≥2 SHUEE assessments; Manual Ability Classification System levels I (3), II (8), III (7), IV (1); Gross Motor Function Classification System levels I (10), II (7), IV (2); mean age at baseline 11.9 (5.1 to 19.1) years; and follow-up at 13.4 (5.5 to 19.7) years. Six people had≥2 visits leading to 14 surgical pairs and 10 non-surgical pairs. At baseline, DPA of the wrist and forearm were significantly lower in the surgical group ( P <0.05). At follow-up, no significant difference between the groups existed in DPA measures ( P >0.05). After surgical intervention, there was a significant change in overall and wrist DPA ( P <0.05).

CONCLUSIONS

The DPA measures demonstrated responsiveness to expected positional changes in the arm after orthopaedic surgery in people with CP. The SHUEE was useful in identifying abnormal segmental alignment pre-surgically and documenting changes in alignment postoperatively. As orthopaedic surgery does not address limb neglect or bimanual ability, spontaneous functional analysis scores were as expected-unchanged.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Surgical approach to forearm pronation deformity in patients with cerebral palsy: a systematic review

Background

Pronation deformity in patients with cerebral palsy can have a major impact on upper limb functionality. There is lack of consensus in the literature about the preferred surgical technique to address this deformity.

Study aim

To evaluate and synthesize the outcome of different surgical techniques for pronation deformity in patients with cerebral palsy.

Methodology

The databases MEDLINE and Embase were searched for publications up to December 2021. Articles were considered eligible for inclusion when the included patients had a pronation deformity caused by cerebral palsy and results of surgical intervention for pronation deformity were examined. Evaluation of the quality of the retrieved study was conducted using the MINORS tool. Meta-analysis was not possible due to the heterogeneity of interventions and reported outcomes.

Results

Nineteen studies, involving 475 patients and eight different techniques were included. All studies reported gain of active supination in most patients. The effect of surgery on functional gain was less clear and there was a large heterogeneity of reported functional outcome measures. There were 46 reported complications. Overall quality of study design was poor, illustrated by the average MINOR score of 6.9/16. Overall, there is a high risk of bias due to poor internal and external validity of the studies.

Conclusion

Despite positive reports on gain in supination and functionality after most procedures addressing pronation deformity in CP patients, no conclusions can be drawn concerning the preferred technique due to the low quality of the evidence.

Barriers to Upper Extremity Reconstruction for Patients With Cerebral Palsy

BACKGROUND

Reconstructive surgery for upper extremity manifestations of cerebral palsy (CP) has been demonstrated to be safe and effective, yet many potential candidates are never evaluated for surgery. The purpose of this study was to determine barriers to upper extremity reconstruction for patients with CP in a cohort of upper extremity surgeons and nonsurgeons.

METHODS

We sent a questionnaire to 4167 surgeons and nonsurgeon physicians, aggregated responses, and analyzed for differences in perceptions regarding surgical efficacy, patient candidacy for surgery, compliance with rehabilitation, remuneration, complexity of care, and physician comfort providing care.

RESULTS

Surgeons and nonsurgeons did not agree on the literature support of surgical efficacy (73% vs 35% agree or strongly agree, respectively). Both surgeons and nonsurgeons felt that many potential candidates exist, yet there was variability in their confidence in identifying them. Most surgeons (59%) and nonsurgeons (61%) felt comfortable performing surgery and directing the associated rehabilitation, respectively. Neither group reported that patient compliance, access to rehabilitation services, and available financial resources were a major barrier, but surgeons were more likely than nonsurgeons to feel that remuneration for services was inadequate (37% vs 13%). Both groups agreed that surgical treatments are complex and should be performed in the setting of a multidisciplinary team.

CONCLUSIONS

Surgeons and nonsurgeons differ in their views regarding upper extremity reconstructive surgery for CP. Barriers to reconstruction may be addressed by performing higher level research, implementing multispecialty educational outreach, developing objective referral criteria, increasing surgical remuneration, improving access to trained upper extremity surgeons, and implementing multidisciplinary CP clinics.

Treatment of upper extremity palsies, gunshot wounds and scaphoid nonunion: my preferred approaches

The article reviews key considerations and our preferred methods in treating upper extremity palsies, gunshot wounds and scaphoid nonunion. For these three difficult conditions, I highlight the importance of a team approach when treating upper extremity neuromuscular disease, flexibility and creativity when treating gunshot wounds, and my personal protocol for dealing with scaphoid fracture nonunions.Level of evidence: V.

Self-selection vs Randomized Assignment of Treatment for Appendicitis

Importance

For adults with appendicitis, several randomized clinical trials have demonstrated that antibiotics are an effective alternative to appendectomy. However, it remains unknown how the characteristics of patients in such trials compare with those of patients who select their treatment and whether outcomes differ.

Objective

To compare participants in the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) randomized clinical trial (RCT) with a parallel cohort study of participants who declined randomization and self-selected treatment.

Design, Setting, and Participants

The CODA trial was conducted in 25 US medical centers. Participants were enrolled between May 3, 2016, and February 5, 2020; all participants were eligible for at least 1 year of follow-up, with all follow-up ending in 2021. The randomized cohort included 1094 adults with appendicitis; the self-selection cohort included patients who declined participation in the randomized group, of whom 253 selected appendectomy and 257 selected antibiotics. In this secondary analysis, characteristics and outcomes in both self-selection and randomized cohorts are described with an exploratory analysis of cohort status and receipt of appendectomy.

Interventions

Appendectomy vs antibiotics.

Main Outcomes and Measures

Characteristics among participants randomized to either appendectomy or antibiotics were compared with those of participants who selected their own treatment.

Results

Clinical characteristics were similar across the self-selection cohort (510 patients; mean age, 35.8 years [95% CI, 34.5-37.1]; 218 female [43%; 95% CI, 39%-47%]) and the randomized group (1094 patients; mean age, 38.2 years [95% CI, 37.4-39.0]; 386 female [35%; 95% CI, 33%-38%]). Compared with the randomized group, those in the self-selection cohort were less often Spanish speaking (n = 99 [19%; 95% CI, 16%-23%] vs n = 336 [31%; 95% CI, 28%-34%]), reported more formal education (some college or more, n = 355 [72%; 95% CI, 68%-76%] vs n = 674 [63%; 95% CI, 60%-65%]), and more often had commercial insurance (n = 259 [53%; 95% CI, 48%-57%] vs n = 486 [45%; 95% CI, 42%-48%]). Most outcomes were similar between the self-selection and randomized cohorts. The number of patients undergoing appendectomy by 30 days was 38 (15.3%; 95% CI, 10.7%-19.7%) among those selecting antibiotics and 155 (19.2%; 95% CI, 15.9%-22.5%) in those who were randomized to antibiotics (difference, 3.9%; 95% CI, -1.7% to 9.5%). Differences in the rate of appendectomy were primarily observed in the non-appendicolith subgroup.

Conclusions and Relevance

This secondary analysis of the CODA RCT found substantially similar outcomes across the randomized and self-selection cohorts, suggesting that the randomized trial results are generalizable to the community at large.

Trial Registration

ClinicalTrials.gov Identifier: NCT02800785.

The Spastic Upper Extremity in Children: Multilevel Surgical Decision-making

Multilevel surgery for upper extremity spasticity is the current surgical standard. While the literature details surgical techniques and outcomes, a comprehensive guide to surgical planning is lacking. Patients commonly present with posturing into shoulder internal rotation, elbow flexion, forearm pronation, wrist flexion with ulnar deviation, finger flexion, and thumb adduction, although variations exist. Multiple surgical options exist for each segment; therefore, repeated examinations for contracture, pathologic laxity, and out of phase activity are necessary to optimize the surgical plan. To avoid decreasing function, one must carefully balance the benefits of contracture release and tendon transfers with their weakening effects. In certain cases, stability from joint fusion outweighs the loss of motion. Failure to recognize dynamic posturing, grasp and release requirements, or hand intrinsic spasticity can worsen function and cause new deformities. Surgical indications are formulated for individual deformity patterns and severity along with personal/family goals. General comprehension, voluntary control, and sensation, although not modifiable, influence decision making and are prognostic indicators. Functional improvement is unlikely without preexisting voluntary control, but appearance and visual feedback may be improved by repositioning nonetheless. Appropriate interventions and management of expectations will optimize limb appearance and function while avoiding unexpected sequelae.

Cost Comparison of Botulinum Toxin Injections Versus Surgical Treatment in Pediatric Patients With Cerebral Palsy: A Markov Model

PURPOSE

The purpose of this study was to compare the cost-effectiveness of surgical release to botulinum toxin injections in the treatment of upper-extremity (UE) cerebral palsy (CP).

METHODS

A Markov transition-state model was developed to assess the direct and indirect costs as well as accumulated quality-adjusted life-years associated with surgery (surgery group) and continuous botulinum toxin injections (botulinum group) for the treatment of UE CP in children aged 7 to 12 years. Direct medical costs were obtained from institutional billing departments. The number of parental missed workdays associated with each treatment was estimated and previously published regressions were used to calculate indirect costs associated with missed work. Total costs, cost-effectiveness, and incremental cost-effectiveness ratios were calculated. Incremental cost-effectiveness ratios and willingness to pay thresholds were used to make decisions regarding society's willingness to pay for the incremental cost of each treatment given the incremental benefit.

RESULTS

The surgery group demonstrated lower direct, indirect, and total costs compared with the botulinum group. Direct costs were $29,250.50 for the surgery group and $50,596.00 for the botulinum group. Indirect costs were $9,467.46 for the surgery group and $44,428.60 for the botulinum group. Total costs were $38,717.96 for the surgery group and $95,024.60 for the botulinum group, a difference of $56,306.64. The incremental cost-effectiveness ratio was -$42,019.88, indicating that surgery is a less costly and more effective treatment and that botulinum injections fall outside the societal willingness to pay threshold. Excluding indirect costs associated with parental missed work during home occupational therapy did not have a significant impact on the model.

CONCLUSIONS

Surgery is associated with lower direct, indirect, and total costs, as well as a greater number of accumulated quality-adjusted life-years. Surgery provides a greater benefit at a lower cost, which suggests that botulinum injections should be used sparingly in this population. Treatment with surgery could represent savings of $5.6 to $11.3 billion annually in the United States.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analysis II.

A prospective study on transfer of pronator teres to extensor carpi radialis brevis for forearm and wrist deformity in children with cerebral palsy

We prospectively evaluated the clinical and functional outcomes of pronator teres to extensor carpi radialis brevis transfer in children with cerebral palsy. Patients were followed-up at 6 months postoperatively, and functionally assessed using the House classification, Manual Ability Classification System (MACS) and Upper Extremity Functional Index (UEFI). Fifteen children with a mean age of 8.1 years underwent tendon transfers. All patients were of Gschwind and Tonkin Grade 2 for pronation deformity; eight patients were of Zancolli's classification Group 1 and seven, Group 2 for wrist flexion deformity. The average gain in active supination was 67°, and wrist extension 15°. An increase of 7.0 in the UEFI score was recorded, although no significant improvement in MACS and House classification was observed. We conclude that the pronator teres to extensor carpi radialis brevis transfer improves upper limb function through effective correction of forearm pronation and wrist flexion deformities.Level of evidence: II.

Feasibility and effectiveness of home-based therapy programmes for children with cerebral palsy: a systematic review

OBJECTIVE

To assess the feasibility and effectiveness of home-based occupational therapy and physiotherapy programmes in children with cerebral palsy (CP), focusing on the upper extremity and reporting on child-related and/or parent-related outcomes.

DESIGN

Systematic review.

DATA SOURCES

Electronic searches were performed in MEDLINE, EMBASE, CINAHL, PsycINFO, OTseeker and PEDro, and in ICTRP and CENTRAL trial registers, from inception to 6 June 2019.

ELIGIBLE CRITERIA

The review included all types of original studies concerning feasibility or effectiveness of home-based therapy in children aged <18 years with any type of CP. No language, publication status or publication date restrictions were applied.

DATA EXTRACTION AND SYNTHESIS

Study and intervention characteristics and the demographics of participating children and their parents were extracted. Feasibility was assessed by outcomes related to acceptability, demand, implementation, practicality, adaptation, expansion or integration. Regarding effectiveness, child-related outcome measures related to any level of the International Classification of Functioning, Disability and Health, or parent-related outcomes were investigated. Two authors independently extracted the data. Risk of bias was assessed using the Downs and Black checklist and the Joanna Briggs Institute Critical Appraisal Checklist.

RESULTS

The search resulted in a total of 92 records: 61 studies and 31 conference abstracts. Feasibility studies reported mainly on acceptability and implementation. Overall compliance to home-based training programmes (implementation) was moderate to high, ranging from 56% to 99%. In the effectiveness studies, >40 different child-related outcome measures were found. Overall, an improvement in arm-hand performance within group across time was shown. Only two studies reported on a parent-related outcome measure. No increase in parental stress was found during the intervention.

CONCLUSIONS

Based on the results of the included studies, home-based training programmes seem to be feasible. However, conclusions about the effectiveness of home programmes cannot be made due to the large variability in the study, patient and intervention characteristics, comparators, and outcome measures used in the included studies.

PROSPERO REGISTRATION NUMBER

CRD42016043743.

BRAZILIAN VERSION OF THE SHRINERS HOSPITAL UPPER EXTREMITY EVALUATION (SHUEE): TRANSLATION, CULTURAL ADAPTATION, AND EVALUATION OF PSYCHOMETRIC PROPERTIES

Objective:

To validate the upper limb assessments tool, Shriners Hospital Upper Extremity Evaluation (SHUEE), for individuals with hemiplegic cerebral palsy in the Brazilian population.

Methods:

Validation study to translate and culturally adapt the Manual and the instrument. The psychometric properties evaluated were reliability and convergent validity. Reliability was determined by internal consistency (Cronbach’s α coefficient), ceiling and floor effect, sensitivity to changes, and intra- and interobserver agreement. Convergent validity was performed using the Pediatric Motor Activity Log, the self-care scale of the Pediatric Evaluation of Disability Inventory, and the Manual Ability Classification System.

Results:

We evaluated 21 individuals with hemiplegic cerebral palsy, with a mean age of 8.7±4.0 years. After the instrument was translated, there was no need for cultural adaptation. The total Cronbach’s α coefficient was 0.887 (95% confidence interval [95%CI] 0.745-0.970). We calculated sensitivity to changes in five subjects who underwent treatment with Botulinum Toxin Type A and physical therapy, with a significant difference between pre- and post-treatment evaluations in the Spontaneous Functional Analysis and Dynamic Positional Analysis. Convergent validity showed a significant correlation of the Spontaneous Functional Analysis and Dynamic Positional Analysis with the scales evaluated. All items of SHUEE presented high intra- and interobserver agreement.

Conclusions:

The results revealed that the Brazilian version of the SHUEE demonstrated good reliability and convergent validity, suggesting that it is an adequate and reliable tool for individuals with hemiplegic cerebral palsy in the Brazilian population.

Surgery for the Pronated Forearm and Flexed Wrist in Children with Cerebral Palsy

AIM

There is no consensus in the literature on how best to manage wrist flexion and forearm pronation deformities in children with cerebral palsy (CP). The aim of this research was to come up with a treatment algorithm for the surgical management of such cases.

METHODS

Children with CP who underwent upper limb surgery between 2009 and 2016 at a single centre and by a single lead surgeon were reviewed retrospectively. Movement analysis and Shriners Hospital Upper Extremity Evaluation (SHUEE) data collected pre- and post-operatively.

RESULTS

Thirteen patients were recruited. Most patients underwent a flexor carpi ulnaris (FCU) to extensor carpi radialis brevis (ECRB) transfer, with or without pronator teres (PT) re-routing, and finger flexor or elbow flexor releases. Mean increase in active range of supination was 40.8° (p = 0.002) and wrist extension 28.9° (p = 0.004). The mean increase in dynamic positional analysis (part of the SHUEE) was 25.4% (of which 40.3% was due the increases in wrist function and 16.8% due to forearm function). The loss of wrist flexion was not significant (p = 0.125). The mean follow-up was 14 months (range 9-21).

CONCLUSIONS

To tackle both a pronation and flexion deformity, the authors favour performing a FCU to ECRB transfer in isolation if there is active supination to neutral; if active supination is short of neutral, then a FCU to ECRB with a PT release and possible re-routing performed. A treatment algorithm is proposed.

LEVEL OF EVIDENCE

IV.

Preferred options and evidence for upper limb surgery for spasticity in cerebral palsy, stroke, and brain injury

Surgical interventions for the spastic upper extremity secondary to stroke, traumatic brain injury, and cerebral palsy aim to correct the common deformities of elbow flexion, forearm pronation, wrist and finger flexion, ulnar deviation, and thumb-in-palm deformity. After appropriate evaluation, as well as determining the goals of surgery, deformity correction can be achieved through single-event, multi-level surgery. Surgery includes a combination of soft tissue lengthening, tendon transfer, and joint stabilization procedures. Surgical treatment for shoulder adduction/internal rotation, elbow flexion, forearm pronation, wrist flexion, thumb-in-palm, and clenched fist deformities due to spasticity are discussed, and treatment outcomes are reviewed.

Effects of upper extremity surgery on activities and participation of children with cerebral palsy: a systematic review

AIM

To evaluate and synthesize the evidence for effects of upper extremity surgery (UES) on activities and participation of children and adolescents with cerebral palsy (CP).

METHOD

The databases MEDLINE, Embase, and PsycINFO were searched for publications up to September 2018. Studies included were comparative studies with or without concurrent comparison groups or case series with pretest/posttest outcomes with a minimal sample size of 10 participants; those that reported the effects of UES with a follow-up time of at least 5 months; those including patients diagnosed with CP aged up to 20 years; and those that used a validated activity-based instrument. Risk of bias was assessed using the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool and quality assessment was performed using the Grading of Recommendations Assessment, Development and Evaluation.

RESULTS

Twelve studies, involving 310 children and adolescents, were included. The ability and perception of the patient to use the hand(s) and perform activities (measured with the Shriners Hospital Upper Extremity Evaluation, Assisting Hand Assessment, and House Functional Classification) improved significantly after UES. The quality of evidence was very low for each of the activity outcomes of interest.

INTERPRETATION

The very low evidence prohibits recommendations on the use of UES to guide clinical practice. More high-quality comparative studies are needed to obtain better insight into the effects of UES on activities and participation.

WHAT THIS PAPER ADDS

Low quality of evidence for effects of upper extremity surgery (UES) on activities and participation. Limited evidence for improvement in activities and participation after UES.

Effect of botulinum toxin type-A in spasticity and functional outcome of upper limbs in cerebral palsy

INTRODUCTION

Spasticity has been considered to be a main contributor to both the impairment of function as well as posture in children with cerebral palsy (CP). Patterns of upper limb motor involvement in CP vary with resultant limitations in daily independence, participation, and quality of life. Botulinum Toxin-A (BTX-A) is a potent neurotoxin which acts by preventing the release of acetylcholine (Ach) from presynaptic axon at motor end plate reducing focal spasticity. With literature established role of BTX-A available for lower limb spasticity in CP, the purpose of this study was to present an objective analysis of the effect of a single i.m. injection of BTX-A in reduction of spasticity in the upper limb as well as functional outcome in children (4-12yrs) with spastic CP.

METHODS

A total of 28 patients (30 upper limbs) of spastic CP with minimum follow up of 6months were included in the study. Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS) were used to measure the spasticity. Surface landmarks were used to give I.m. Botox in selected spastic muscles followed by targeted rehabilitation. Functional outcomes were measured by MACS (Manual Ability Classification System) and Canadian Occupational Performance Measure (COPM) before treatment, at 3 and 6 months follow up.

RESULTS

Pronator teres was the most frequently injected muscle followed by FCU and Adductor pollicis. MAS scores at all joints and MTS scores at forearm deteriorated between 3 and 6 months. However, MACS and COPM showed sustained improvement at 3months and 6months with statistically significant change.

CONCLUSION

I.m. BTX-A injected using anatomical landmarks had significant improvement in both clinical and functional outcome measures. We noticed significant improvement in MACS and COPM at 6 months despite return of local spasticity. It is safe and effective for spasticity of upper limbs in cerebral palsy and capable of improving function without major side effects. MACS & COPM are easy to use, less time consuming & easily adjusted to local needs. Randomized control trials with long follow up are required in future with special focus on dosing and timing, scoring system for functional outcome as per regional needs and issue for antibody formation for repeat injections of BTX-A.

Treating Pediatric Hand Problems in a Low-resource Environment

Although individual pediatric hand problems are rare, the combined burden of congenital anomalies, neuromuscular disease, and trauma is considerable in low-resource environments where treatment is unavailable. Surgeons from high-income countries respond to the need for care with short-term trips to low-resource environments to operate and teach local surgeons. Hand problems are amenable to this model, because they may be disabling and treatable with low-risk, low-resource surgery. Pediatric hand problems are especially compelling, because growth may adversely affect outcomes, and resulting disability is lifelong. This article addresses considerations for treating children's hands in low-resource environments, and approaches to specific conditions.

Partially randomised patient preference trials as an alternative design to randomised controlled trials: systematic review and meta-analyses

OBJECTIVE

Randomised controlled trials (RCT) are the gold standard to provide unbiased data. However, when patients have a treatment preference, randomisation may influence participation and outcomes (eg, external and internal validity). The aim of this study was to assess the influence of patients' preference in RCTs by analysing partially randomised patient preference trials (RPPT); an RCT and preference cohort combined.

DESIGN

Systematic review and meta-analyses.

DATA SOURCES

MEDLINE, Embase, PsycINFO and the Cochrane Library.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

RPPTs published between January 2005 and October 2018 reporting on allocation of patients to randomised and preference cohorts were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data. The main outcomes were the difference in external validity (participation and baseline characteristics) and internal validity (lost to follow-up, crossover and the primary outcome) between the randomised and the preference cohort within each RPPT, compared in a meta-regression using a Wald test. Risk of bias was not assessed, as no quality assessment for RPPTs has yet been developed.

RESULTS

In total, 117 of 3734 identified articles met screening criteria and 44 were eligible (24 873 patients). The participation rate in RPPTs was >95% in 14 trials (range: 48%-100%) and the randomisation refusal rate was >50% in 26 trials (range: 19%-99%). Higher education, female, older age, race and prior experience with one treatment arm were characteristics of patients declining randomisation. The lost to follow-up and cross-over rate were significantly higher in the randomised cohort compared with the preference cohort. Following the meta-analysis, the reported primary outcomes were comparable between both cohorts of the RPPTs, mean difference 0.093 (95% CI -0.178 to 0.364, p=0.502).

CONCLUSIONS

Patients' preference led to a substantial proportion of a specific patient group refusing randomisation, while it did not influence the primary outcome within an RPPT. Therefore, RPPTs could increase external validity without compromising the internal validity compared with RCTs.

PROSPERO REGISTRATION NUMBER

CRD42019094438.

Extensor pollicis longus rerouting for thumb-in-palm deformity in cerebral palsy: a biomechanical analysis

Extensor pollicis longus rerouting is a common procedure to improve thumb abduction in thumb-in-palm deformity seen with spastic cerebral palsy. In 1985, Manske redirected the extensor pollicis longus tendon in this procedure through the first extensor compartment. They also proposed an alternative subcutaneous route around the extensor pollicis brevis and abductor pollicis longus tendons proximal to the extensor compartment. In this study, we performed a three-dimensional analysis of thumb motion on 11 cadaver arms with the subcutaneous route and the first extensor compartment route. We found that with the two different routing methods, the mean difference in thumb radial abduction and retropulsion (0° or 6°, respectively) was very small. Such differences are unlikely to have clinical relevance. We were unable to find significant differences in the motion range of the thumb after these rerouting techniques or sites of insertion. Our biomechanical data support the simpler subcutaneous route.

Botulinum Toxin in the Management of Children with Cerebral Palsy

During the past 25 years, botulinum toxin type A (BoNT-A) has become the most widely used medical intervention in children with cerebral palsy. In this review we consider the gaps in our knowledge in the use of BoNT-A and reasons why muscle morphology and function in children with cerebral palsy are impaired. We review limitations in our knowledge regarding the mechanisms underlying the development of contractures and the difficulty in preventing them. It is clear from this review that injection of BoNT-A in the large muscles of both the upper and lower limbs of children with cerebral palsy will result in a predictable decrease in muscle activity, which is usually reported as a reduction in spasticity, for between 3 and 6 months. These changes are noted by the use of clinical tools such as the Modified Ashworth Scale and the Modified Tardieu Scale. Decreased muscle over-activity usually results in improved range of motion in distal joints. Injection of the gastrocnemius muscle for toe-walking in a child with hemiplegia or diplegia usually has the effect of increasing the passive range of dorsiflexion at the ankle. In our review, we found that this may result in a measurable improvement in gait by the use of observational gait scales or gait analysis, in some children. However, improvements in gait function are not always achieved and are small in magnitude and short lived. We found that some of the differences in outcomes in clinical trials may relate to the use of adjunctive interventions such as serial casting, orthoses, night splints and intensive therapy. We note that the majority of clinical trials of the use of BoNT-A in children with cerebral palsy have focussed on a single injection cycle and this is insufficient to understand the balance between benefit and harm. Most outcomes were reported in terms of changes in muscle tone and there were fewer studies with robust methodology that reported improvements in function. Changes in the domains of activities and participation have rarely been reported in studies to date. There were no clinical reviews to date that consider the findings of studies in human volunteers and in experimental animals and their relevance to clinical protocols. In this review we found that studies in human volunteers and in experimental animals show muscle atrophy after an injection of BoNT-A for at least 12 months. Muscle atrophy was accompanied by loss of contractile elements in muscle and replacement with fat and connective tissue. It is not currently known if these changes, mediated at a molecular level, are reversible. We conclude that there is a need to revise clinical protocols by using BoNT-A more thoughtfully, less frequently and with greatly enhanced monitoring of the effects on injected muscle for both short-term and long-term benefits and harms.

Outcome of hand surgery in children with spasticity - a 9-year follow-up study

The aim of this study was to evaluate whether short-term positive effects on bimanual function after surgery of the paretic arm in cerebral palsy are maintained long term. Assisting Hand Assessment (AHA) and active range of motion was tested before surgery and at 7 month and 9-year follow-up (n=18). AHA improved significantly from 50 to 52 U at 7 months, but was not different from before surgery at the 9-year follow-up, 49 U. Surgery of wrist and elbow flexors significantly improved active extension. Improvement in wrist and elbow extension was maintained at the 9-year follow-up, but usefulness of the hand measured with AHA had returned to the same level as before surgery.

Constraint-induced movement therapy in children with unilateral cerebral palsy

BACKGROUND

Unilateral cerebral palsy (CP) is a condition that affects muscle control and function on one side of the body. Children with unilateral CP experience difficulties using their hands together secondary to disturbances that occur in the developing fetal or infant brain. Often, the more affected limb is disregarded. Constraint-induced movement therapy (CIMT) aims to increase use of the more affected upper limb and improve bimanual performance. CIMT is based on two principles: restraining the use of the less affected limb (for example, using a splint, mitt or sling) and intensive therapeutic practice of the more affected limb.

OBJECTIVES

To evaluate the effect of constraint-induced movement therapy (CIMT) in the treatment of the more affected upper limb in children with unilateral CP.

SEARCH METHODS

In March 2018 we searched CENTRAL, MEDLINE, Embase, CINAHL, PEDro, OTseeker, five other databases and three trials registers. We also ran citation searches, checked reference lists, contacted experts, handsearched key journals and searched using Google Scholar.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs or clinically controlled trials implemented with children with unilateral CP, aged between 0 and 19 years, where CIMT was compared with a different form of CIMT, or a low dose, high-dose or dose-matched alternative form of upper-limb intervention such as bimanual intervention. Primarily, outcomes were bimanual performance, unimanual capacity and manual ability. Secondary outcomes included measures of self-care, body function, participation and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts to eliminate ineligible studies. Five review authors were paired to extract data and assess risk of bias in each included study. GRADE assessments were undertaken by two review authors.

MAIN RESULTS

We included 36 trials (1264 participants), published between 2004 and 2018. Sample sizes ranged from 11 to 105 (mean 35). Mean age was 5.96 years (standard deviation (SD) 1.82), range three months to 19.8 years; 53% male and 47% participants had left hemiplegia. Fifty-seven outcome measures were used across studies. Average length of CIMT programs was four weeks (range one to 10 weeks). Frequency of sessions ranged from twice weekly to seven days per week. Duration of intervention sessions ranged from 0.5 to eight hours per day. The mean total number of hours of CIMT provided was 137 hours (range 20 to 504 hours). The most common constraint devices were a mitt/glove or a sling (11 studies each).We judged the risk of bias as moderate to high across the studies.

KEY RESULTS

Primary outcomes at primary endpoint (immediately after intervention)CIMT versus low-dose comparison (e.g. occupational therapy)We found low-quality evidence that CIMT was more effective than a low-dose comparison for improving bimanual performance (mean difference (MD) 5.44 Assisting Hand Assessment (AHA) units, 95% confidence interval (CI) 2.37 to 8.51).CIMT was more effective than a low-dose comparison for improving unimanual capacity (Quality of upper extremity skills test (QUEST) - Dissociated movement MD 5.95, 95% CI 2.02 to 9.87; Grasps; MD 7.57, 95% CI 2.10 to 13.05; Weight bearing MD 5.92, 95% CI 2.21 to 9.6; Protective extension MD 12.54, 95% CI 8.60 to 16.47). Three studies reported adverse events, including frustration, constraint refusal and reversible skin irritations from casting.CIMT versus high-dose comparison (e.g. individualised occupational therapy, bimanual therapy)When compared with a high-dose comparison, CIMT was not more effective for improving bimanual performance (MD -0.39 AHA Units, 95% CI -3.14 to 2.36). There was no evidence that CIMT was more effective than a high-dose comparison for improving unimanual capacity in a single study using QUEST (Dissociated movement MD 0.49, 95% CI -10.71 to 11.69; Grasp MD -0.20, 95% CI -11.84 to 11.44). Two studies reported that some children experienced frustration participating in CIMT.CIMT versus dose-matched comparison (e.g. Hand Arm Bimanual Intensive Therapy, bimanual therapy, occupational therapy)There was no evidence of differences in bimanual performance between groups receiving CIMT or a dose-matched comparison (MD 0.80 AHA units, 95% CI -0.78 to 2.38).There was no evidence that CIMT was more effective than a dose-matched comparison for improving unimanual capacity (Box and Blocks Test MD 1.11, 95% CI -0.06 to 2.28; Melbourne Assessment MD 1.48, 95% CI -0.49 to 3.44; QUEST Dissociated movement MD 6.51, 95% CI -0.74 to 13.76; Grasp, MD 6.63, 95% CI -2.38 to 15.65; Weightbearing MD -2.31, 95% CI -8.02 to 3.40) except for the Protective extension domain (MD 6.86, 95% CI 0.14 to 13.58).There was no evidence of differences in manual ability between groups receiving CIMT or a dose-matched comparison (ABILHAND-Kids MD 0.74, 95% CI 0.31 to 1.18). From 15 studies, two children did not tolerate CIMT and three experienced difficulty.

AUTHORS' CONCLUSIONS

The quality of evidence for all conclusions was low to very low. For children with unilateral CP, there was some evidence that CIMT resulted in improved bimanual performance and unimanual capacity when compared to a low-dose comparison, but not when compared to a high-dose or dose-matched comparison. Based on the evidence available, CIMT appears to be safe for children with CP.

Surgical Management of Spasticity of the Thumb and Fingers

Spasticity of the hand profoundly limits an individual's independent ability to accomplish self-care and activities of daily living. Surgical procedures should be tailored to patients' needs and functional ability, and even patients with severe cognitive injuries and poor upper extremity function may benefit from surgery to improve appearance and hygiene. Careful preoperative examination and planning are needed, and consideration is given to the potential unintended detrimental effect of a surgical procedure on hand function.

Outcomes After Surgical Treatment of Spastic Upper Extremity Conditions

Surgical interventions for the spastic upper extremity aim to correct the common deformities of elbow flexion, forearm pronation, wrist flexion and ulnar deviation, and thumb-in-palm deformity. One goal is achieving optimal function and improved limb positioning. Aesthetics of the limb have a profound impact on self-esteem and satisfaction. Surgical deformity correction has not reliably been shown to improve sensory function such as stereognosis. Validated outcome measures are used to present outcomes after surgical treatment of the spastic upper extremity as it relates to motor function and limb positioning, sensory function, and self-esteem.

Neurosurgical Management of Spastic Conditions of the Upper Extremity

Spasticity is a hypertonic segmental reflex pathway caused by a central nervous system injury. Spasticity of the upper extremity causes loss of function, joint contracture, pain, and poor cosmesis. Treatment aims to reduce or change the pathophysiology underlying the hyperactive reflex from dorsal sensory rootlets through the intrinsic machinery of the spinal cord to the neuromuscular junction. There are many treatments for upper extremity spasticity including oral medication, physiotherapy, intrathecal baclofen, and lesional or neuromodulatory surgical approaches. Goals of treatment must always be clearly defined, but neurosurgical management is most effective when paired with multidisciplinary therapies and caregiver participation.

Evaluation of hand function in patients with unilateral cerebral palsy who underwent multilevel functional surgery: a retrospective observational study

BACKGROUND

Hemiplegia is the most common form of cerebral palsy. Upper limb is generally more affected than lower one. Indeed, hemiplegic children can spontaneously acquire standing and walking ability, while manipulation remains uncertain, with severe limitations in activity and participation, which define a child's functional status (International Classification of Functioning [ICF]). Several non-surgical tools are currently available to approach upper limb impairments. Studies regarding upper limb multilevel surgery in Hemiplegic Cerebral Palsy are relatively few and inhomogeneous.

AIM

The aim of this study is to propose a surgical approach based on upper limb functional level and manipulation strategy and establish whether multilevel surgery can improve segmental alignment, performance and capacity, that ICF defines as activities and participation qualifiers.

DESIGN

This study is an observational retrospective study.

SETTING

This study involves patients who referred to the Unit of Children Rehabilitation of S. Maria Nuova Institute for Research and Care, in Reggio Emilia (Italy), over a four-year period.

POPULATION

Children affected by hemiplegic cerebral palsy who underwent upper limb multilevel surgery.

METHODS

For each patient, we previously defined functional use of affected upper limb applying the House classification and the Ferrari one of manipulation pattern. Patients are divided into three groups: synergic hand (House 4, 5), imprisoned hand (House 3), excluded hand (House 0). We recorded goals achievement through Goal Attainment Scale and unimanual and bimanual abilities through Melbourne Assessment of Unilateral Upper Limb Function and through Assisting Hand Assessment respectively.

RESULTS

We recorded 16 upper limb multilevel surgical interventions in 13 children and report their results.

CONCLUSIONS

This study suggests that surgery can induce a segmental and/or aesthetic and/or a functional change depending on manipulation pattern. It also underlines the importance to analyze results in term of spontaneous manipulation abilities and daily use.

CLINICAL REHABILITATION IMPACT

This study provides a preliminary guide to plan surgery in relation to segmental deformities and overall manipulation pattern and describes their feasible improvement measures. It also suggests the most useful tools to record goal achievements in modifying manipulation function. Further controlled, randomized and prospective studies are required to support this idea.

Effects of Upper-Extremity Surgery on Manual Performance of Children and Adolescents with Cerebral Palsy: A Multidisciplinary Approach Using Shared Decision-Making

BACKGROUND

Little is known about the effects of upper-extremity surgery on the manual performance of children and adolescents with cerebral palsy (CP). This clinical cohort study describes our experience with patient selection based on multidisciplinary assessment and shared decision-making and the effects of upper-extremity surgery on manual performance and patient-relevant outcomes.

METHODS

All patients (up to 20 years of age) with CP referred to our multidisciplinary team for evaluation for upper-extremity surgery between July 2011 and May 2017 were included. Suitability for upper-extremity surgery was assessed with comprehensive, multidisciplinary screening, and the decision to proceed with surgery was made together with the patient. Individual patient-relevant goals were identified with the Canadian Occupational Performance Measure (COPM); perceived independence in performing bimanual activities at home was assessed with the ABILHAND-Kids tool, and perceived quality of use of the affected hand during daily activities was assessed with a visual analog scale (VAS). The quality of use of the affected hand during bimanual performance was measured with the Assisting Hand Assessment (AHA), and gross manual dexterity was evaluated with the Box and Block Test (BBT). All baseline assessments were repeated at an average of 9 months after the surgery.

RESULTS

Of 66 patients assessed by the multidisciplinary upper-extremity-surgery team, 44 were considered eligible for upper-extremity surgery. Of these patients, 39 (mean age and standard deviation [SD], 14.9 ± 2.10 years, 87% with unilateral CP, and 72% at Manual Ability Classification System [MACS] level II) underwent upper-extremity surgery and were evaluated in the pre-post study. All outcomes improved significantly after upper-extremity surgery, with average improvements of 3.1 ± 1.6 points in the COPM-Performance (COPM-P) score (p < 0.001), 3.3 ± 2.1 points in the COPM-Satisfaction (COPM-S) score (p < 0.001), 1.5 ± 1.2 logits in the ABILHAND score (p < 0.001), 2.4 ± 1.9 cm in the VAS score (p < 0.001), 6.7 ± 4.2 units in the AHA score (p < 0.001), and 2.2 ± 5.0 blocks/minute on the BBT (p = 0.021). The improvement in the COPM-P, COPM-S, ABILHAND, VAS, AHA, and BBT scores was clinically meaningful in 80%, 77%, 55%, 62%, 71%, and 31% of the patients, respectively.

CONCLUSIONS

Careful assessment of eligibility for upper-extremity surgery, based on multidisciplinary screening and shared decision-making, resulted in a clinically relevant improvement in patient-specific functional and/or cosmetic goals and manual performance after upper-extremity surgery in most patients with CP.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

APPLICABILITY OF RANDOMIZED TRIALS IN HAND SURGERY: SURVEY STUDY

OBJECTIVE

To assess the applicability of randomized clinical trials and whether certain factors (surgeon experience/journal impact factor) influence their applicability.

METHODS

In this survey study we used the Pubmed/Medline database to select 32 consecutive randomized clinical trials published between 2013 and 2015, involving hand surgery (high/low impact). These studies were independently assessed by 20 hand surgeons (with more or less than 10 years of practice) who answered 4 questions regarding their applicability. Agreement was assessed using Cohen's kappa and comparison of proportions via chi-square statistics. P-value <5% constituted statistical significance.

RESULTS

A total of 640 evaluations were produced, generating 2560 responses. A weak correlation was observed between less and more experienced respondents (kappa <0.2; range 0.119-0.179). Applicability between the least and most experienced respondents was similar (p = 0.424 and p = 0.70). Stratification by journal impact factor showed no greater propensity of applicability (p = 0.29) for any of the groups.

CONCLUSIONS

Low agreement was found between the respondents for the applicability of the randomized studies. Surgeon experience and journal impact do not seem to influence this decision. Level of Evidence II, Prospective comparative study.

Musculotendon adaptations and preservation of spinal reflex pathways following agonist-to-antagonist tendon transfer

Tendon transfer surgeries are performed to restore lost motor function, but outcomes are variable, particularly those involving agonist‐to‐antagonist muscles. Here, we evaluated the possibility that lack of proprioceptive feedback reorganization and musculotendon adaptations could influence outcomes. Plantaris‐to‐tibialis anterior tendon transfer along with resection of the distal third of the tibialis anterior muscle belly was performed in eight cats. Four cats had concurrent transection of the deep peroneal nerve. After 15–20 weeks, intermuscular length and force‐dependent sensory feedback were examined between hindlimb muscles, and the integrity of the tendon‐to‐tendon connection and musculotendon adaptations were evaluated. Three of the transferred tendons tore. A common finding was the formation of new tendinous connections, which often inserted near the original location of insertion on the skeleton (e.g., connections from plantaris toward calcaneus and from tibialis anterior toward first metatarsal). The newly formed tissue connections are expected to compromise the mechanical action of the transferred muscle. We found no evidence of changes in intermuscular reflexes between transferred plantaris muscle and synergists/antagonists whether the tendon‐to‐tendon connection remained intact or tore, indicating no spinal reflex reorganization. We propose the lack of spinal reflex reorganization could contribute the transferred muscle not adopting the activation patterns of the host muscle. Taken together, these findings suggest that musculotendon plasticity and lack of spinal reflex circuitry reorganization could limit functional outcomes after tendon transfer surgery. Surgical planning and outcomes assessments after tendon transfer surgery should consider potential consequences of the transferred muscle's intermuscular spinal circuit actions.

Correlation Between Standard Upper Extremity Impairment Measures and Activity-based Function Testing in Upper Extremity Cerebral Palsy

BACKGROUND

Although the treatment of cerebral palsy should be based on improving function as assessed by measures of impairment, activity, and participation, the standard indications for surgical treatment of upper extremity cerebral palsy (UECP) are impairment measures, primarily active and passive range of motion (ROM). Recently, validated activity measures have been developed for children with UECP. The purposes of this study were to determine the relationship between impairment and activity measures in this population, and whether measures of activity correlate with each other.

METHODS

A total of 37 children, ages 5 to 16 years, who met standard ROM surgical indications for UECP were evaluated with the impairment measures of active and passive ROM and stereognosis, as well as 3 activity measures [Assisting Hand Assessment (AHA), Box and Blocks test, and the Shriners Hospitals Upper Extremity Evaluation Dynamic Positional Analyses (SHUEE DPA)]. Impairment measures were correlated with activity measures using Spearman rank correlation coefficients.

RESULTS

Impairment measures showed inconsistent correlation with activity measures. Of the 12 comparisons, only 4 correlated: active forearm supination (ρ=0.47, P=0.003), wrist extension (ρ=0.55, P=0.001), and stereognosis scores (ρ=0.54, P=0.001) were correlated with AHA; and wrist extension was correlated with the SHUEE DPA (ρ=0.41, P=0.01). When the results of activity tests were compared, the AHA was correlated with the Box and Blocks tests (ρ=0.63, P<0.001), and the SHUEE DPA and Box and Blocks tests were correlated with each other (ρ=0.35, P=0.04).

CONCLUSIONS

The goal of surgery in UECP is to improve the child's ability to perform activities, and ultimately to participate in life situations. Impairment measures, such as ROM, were inconsistently correlated with validated measures of activity. Some activity measures correlated with each other, although they did not correlate with the same impairment measures. We conclude that impairment measures, including ROM, do not consistently predict functional dynamic ROM used to perform activities for children with UECP. Activity limitation measures may provide more appropriate indicators than impairment measures for upper extremity surgery for this population.

LEVEL OF EVIDENCE

Level II-diagnostic.

Flexion Deformities of the Wrist and Fingers in Spastic Cerebral Palsy: A Protocol of Management

BACKGROUND

Literature is confusing regarding grading and treatment of flexion deformities of wrist and fingers in spastic cerebral palsy (CP). The most established classification is that described by Zancolli; unfortunately, it has its shortcomings which we experienced in the beginning of our approach to manage this rather difficult deformity. We thus modified Zancolli's classification and developed a classification system and treatment protocol.

MATERIALS AND METHODS

Thirty patients with spastic CP were operated upon due to flexion deformity of the wrist and fingers and were included in this study. Age ranged from 4 to 14 years, average 7 years. There were twenty boys and ten girls.

RESULTS

The average followup was 18 months (range 9 months - 3 years). The power of wrist dorsiflexion, the "House's classification of upper extremity functional use" and the clinical assessment of hand function were used for evaluation; they improved in all patients and this improvement was statistically significant. In all patients, cosmetic appearance improved without any residual flexion deformity.

CONCLUSION

This study introduces a new grading system for flexion deformity of wrist and fingers in spastic CP that correlates with severity of the condition and allows a treatment protocol to be established.

Cerebral Palsy Tendon Transfers: Flexor Carpi Ulnaris to Extensor Carpi Radialis Brevis and Extensor Pollicis Longus Reroutement

The flexor carpi ulnaris to extensor carpi radialis brevis transfer and extensor pollicis longus rerouting combined with thenar release are 2 successful surgical interventions for children with spastic cerebral palsy. The goal of both procedures is to improve quality of life for patients who have previously failed conservative management, and the degree of expected improvement is predicated on several patient variables, making careful patient selection crucial for ensuring successful outcomes. Here, surgical technique is described; risk factors are discussed, and outcomes related to both procedures are presented.

Surgical Treatment of Pediatric Upper Limb Spasticity: The Wrist and Hand

The wrist and hand are essential in the placement of the upper extremity in a functional position for grasp, pinch, and release activities. This depends on the delicate balance between the extrinsic and intrinsic muscles of the wrist and hand. Spasticity alters this equilibrium, limiting the interaction of the upper limb with the environment. Classically, pediatric patients with upper limb spasticity present with a flexed wrist, thumb-in-palm, and flexed finger posture. These contractures are typically secondary to spasticity of the extrinsic flexor muscles of the wrist and hand and intrinsic muscles of the thumb and digits. Tendon release, lengthening, or transfer procedures may help correct the resultant abnormal postures. A total wrist arthrodesis with or without proximal row carpectomy may help address the severely flexed wrist deformity. With proper diagnosis, a well-executed surgical plan, and a consistent hand rehabilitation regimen, successful surgical outcomes can be achieved.

The Effect of Treatment on Stereognosis in Children With Hemiplegic Cerebral Palsy

PURPOSE

To determine if rehabilitation alone or combined with surgery or botulinum toxin injection improved stereognosis in children with hemiplegic cerebral palsy.

METHODS

Inclusion criteria were children with spastic hemiplegic cerebral palsy who had stereognosis testing 2 separate times with documentation of intervening treatment. Sixty-three children were included, 30 girls and 33 boys at an average age of 9.1 years (range, 4.4-16.0 years). Twelve standardized objects were used for manual identification. Baseline and postintervention stereognosis results were recorded for the hemiplegic and the dominant limb of each patient. The patients were separated into 3 groups based on intervening treatment: surgery with rehabilitation (27 patients), botulinum toxin injection with rehabilitation (19 subjects), and rehabilitation alone (7 subjects). Results were also analyzed by patient age group.

RESULTS

Baseline testing of the hemiplegic limb revealed that 27 patients (43%) exhibited severe stereognosis impairment (0-4 objects identified correctly), 18 (28%) were moderately impaired (5-8 objects), 13 (21%) were mildly impaired (9-11 objects), and 5 (8%) had intact stereognosis (12 objects). There was no statistically significant difference in change in stereognosis scores postintervention among the 3 different treatment groups or between patients who had surgery and those who did not have surgery. There was no statistically significant difference in stereognosis function or postintervention change based on patient age at time of testing.

CONCLUSIONS

In this study, 92% of children with spastic hemiplegic cerebral palsy had stereognosis impairment with a wide spectrum of severity. After operative or nonoperative treatment interventions, stereognosis as a secondary outcome measure was not changed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.