Introduction and Aims: The hypothesis that ‘utilisation of gradual distraction and soft tissue correction by external fixation improves outcomes in hand and wrist deformity’ was analysed in 29 extremities in 24 patients, to define the indications for gradual soft tissue correction of congenital and acquired deformity and distraction osteogenesis in hypoplastic digits.

Method: This retrospective review of 29 extremities in 24 patients evaluated the role of monolateral external fixators with uniplanar (n=20) and multiplanar (n=9) correction capability (Orthofix, International). Evaluation included an assessment of complications, patient satisfaction, functional outcome, and impact on health-related quality of life.

Results: The devices were successfully used to correct radial longitudinal deficiency of the radius (radial club hand) (n=9); digital hypoplasia (n=15) and wrist flexion contracture secondary to spasticity (n=5). There were no significant complications related to the devices. Pin track irritation and drainage occurred in two of 108 pins. One pin became loose and needed to be replaced, and one fixator required two intraoperative adjustments. Multiplanar fixators used for correction of radial club hands and wrist flexion contracture improved soft tissue position in allowing secondary bony procedures and/or tendon transfers. Distraction osteogenesis of metacarpals and phalanges (included seven previously transferred extraperiostial toe phalanges) was successful with an average lengthening of 2.1 centimetres.

Conclusion: Gradual distraction and soft tissue correction improves outcomes in congential and acquired hand and wrist deformity in children and adolescents. Mono-lateral fixation devices allow correction with hinges or gears, enhance correction of complex deformity, and is well tolerated by patients and caregivers.

Introduction and Aims: In order to evaluate the hypothesis that ‘Botulinum A Toxin (BoNT-A) improves function and health-related quality of life in patients and their caregivers’, the experience of a single institution that performed over 7500 injections in 515 patients was evaluated to provide safety data, injection guidelines, and current indications.

Method: This retrospective review utilised a computerised database that contains information from open-label trials (n=6), double-blind randomised trials (n=4), and cumulative treatment experience in 1100 children and adults with cerebral palsy. Standardised data collected over the past 15 years was analysed with respect to indications, complications, dosage, function, health-related quality of life of patients and their caregivers, rehabilitation (WeeFIM), gross motor function classification (GMFCS), and response rates. Pharmacoeconomic analysis was performed by linking with state Medicaid data.

Results: BoNT-A is safe and well tolerated. There were no systemic side effects in dosages ranging from four to 25 units per kilogram body weight. Standardised injection techniques included dilution from 10 to 100 units per cc with a maximum dose of six units per kilogram in a single muscle and 25 units per kilogram in a single patient. The maximum dose was 600 units.

Short-term response rates were 65–70%; intermediate response rates 45–50%. The most frequent complications were soreness of the injection site (15%) and transient weakness (2%). Ninety-five percent of injections were performed in the office without conscious sedation. Five percent were performed under general anaesthesia or with conscious sedation.

Based on these data, current indications include dynamic tone interfering with caregiver function (e.g., equinus gait), painful spasticity, post-operative spasticity, and pain management. Contraindications are failure to respond to previous injections. Pharmacoeconomic analysis diminished cost and improved function and quality of life of patients and/or caregivers.

Conclusion: Botulinum A Toxin is a safe and cost-effective drug in patients with cerebral palsy. Response rate is 50–70%. Optimal results are obtained with appropriate intramuscular localisation and sufficient volume to saturate neuromuscular junctions.

Introduction and Aims: In order to evaluate the hypothesis that the ‘temporary and controlled reduction of muscle force protects repair sites come from its safe, active, and passive range of motion and diminishes complications’, a tendon repair model was evaluated.

Method: After heel cord tenotomy, Sprague-Dawley rats (n=36) were randomised to Botulinum A Toxin at six units per kilogram or saline and the tendon repaired with a two-strand core suture and a peritenon running suture. The ankles were pinned in equinus for two days, and then the animals were allowed to move freely within their cages. Analysis included gap, rupture rates, electrophysiologic measurements and mechanical testing.

Results: The treatment group had a statistically significant lower spontaneous partial or total rupture rate than the control (P=0.38). Tendon electrophysiologic testing showed that the toxin group had lower twitch and tetanus values than the control group (evidence of effective denervation). The toxin group also had better histologic healing and better strength of repair (higher rupture strength values). Histologic assessment showed that the toxin-treated group had more normal histology with less scar.

Conclusion: Chemoprotection decreases significantly spontaneous tendon rupture rates following repair in active versus control groups. The active toxin group demonstrated better healing. Decreasing tension across repair sites is equally effective in increasing inastamotic strength and permits active range of motion without rupture.