Benefits of Tendon Transfer Surgery in Cerebral Palsy

Source: Van Heest A, Bagley A, Molitor F, et al. Tendon transfer surgery in upper-extremity cerebral palsy is more effective than botulinum toxin injections or regular, ongoing therapy. J Bone Joint Surg. 2015; 97(7): 529– 536; doi: 10.2106/JBJS.M.01577Investigators from 7 Shriners Hospitals sought to determine the most effective treatment for upper extremity muscle contractures in children with spastic, hemiplegic cerebral palsy (CP). Patients with upper extremity CP, aged 4 to 16 years, were prospectively assigned randomly or by patient/family preference to 1 of 3 treatment groups: surgery (Group 1), botulinum toxin injections (Group 2), or regular ongoing therapy (Group 3). All 3 patient groups also received standard supervised occupational therapy (OT) followed by home therapy. Standardized validated outcome tools were used for assessment. Outcomes measurements included active range of motion, pinch and grip strength, stereognosis, and scores from 8 other functional or patient-orientated validated outcome tools including dynamic positional analysis (DPA), 5 domains in the Pediatric Quality of Life Inventory (PedsQL), and the Canadian Occupational Performance Measure (COPM-satisfaction score). Change from baseline for each of these outcomes was compared among children in the 3 treatment groups.Thirty-nine patients were enrolled in the study, 29 by randomization and 10 by patient/family preference. Thirty-four patients (25 randomized and 9 patient/family-preference) were evaluated 12 months post-treatment. This included 16 in Group 1, 9 in Group 2, and 9 in Group 3. Significantly greater improvement in DPA was seen among those in Group 1 (surgery) compared to the other 2 groups (P < .001). These changes reflected improvement in supination and wrist extension during functional activities after surgical treatment. Participants in Group 1 also showed more improvement in the PedsQL-CP module domain of movement compared to those in the other groups (P = .002). The mean increase in Group 1 was 26.4% while Group 2 and Group 3 both had a mean decrease of 3.3%. For the other 4 domains of the PedsQL-CP module – school, fatigue, eating, and speech – there were no significant differences among treatment groups. Group 1 also showed more improvement in the COPM score than Groups 2 and 3 (P = .002). Children in groups 1 and 3 showed significantly more improvement in pinch strength than those from Group 2.The authors conclude that for children with upper extremity CP, surgical treatment results in significantly greater functional improvement and satisfaction than botulinum toxin injections or regular therapy.Dr Hennrikus has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.In children with hemiplegic CP, the abnormal muscle tone patterns cause the arm and hand to be positioned in elbow flexion, forearm pronation, wrist flexion, and thumb in palm. These contractures limit function. Nonsurgical and surgical treatments exist to reduce the deformities and improve function. Nonsurgical treatments include botulinum toxin injections and OT.1–3Botulinum toxin injections cause a chemical denervation of spastic muscles, which decreases the deforming force across the joints. Therapy includes range of motion, strengthening, dexterity training, and splinting. Surgery includes tendon transfers and muscle releases to reduce deformity and improve power and position.4,5To help clinicians evaluate treatment options for this group of patients, the authors of the current study designed a randomized multicenter trial. Results suggest that tendon transfer surgery was more effective than botulinum toxin injections or regular ongoing therapy in children with upper extremity CP for improving pinch strength, limb positioning, and functional tasks. The primary benefits of tendon transfer surgery are improved joint positioning of the wrist into extension and supination with resulting improved function. The functional improvements were of modest magnitude. Dexterity was not assessed in this study.Botulinum toxin injections resulted in no significant improvements in measurements of bodily impairment, activity limitations, or participation restrictions. The major detriment to botulinum toxin injections was a persistent loss of grip and pinch strength. The authors no longer recommend botulinum toxin injections as treatment for upper extremity contractures in children with hemiplegic CP. They continue to recommend OT for maintenance treatment after surgery.Limitations of the study include the assessment tools, which were associated with difficulty measuring changes in thumb position and function. Additional investigation into more sensitive assessment tools for thumb position and function is recommended. Longer length of follow-up and different patient populations may lead to different results. There was also a high rate of parental refusal for randomization, prompting the addition of a patient-preference option for families who refused randomization; 13% of the patients still did not complete the study. Regardless, the results of the study have prompted the investigators to change their recommendations.

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.