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Early ultrasonographic evaluation of idiopathic clubfeet treated with manipulations, casts, and Botox(®): a double-blind randomized control trial.

Howren AM, Jamieson DH, Alvarez CM - J Child Orthop (2015)

Bottom Line: The complex length within each of the three treatment groups displayed no significant change between baseline and 6 weeks.The complex-tendon ratio and muscle-tendon ratio of the Botox(®) treatment group was significantly decreased compared to controls (p = 0.049 and 0.042, respectively).Only in the Botox(®) treatment cohort did the muscle shrink to uncover tendon (seen as a decreased complex-tendon ratio and muscle-tendon ratio) over the 6-week interval to effectively increase tendon length with respect to the unit as a whole.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedics, British Columbia's Children's Hospital, 1D18-4480 Oak Street, Vancouver, BC V6H 3V4, Canada, ahowren@cw.bc.ca.

ABSTRACT

Background: The manipulations, casts, and Botox(®) method for treating idiopathic clubfoot is an alternative non-surgical treatment method. Botox(®)-induced reversible muscle paralysis of the gastrocsoleus enables a physician to manipulate and cast the clubfoot in greater dorsiflexion. Ultrasound is incorporated during the early treatment stages to monitor the underlying physiology of the muscle-tendon unit following Botox(®).

Methods: Ultrasonographic evaluation was performed parallel to a double-blind randomized control trial administering Botox(®) or placebo to correct clubfoot. Patients underwent two-dimensional ultrasound to monitor the length changes to the gastrocsoleus and Achilles tendon unit at two time points: pre-injection (baseline) and 6 weeks post-blinded injection. Gastrocsoleus and Achilles tendon length measurements were analyzed among placebo, Botox(®) and contralateral controls using repeated measures ANOVA.

Results: The baseline gastrocsoleus length of the clubfoot (322.4 pixels) before blinded injection appears shorter than controls (337.5 pixels), but fails to reach significance (p = 0.05). The complex length within each of the three treatment groups displayed no significant change between baseline and 6 weeks. The complex-tendon ratio and muscle-tendon ratio of the Botox(®) treatment group was significantly decreased compared to controls (p = 0.049 and 0.042, respectively). Briefly, when expressed as a proportion, an increase in Achilles tendon length and decrease in gastrocsoleus is observed when clubfeet are treated with Botox(®).

Conclusions: Only in the Botox(®) treatment cohort did the muscle shrink to uncover tendon (seen as a decreased complex-tendon ratio and muscle-tendon ratio) over the 6-week interval to effectively increase tendon length with respect to the unit as a whole.

No MeSH data available.


Related in: MedlinePlus

Ultrasound image depicting measurements of (a) Achilles tendon length and (b) gastrocsoleus muscle and Achilles tendon complex length
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Related In: Results  -  Collection


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Fig2: Ultrasound image depicting measurements of (a) Achilles tendon length and (b) gastrocsoleus muscle and Achilles tendon complex length

Mentions: The infant was placed prone with knee straight and the foot protruding off the edge of the bed so that it could be readily grasped and dorsiflexed, attempting to achieve 90° between the tibia and foot plantar surface and create a uniform measuring situation. The fixed point for Achilles tendon insertion was the posterior superior corner of the calcaneous bone. The chosen surrogate for origin of gastrocsoleus muscle was the superior lateral margin of the tibia. In Siescape mode, a probe runs smoothly between these two points to produce an extended field of view image. Three suitable images per limb were obtained. Two paediatric radiologists performed the study, one of whom (D.J.) did all the post-imaging calculations. The extended field of view images are composite images providing pixel distances, not direct millimeter measurement. Thus a ratio of “lateral superior tibia” to “posterior superior calcaneous” (representing the muscle tendon complex) divided by the “posterior superior calcaneous” to “Achilles aponeurosis” (representing the upper limit of the Achilles tendon) was calculated (Fig. 2). To account for the potential error associated with the difficultly in precisely delineating the aponeurosis, both measurements were obtained three times per limb. An average value for each measure was calculated for analysis.Fig. 2


Early ultrasonographic evaluation of idiopathic clubfeet treated with manipulations, casts, and Botox(®): a double-blind randomized control trial.

Howren AM, Jamieson DH, Alvarez CM - J Child Orthop (2015)

Ultrasound image depicting measurements of (a) Achilles tendon length and (b) gastrocsoleus muscle and Achilles tendon complex length
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4340848&req=5

Fig2: Ultrasound image depicting measurements of (a) Achilles tendon length and (b) gastrocsoleus muscle and Achilles tendon complex length
Mentions: The infant was placed prone with knee straight and the foot protruding off the edge of the bed so that it could be readily grasped and dorsiflexed, attempting to achieve 90° between the tibia and foot plantar surface and create a uniform measuring situation. The fixed point for Achilles tendon insertion was the posterior superior corner of the calcaneous bone. The chosen surrogate for origin of gastrocsoleus muscle was the superior lateral margin of the tibia. In Siescape mode, a probe runs smoothly between these two points to produce an extended field of view image. Three suitable images per limb were obtained. Two paediatric radiologists performed the study, one of whom (D.J.) did all the post-imaging calculations. The extended field of view images are composite images providing pixel distances, not direct millimeter measurement. Thus a ratio of “lateral superior tibia” to “posterior superior calcaneous” (representing the muscle tendon complex) divided by the “posterior superior calcaneous” to “Achilles aponeurosis” (representing the upper limit of the Achilles tendon) was calculated (Fig. 2). To account for the potential error associated with the difficultly in precisely delineating the aponeurosis, both measurements were obtained three times per limb. An average value for each measure was calculated for analysis.Fig. 2

Bottom Line: The complex length within each of the three treatment groups displayed no significant change between baseline and 6 weeks.The complex-tendon ratio and muscle-tendon ratio of the Botox(®) treatment group was significantly decreased compared to controls (p = 0.049 and 0.042, respectively).Only in the Botox(®) treatment cohort did the muscle shrink to uncover tendon (seen as a decreased complex-tendon ratio and muscle-tendon ratio) over the 6-week interval to effectively increase tendon length with respect to the unit as a whole.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopaedics, British Columbia's Children's Hospital, 1D18-4480 Oak Street, Vancouver, BC V6H 3V4, Canada, ahowren@cw.bc.ca.

ABSTRACT

Background: The manipulations, casts, and Botox(®) method for treating idiopathic clubfoot is an alternative non-surgical treatment method. Botox(®)-induced reversible muscle paralysis of the gastrocsoleus enables a physician to manipulate and cast the clubfoot in greater dorsiflexion. Ultrasound is incorporated during the early treatment stages to monitor the underlying physiology of the muscle-tendon unit following Botox(®).

Methods: Ultrasonographic evaluation was performed parallel to a double-blind randomized control trial administering Botox(®) or placebo to correct clubfoot. Patients underwent two-dimensional ultrasound to monitor the length changes to the gastrocsoleus and Achilles tendon unit at two time points: pre-injection (baseline) and 6 weeks post-blinded injection. Gastrocsoleus and Achilles tendon length measurements were analyzed among placebo, Botox(®) and contralateral controls using repeated measures ANOVA.

Results: The baseline gastrocsoleus length of the clubfoot (322.4 pixels) before blinded injection appears shorter than controls (337.5 pixels), but fails to reach significance (p = 0.05). The complex length within each of the three treatment groups displayed no significant change between baseline and 6 weeks. The complex-tendon ratio and muscle-tendon ratio of the Botox(®) treatment group was significantly decreased compared to controls (p = 0.049 and 0.042, respectively). Briefly, when expressed as a proportion, an increase in Achilles tendon length and decrease in gastrocsoleus is observed when clubfeet are treated with Botox(®).

Conclusions: Only in the Botox(®) treatment cohort did the muscle shrink to uncover tendon (seen as a decreased complex-tendon ratio and muscle-tendon ratio) over the 6-week interval to effectively increase tendon length with respect to the unit as a whole.

No MeSH data available.


Related in: MedlinePlus