Adding botulinum toxin-A injections prior to cast treatment for idiopathic toe-walking does not improve the outcome of cast-only treatment.

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Background Numerous recommendations have been made for treating idiopathic toe-walking (ITW), but the treatment results have been questioned. The purpose of this study was to investigate whether botulinum toxin A (BTX) improves the walking pattern in ITW as examined with 3-D gait analysis. Participants and methods A consecutive series of 15 children (aged 5-13 years) were enrolled in the study. The children underwent a 3-D gait analysis prior to treatment with a total of 6 units/kg bodyweight Botox Ò in the calf muscles and an exercise program. The gait analysis was repeated 3 weeks and 3, 6, and 12 months after treatment. A classification of toe-walking severity was made before treatment and after 12 months.The parents rated the perceived amount of toe-walking prior to treatment and 6 and 12 months after treatment. Results Eleven children completed the 12-month follow-up. The gait analysis results displayed a significant improvement, indicating decreased plantarflexion angle at initial contact and during swing phase and increased dorsiflexion angle during midstance at all post-treatment testing instances. According to the parents' perception of toewalking, 3/11 children followed for 12 months had ceased toe-walking completely, 4/11 decreased toe-walking, and 4/11 continued toe-walking. After 6-12 months, the toewalking severity classification improved in 9 of the 14 children for whom data could be assessed. Conclusions A single injection of BTX in combination with an exercise program can improve the walking pattern in children with ITW seen at gait analysis, but the obvious goal of ceasing toe-walking is only occasionally reached.

Early treatment of BoNT-A in children with spastic CP may decrease muscle tone and decelerate contracture development after 3.5 years. The effect on gait development remains inconclusive.

A consecutive series of 17 children (six males, 11 females; mean age 11y 11mo [SD 4y 5mo]; range 3y 11mo-17y 4mo) with plantarflexor weakness was assessed to compare gait differences between a carbon fibre spring orthosis (CFSO) and participants' regular orthoses. Twelve children had myelomeningocele, four children had arthrogryposis, and one child had neuropathy with peripheral muscle pareses. All participants underwent clinical examination and 3D gait analysis. Parents answered a questionnaire to assess subjective perceptions of the orthoses. Results from 3D gait analysis provided evidence that CFSOs enhance gait function in most participants by improving ankle plantarflexion moment (p<0.001), ankle positive work (p<0.001), and stride length (p<0.001). The CFSO did not suit all participants, which emphasizes the importance of analyzing each patient's needs.During gait, the plantarflexors contribute to knee and ankle stability, restrain the forward rotation of the tibia during stance phase, and conserve energy by minimizing vertical oscillation of the whole-body centre of mass. 1 The positive work done by the plantarflexors during push-off adds to the potential and kinetic energy of the leg, thigh, and upper part of the body, and propels the body forward. 2 Children with various motor disorders exhibit weakness of plantarflexor muscles. Children with myelomeningocele (MMC) with neurological lesions at as low as the sacral and low lumbar levels are generally unable to stand still without external support, despite sufficient muscle strength in hip and knee muscles to walk independently. 3,4 Extensive plantarflexor weakness results in kinematic alterations (such as increased knee flexion, anterior pelvic tilt, and trunk and pelvic rotation), 5 increased vertical excursions, and is associated with an anterior trend in the centre of mass motion. 6 In children with arthrogryposis multiplex congenita (AMC), equinuovarus adductus foot is frequently observed, 7 which is often associated with plantarflexor muscle weakness.Due to the essential role of the plantarflexors in walking, orthotic substitutions are essential in patients with plantarflexor paralysis. 1 In children with MMC at L4 and L5, ankle-foot orthoses (AFOs) have been shown to improve sagittal plane function by reducing excessive ankle dorsiflexion, increasing plantarflexor moment, and reducing crouch and associated knee extensor moments. 8 In the authors' experience, ambulatory children with AMC and unstable feet, ankle, and knee joints also benefit from orthoses, but no gait study has been found in this field.One major challenge in the field of orthotics is to compensate for the plantarflexors' propulsive function, namely, to sustain a plantarflexion moment and to allow simultaneous plantarflexion movement. The posterior-leaf spring AFO was tested in patients with cerebral palsy. While it allowed ankle dorsiflexion in midstance, it was not shown to augment ankle function through storage and return of mechanical or spring energy. 9 Carbon fibre orthoses hav...

Mechanical stimuli play a significant role in the process of endochondral growth. Thus far, approaches to understand the endochondral mechanical growth rate have been limited to the use of approximated location and geometry of the growth plate. Furthermore, growth has been simulated based on the average deflection of the growth plate or of the femoral neck. It has also been reported in the literature that the growth plate lies parallel to one of the principal stresses acting on it, to reduce the shear between epiphysis and diaphysis. Hence the current study objectives were (1) to evaluate the significance of a subject-specific finite element model of the femur and growth plate compared to a simplified growth plate model and (2) to explore the different growth direction models to better understand proximal femoral growth mechanisms. A subject-specific finite element model of an able-bodied 7-year old child was developed. The muscle forces and hip contact force were computed for one gait cycle and applied to a finite element model to determine the specific growth rate. Proximal femoral growth was simulated for two different growth direction models: femoral neck deflection direction and principal stress direction. The principal stress direction model captured the expected tendency for decreasing the neck shaft angle and femoral anteversion for both growth plate models. The results of this study suggest that the subject-specific geometry and consideration of the principal stress direction as growth direction may be a more realistic approach for correct prediction of proximal femoral growth morphology.

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