Infiltración del psoas con toxina botulínica guiada por tomografía axial computarizada: serie de casos / Infiltration of the psoas muscles with botulinum toxin guided by computerised axial tomography: a series of cases

Objetivo. Evaluar la eficacia y seguridad de la infiltración del psoas con toxina botulínica guiada por tomografía axial computarizada (TAC) en la reducción de la contractura dinámica en la flexión de la cadera. Pacientes y métodos. Serie de cinco niños diagnosticados de parálisis cerebral espástica y afectación bilateral. Todos los niños eran ambulantes, presentaban una actitud en la flexión de las caderas y rodillas con la típica ‘marcha agazapada’, una contractura dinámica de caderas y rodillas, no presentaban contraindicaciones para el uso de toxina botulínica, y sus padres dieron su consentimiento. Bajo control de TAC y sedación anestésica, se infiltraron ambos psoas con una dosis de 3 U/kg de peso; posteriormente, se infiltraron ambos isquiotibiales en dosis de 3 U/kg. Los pacientes fueron evaluados previamente y cuatro semanas después de la infiltración, valorándose el rango muscular mediante goniometría, el tono muscular mediante la escala modificada de Ashworth, la espasticidad mediante el test dinámico de Tardieu, y la actitud en la flexión de las caderas y rodillas en carga mediante medición goniométrica. Igualmente, se registraron efectos adversos secundarios a la punción o al uso de la toxina. Resultados. En los cinco pacientes se produjo una mejora de la movilidad, y una disminución del tono y la contractura, así como de la postura en bipedestación. Conclusiones. La infiltración del psoas guiada por TAC es una técnica efectiva y segura para disminuir la espasticidad en la flexión de la cadera, que, acompañada de la infiltración de los isquiotibiales, mejora la actitud en la flexión de cadera y rodilla (AU)

Aim. To evaluate the effectiveness and safety of infiltrating the psoas muscle with botulinum toxin guided by computerised tomography (CT) in order to reduce dynamic contracture in bending the hip. Patients and methods. The study involves a series of five children diagnosed with spastic cerebral palsy and bilateral involvement. All the children were able to walk and they presented an attitude on bending the hips and knees consisting in the typical ‘crouch gait’ together with a dynamic contracture of the hips and knees. They did not present any contraindications for the use of botulinum toxin and their parents gave their consent. Under CT control and anaesthetic sedation, both psoas muscles were infiltrated with a dose of 3 U/kg of body weight; later, both ischiotibial muscles were infiltrated using 3 U/kg doses. The patients were evaluated both prior to and four weeks after infiltration; the muscular range was assessed by means of goniometry, muscular tone was evaluated using the modified Ashworth scale, spasticity was measured using Tardieu’s dynamic test and the attitude in bending the hips and knees under a load was assessed by goniometric measurement. Likewise, adverse secondary effects to the puncture or to the use of the toxin were recorded. Results. The five patients reported an improvement in both mobility (with a reduction of tone and contracture) and the posture when standing. Conclusions. Infiltration of the psoas muscle guided by CT is an effective, safe technique for reducing spasticity in bending the hip, which, if accompanied by infiltration of the ischiotibial muscles, improves the attitude on bending the hip and knee (AU)

Botulinum toxin type A in the treatment of painful adductor muscle contracture after total hip arthroplasty.

Painful adductor muscle contracture is an important cause of failure during rehabilitation following total hip arthroplasty (THA). Adductor muscle contracture may be caused by postoperative muscle retractions, adhesive capsulitis, postoperative leg-length inequalities caused by implant failure, or preexisting hip pathologies. A 34-year-old woman experienced a persistent painful contracture into the left adductor magnus muscle after THA. She had no leg-length inequalities and, according to the Medical Research Council scale (grades 0-5), muscle strength of the quadriceps was 5/5 for the right side and 3/5 for the left. The degree of functionality according to the Harris hip score (HHS) was 16/100 in the left hip. The pain level, measured with the visual analog scale (VAS), was 7/10. The patient was unable to fully adhere to the rehabilitation program and walked with a limp during the stance phase of gait. After 7 days of treatment with injections of botulinum toxin type A into the left adductor magnus muscle (dose, 150 UM) and subsequent rehabilitation, a great reduction of painful contracture was observed (VAS score, 2/10). The procedure was well tolerated and no adverse effects were noted. After 20 days, hip articular range of motion and gait had improved (HHS score, 75/100). The clinical effects of botulinum toxin type A were present at 2-month follow-up. This treatment may be a viable alternative for the management of painful adductor muscle contracture after THA, without significant side effects.

Treatment of lateralisation and subluxation of the hip in cerebral palsy with Botulinum toxin A: preliminary results based on the analysis of migration percentage data.

It has been reported that cerebral palsy patients with adductor spasm and lateralisation/subluxation of the hip can be treated with Botulinum toxin A, but statistical evaluation is lacking. We present the radiological results in 5 patients. The follow-up ranged from 18 (5 patients) to 24 months (4 patients). Reimers' migration percentage was chosen as parameter for lateralisation/subluxation. Statistical analysis was performed by the Wilcoxon test. The migration percentage improved from 51% to 44% at 9 months, 37% at 18 months, and 34% at 24 months. The improvement was significant from the 9th to the 18th month (p=0.04).

Retracción de miembros inferiores en un paciente con hipertiroidismo / Retraction of lower limbs in a patient with hyperthyroidism

We report a 47 years old woman with hyperthyroidism that had a severe tendinous retraction of hips and knees that subsided with propylthiouracil treatment. Electrodiagnosis showed myopathic alterations and muscle strength was moderately reduced. The authors did not find references of a similar condition in patients with hyperthyroidism