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Predictive Value of Chemodenervation on the Outcome of Pronator Teres Surgery in Children with Cerebral Palsy
Nicole N. Nemeth, MD; Loyola University Medical Center; Randy Bindra
Loyola Medical Center, Maywood, IL

Background: The purpose of this study was to determine the predictive value of preoperative chemodenervation with botulinum toxin A on the outcome of pronator teres surgery in children with cerebral palsy. Our hypothesis was that the results of chemodenervation would help to select between a tenotomy versus a rerouting procedure.
Methods: Between 2008 and 2012, all patients referred with a pronation deformity were initially assessed using the SHUEE and given Botulinum toxin A (dose range). Based on their post injection SHUEE, completed between 1-3 months, they were offered surgery. Patients who achieved good active supination, were offered a tenotomy and patients who did not achieve good active supination past neutral were offered a rerouting procedure. We performed 13 procedures but were able to prosepectively able to follow only 9 patients. Each patient was evaluated using the Shriner's Hospital for Children Upper Extremity Evaluation (SHUEE) at initial presentation, after chemodenervation and postoperatively.
Results: The forearm scores of the SHUEE exam are scored by the child's ability to complete 4 tasks, with a maximum score of 12. The median SHUEE score for forearm positioning at initial presentation was 7 (4-11). The average SHUEE score for forearm positioning was 8 (4-12) following chemodenervation and 9 (7-12) following surgery. We found a moderate correlation between the amount of improvement following chemodenervation and following pronator teres surgery.
Conclusion: SHUEE is a validated assessment of upper extremity function in children with hemiplegic cerebral palsy. We have found chemodenervation with botulinum toxin A to help guide the treating surgeon to the most appropriate muscle balancing procedure. We have also found that chemodenervation assists the patient and patient's family to understand what a more permanent procedure might hope to accomplish. Although the scores from the SHUEE did not improve as much following chemodenervation as with pronator teres surgery, we were able to identify a moderate correlation between response to botox and response to pronator teres surgery.


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