title: An implantable upper extremity neuroprosthesis in a growing child with a C5 spinal cord injury.
abstract: OBJECTIVE
  To implement a functional electrical stimulation (FES) hand neuroprosthesis called the Freehand System in a growing child with spinal cord injury (SCI) using extra lead wire to accommodate limb growth, and to evaluate the performance of the Freehand System during the subject's maturation.
  
  
  METHODS
  Pediatric orthopedic hospital specializing in SCI rehabilitation.
  
  
  METHODS
  Ten-year-old female patient with a C5 level SCI.
  
  
  METHODS
  The Freehand System was implanted. Eight electrodes were implanted to targeted forearm and hand muscles to provide grasp and release function. The lead wire associated with each electrode was pathed subcutaneously up the arm with 4 cm of extra lead distributed throughout the path to accommodate expected limb growth. All leads were attached to a stimulator placed in the upper chest. Measures of lead unwinding, limb growth, stimulated muscle strength, and hand function were made at 6 and 16 months after implant.
  
  
  RESULTS
  By 16 months post implant, the upper limb growth plates were closed and humeral and radial bone growth combined was 2.7 cm from the time of surgery. For all eight leads, lead unwinding in the upper arm was approximately 1.2 cm and was comparable to humeral bone growth (1.4 cm). Lead unwinding in the lower arm was also measurable for the two electrodes in hand muscles. Six of eight electrodes maintained grade 3 or better stimulated muscle strength throughout the growth period according to a manual muscle test. Of the two other electrodes, one appeared to have lost function due to depletion of excess lead. However, hand function with FES was comparable at 6 and 16 months post implant suggesting that growth did not negatively impact performance with the FES system. Hand function with FES was improved over voluntary hand function as well. Using the Freehand System, a pinch force of approximately 15 N was achieved compared to 1.3 N of voluntary tenodesis pinch force. Scores on the Functional Independence Measure (FIM) increased by 9 points when FES was used as compared to voluntary function. Improvements occurred primarily in eating and grooming. Independence in writing was achieved only with FES.
  
  
  CONCLUSIONS
  For this child, hand function with the Freehand System was sustained over the growth period and was a significant functional improvement over voluntary hand function. By using excess lead wire, the Freehand System was successfully implemented before skeletal maturity, affording the child improved hand function earlier than would be otherwise indicated.
authors.affiliation: Research Department, Shriners Hospitals for Children, Philadelphia, Pennsylvania 19140, USA.
authors.forename: B T
authors.initials: BT
authors.lastname: Smith
authors.forename: M J
authors.initials: MJ
authors.lastname: Mulcahey
authors.forename: R R
authors.initials: RR
authors.lastname: Betz
mesh_terms: D001132:Arm / Q000000981:diagnostic imaging / Q000254:growth & development; D002574:Cervical Vertebrae / Q000293:injuries; D002648:Child; D004599:Electric Stimulation Therapy / Q000295:instrumentation*; D004567:Electrodes, Implanted; D005260:Female; D006801:Humans; D018482:Muscle, Skeletal / Q000503:physiopathology; D011859:Radiography; D013119:Spinal Cord Injuries / Q000503:physiopathology / Q000628:therapy*