title: Tendon transfer surgery in upper-extremity cerebral palsy is more effective than botulinum toxin injections or regular, ongoing therapy.
abstract: BACKGROUND
  For children with upper-extremity cerebral palsy (CP) who meet standard indications for tendon transfer surgery, we hypothesized that surgical treatment would result in greater functional improvement than treatment with botulinum toxin injections or regular, ongoing therapy.
  
  
  METHODS
  Thirty-nine children with upper-extremity CP, who were four to sixteen years of age and surgical candidates for the transfer of the flexor carpi ulnaris to the extensor carpi radialis brevis, pronator teres release, and extensor pollicis longus rerouting with adductor pollicis release, were prospectively assigned, either randomly (twenty-nine patients) or by patient/family preference (ten patients), to one of three treatment groups: surgical treatment (Group 1); botulinum toxin injections (Group 2); or regular, ongoing therapy (Group 3). Seven centers participated. Assessment measurements included active range of motion, pinch and grip strength, stereognosis, and scores as measured with eight additional functional or patient-oriented outcome instruments. Thirty-four patients (twenty-five randomized and nine from the patient-preference arm) were evaluated twelve months post-treatment as the study cohort.
  
  
  RESULTS
  For the primary outcome of the Shriners Hospital Upper Extremity Evaluation (SHUEE) dynamic positional analysis (DPA), significantly greater improvement was seen in Group 1 than in the other two groups (p < 0.001). Improvements in SHUEE DPA reflected improved supination and wrist extension during functional activities after surgical treatment. Group 1 showed more improvement in the Pediatric Quality of Life Inventory (PedsQL) CP module domain of movement and in the Canadian Occupational Performance Measure (COPM) score for satisfaction than Groups 2 and 3. Both Groups 1 and 3 showed more improvement in pinch strength than did Group 2.
  
  
  CONCLUSIONS
  For children with upper-extremity CP who were candidates for standard tendon transfer, surgical treatment was demonstrated to provide greater improvement, of modest magnitude, than botulinum toxin injections or regular, ongoing therapy at twelve months of follow-up for the SHUEE DPA, the PedsQL CP module domain of movement, and COPM satisfaction.
authors.affiliation: Department of Orthopaedic Surgery, University of Minnesota, 2450 Riverside Avenue, Suite R200, Minneapolis, MN 55454. E-mail address: vanhe003@umn.edu.
authors.forename: Ann E
authors.initials: AE
authors.lastname: Van Heest
authors.affiliation: Shriners Hospitals for Children-Northern California, 2425 Stockton Boulevard, Sacramento, CA 95817.
authors.forename: Anita
authors.initials: A
authors.lastname: Bagley
authors.affiliation: Shriners Hospitals for Children-Northern California, 2425 Stockton Boulevard, Sacramento, CA 95817.
authors.forename: Fred
authors.initials: F
authors.lastname: Molitor
authors.affiliation: Shriners Hospitals for Children-Northern California, 2425 Stockton Boulevard, Sacramento, CA 95817.
authors.forename: Michelle A
authors.initials: MA
authors.lastname: James
mesh_terms: D000293:Adolescent; D019274:Botulinum Toxins, Type A / Q000627:therapeutic use*; D002547:Cerebral Palsy / Q000188:drug therapy* / Q000503:physiopathology / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D005260:Female; D018737:Hand Strength; D006801:Humans; D008297:Male; D009465:Neuromuscular Agents / Q000627:therapeutic use*; D016059:Range of Motion, Articular; D013709:Tendon Transfer; D016896:Treatment Outcome; D034941:Upper Extremity
chemical_list: D009465:Neuromuscular Agents; D019274:Botulinum Toxins, Type A