1149 - Optimizing Outcomes: Intraoperative Serial Casting and Botulinum Toxin for Spastic Lower Limbs

Objectives: The ongoing debate revolves around the choice between Botulinum toxin injection (BTX) and serial casting (SC) to address ankle equinus deformities in patients with cerebral palsy (CP). While a combined approach shows promise, concerns exist regarding poor patient tolerance and short-lived effects with SC. We hypothesized that simultaneously applying SC with BTX could lead to longer-lasting improvements in ankle range of motion (AROM) and better tolerance. We initiated an interdisciplinary program where we applied the first SC immediately after BTX under sedation. Our objective was to assess safety, patient tolerance, and the duration of improvement, both short-term (< 3 months) and long-term (≥3 months).

Design: This retrospective study was conducted at a tertiary institution. Children with CP with lower limb spasticity and AROM measuring < 5° of dorsiflexion with the knee extended were included. They underwent BTX in the affected limb under sedation, immediately followed by a short leg stretch cast application. The difference in AROM between short and long-term assessments was calculated as an average across all patients. We reviewed any complications, encompassing pressure injuries, pain, and patient tolerance.

Results: Nine patients met the eligibility criteria: four with the Gross Motor Function Classification System (GMFCS) I-II and five with GMFCS III-IV. The average age was 4.5 years. In the short term, an average increase in AROM was 11.9° (left) and 15° (right). In the long term, AROM changes amounted to 5.7° (left) and 10.7° (right). Most patients underwent serial casting for four weeks. No complications were reported during the study.

Conclusions: The simultaneous combination of SC with BTX is well-tolerated and proves to be an effective approach for improving AROM. Administering SC under sedation enhances the capability to stretch spastic muscles, as it overcomes the involuntary movements. The coordination of same-day procedures with an interdisciplinary team, ensuring comprehensive and timely care.