RESEARCH: Botox in hip flexor muscle

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Ultrasound-guided botulinum toxin injection technique

for the iliopsoas muscle.

Westhoff B, Seller K, Wild A, Jaeger M, Krauspe R.

Department of Orthopaedics, Heinrich-Heine University

Duesseldorf, Duesseldorf, Germany.

westhoff@...

Intramuscular botulinum toxin A injections are

beneficial for the treatment of functional shortening

of the iliopsoas muscle, but it is difficult to

achieve precise needle positioning and injection. As a

solution to this we present an ultrasound-guided

injection technique for the iliopsoas muscle using an

anterior approach from the groin. The procedure was

performed 26 times in 13 patients (seven males, six

females; mean age 11 years, SD 9 years 8 months; age

range 4 to 31 years), 10 times bilaterally.

Indications were functional iliopsoas shortening due

to cerebral palsy (17 hips), hereditary spastic

paraplegia (four hips), and Perthes disease (five

hips). In all cases the iliopsoas muscle was

identified easily by ultrasound; the placement of the

injection needle and injection into the site of

interest were observed during real time. No

complications were encountered. Botulinum toxin A

(BTX-A) injections have become established as a

standard procedure for the treatment of functional

shortening of different muscles in persons with

spasticity or dystonia (Kessler et al. 1999, Bakheit

et al. 2001, Kirschner et al. 2001). Optimal needle

placement is essential to avoid severe side effects

and to assess lack of response to the drug or

incorrect region of injection. While injection into

superficial, very palpable muscles is quite easy, the

approach to other muscles such as the iliopsoas muscle

may be more difficult and the placement of the needle

for an optimal injection site is harder to control. As

a solution to this, we present an ultrasound-guided

injection technique. The main indications for BTX-A

injections in the iliopsoas muscle are dynamic hip

flexion deformities mostly due to spastic conditions

which may compromise walking (increased anterior

pelvic tilt during the whole gait cycle, decreased hip

extension at terminal stance, increased peak hip

flexion during swing; Molenaers et al. 1999. Another

indication might be decentration of the femoral head

(as part of an injection programme which also includes

other muscles like the adductors and the medial

hamstrings) for pain relief, reducing care

difficulties and, possibly, prevention of further

decentration (Porta 2000, et al. 2001,

Deleplanque et al. 2002, Lubik et al. 2002). In

Perthes disease, BTX-A injections in the iliopsoas

muscle and the adductors may prevent a fixed

deformity, which is a negative prognostic factor.

SOURCE: Dev Med Child Neurol. 2003 Dec;45(12):829-32.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve & db=PubMed & list_uids=1\

4667075 & dopt=Abstract