Tilting the balance of oxygen supply & demand: Botulinum toxin for stump claudication.
 Kirker SGB, Dansie B, Lennox G. BSRM meeting April 2004

 Introduction. Most lower limb amputations are performed because of peripheral vascular disease. Amputation is considered when conservative treatment and revascularization have failed to control symptoms. When exercise related stump muscle claudication persists, revacularisation is rarely an option and modifications to the prosthesis are unlikely to improve the blood supply to the stump.
We describe an alternative way of matching oxygen supply & demand, using Botulinum toxin to reduce demand.
 History: An 85 year old man (BD), developed right calf claudication in 1963. His walking distance gradually deteriorated and at the age of 80 he retired as a GP when he was developing right calf pain at 10 m. In January 2001, he had a right transtibial amputation which healed up uneventfully. After delivery of his PTB prosthesis, he continued to get the same calf claudication pain, initially at the same distance. At 11 months he could walk 30 m, independently without aids. His stump was bulbous and more muscular than usual, with continuous visible muscle contractions.
 Intervention: To try to suppress this myokimia, increase his walking distance and reduce the bulk of his distal stump, 200-300 units of Dysport Botulinum toxin was injected in to gastrocnemius & soleus on months 11, 12, 14, 17 & 20. After the first injection, his walking distance increased to 100m, the amount of involuntary muscle contraction greatly decreased, and his stump circumference shrank from 35 to 33cm. Following the third injection his stump circumference was 25cm. After the fourth injection he could walk 600m, and 1000m after the final injection. There have been no adverse effects. New sockets were supplied in months 7, 15 & 36.
 Conclusions: Chemical denervation is a simple way of reducing the oxygen demand of overactive muscle in a well healed amputation stump. This application has not been reported before.
Prosthetic Usage in patients with congenital transradial deficiency (transverse below elbow)
B Mancel, B Ramakrishna & S Kirker BSRM SIGAM Meeting November 2004

Background: It is generally recognised that patients with congenital transradial deficiency make more use of functional prostheses in adult life when they have been fitted early in childhood.
 Aim: To investigate the prevalence of functional prosthetic usage in congenital transverse trans-radial deficiency in patients who have reached adulthood.
 Methodology: Retrospective study of case notes of all patients with congenital transradial deficiency currently registered with one DSC.
 Results: 28 patients with congenital trans-radial deficiency attend this DSC, 21 have reached adulthood. Out of these 21, 11 are male and 10 female. Their ages range from 20 to 79 years. They have been followed for a period of 18 to 61 years (mean 35 years). 9 patients were first fitted before reaching one year of age and 12 patients were fitted after one year of age (range 1.5 to 32 years). Out of 9 fitted before age one, 3 do not use any prostheses, 2 use cosmetic prostheses and 4 use functional prostheses. Out of 12 fitted after age one, 8 do not use any prostheses, 3 use cosmetic prostheses and 1 uses a functional prosthesis. With both groups together, out of 10 women, 3 do not use any prostheses, 5 use cosmetic prostheses and 2 use functional prostheses. Out of 11 men, 8 do not use any prostheses, 3 use functional prostheses with none using cosmetic prostheses. Amongst the 5 patients using functional prostheses in adulthood 4 were first fitted before one year of age and 1 was fitted after one year of age (at age three).
 Conclusion: The results confirm the prospects of patients using functional prostheses in adulthood are significantly better if first fitted early (i.e. before age one) than if first fitted later. The prevalence of not using any prostheses is doubled if the first fitting is done after age one.
 Discussion: The implication for practice is to fit children with their first prostheses before age one.