Abstract

Purpose of study

To review the treatment and outcomes of paediatric pelvic ring injuries in the UK

The aim of our study was to assess the outcome of caudal epidural injection for patients with low back pain in relation to fatty infiltration of spinal muscle. This is a prospective study. The spinal muscles were graded on sagittal section T1 MRI at the lower border of lumber 4 vertebra from 3 to 12 depending on the severity of fatty infiltration. The outcome of the intervention was assessed by improvement in pre and post intervention oswestry disability index score as well as visual analog pain score. Patients with significant fatty changes don't respond well to the caudal epidural injection.

The quality of femoral stem cementation has been shown to be a useful indicator of long-term survival of the total hip arthroplasty. Barrack's cementation grading is widely used but has certain limitations. It is based upon second-generation cementation technique and has high inter- and intra-observer variability. We introduce a new femoral cementation index based upon lengths of radiological lucency and cement-bone interface on AP and lateral views.

Five observers graded femoral cementation of radiographs of 30 primary hip arthroplasties using Barrack's grading and the new index on two occasions and Inter- & Intra-observer reliability was assessed. We also assessed the correlation between proximal femoral anatomy (calcar-canal ratio) & structural bone quality (using cortical index) with cementation using the new index in 50 patients.

Inter- and intra-observer reliability of the new index showed intraclass correlation coefficient 0.79 and 0.82 respectively and Barrack's grading system showed Kappa value- 0.20 (inter-observer) and 0.55 (intra-observer) reliability.

There was poor correlation between the calcar-canal ratio and the quality of cementation [Pearson's coefficient −0.04 (p< 0.05)]. There was some correlation between the cortical index and the quality of cementation [Pearson's coefficient 0.46 (p < 0.05)].

Our new index is a reliable method of assessing femoral cementation. The anatomy of femoral canal didn't have any significant influence on the quality of cementation achieved as assessed by our new index. The femoral cortical structural quality seemed to have some positive influence on the quality of cementation.

Quality of cementation in the early postoperative period has been proven to be an indicator of long-term survival of the total hip arthroplasty. Cementation grading described by Barrack et al is widely used but has certain limitations. It is based upon second-generation cementation technique and has unacceptably high inter- and intra-observer variability due to its subjective evaluation method.

We are introducing a new grading system of quality of femoral cementation. It is based upon the ratio of the length of radiological lucency to the total length of cement-bone interface on both antero-posterior and lateral views. Because of its objective nature, it is likely to show reproducible results.

We recruited five observers of various grades of surgical experience (trainees to consultant). Each observer graded the quality of femoral cementation on immediate postop xrays twice (gap of atleast two weeks) of 30 primary hip arthroplasties, using Barrack's grading and a new cementation index measured by dividing the ength of Radiolucency along CBI by the total Length of CBI.

Statistical analysis was performed by SPSS v17.0. Inter-observer and Intra-observer variability was determined by Intraclass Correlation Coefficient for a two way mixed model.

New cementation index showed excellent agreement for both inter and intra-observer reliability with intraclass correlation coefficient of 0.79 and 0.82 respectively. On contrary, results of inter-observer reliability for Barrack's grading were poor with value of 0.20. intra-observer reliability was found to be fair with 0.55.

As evident from this study, it is a more reliable way of assessing the quality of cementation, with excellent agreement in both inter and intra-observer categories.

We have compared the density of nerve fibres in the synovium in club foot with that of specimens obtained from the synovium of the hip at operations for developmental dysplasia. The study focused on the sensory neuropeptides substance P; calcitonin gene-related peptide; protein gene product 9.5, a general marker for mature peripheral nerve fibres; and growth associated protein 43, a neuronal marker for new or regenerating nerve fibres. In order to establish whether there might be any inherent difference we analysed the density of calcitonin gene-related peptide-positive nerve fibres in the hip and ankle joints in young rats.

Semi-quantitative analysis showed a significant reduction in the number of sensory and mature nerve fibres in the synovium in club foot compared with the control hips. Calcitonin gene-related peptide (CGRP) positive fibres were reduced by 28%, substance P-positive fibres by 36% and protein gene product 9.5-positive fibres by 52% in club foot. The growth associated protein 43-positive fibres also seemed to be less in six samples of club foot. No difference in the density of CGRP-positive nerve fibres was observed in the synovium between ankle and hip joints in rats.

The lack of sensory input may be responsible for the fibrosis and soft-tissue contractures associated with idiopathic club foot.

Introduction: Osteogenic Sarcoma is one of the most common malignant bone tumors in the younger population. The advances in chemotherapy in conjunction with surgery has improved the survival rates from less than 20% in 1970s to more than 70% in 1990s. Advanced imaging, better histopathological techniques, availability of bone banks and newer chemotherapeutic agents have made limb salvage surgery a viable option even in advanced stages of the disease. We reviewed the outcome and analysed the complications of patients with Osteogenic Sarcoma at our institution.

Materials and methods: The objective of our study was to evaluate our experience with the treatment of osteogenic sarcoma and to do a survival analysis. It was a retrospective study consisting of 20 patients who were treated between 1990–1998. Mean age was 17 years with equal distribution of males and females. Of all the patients, 18 had stage II b disease and 2 patients had stage III disease. The quetionnaire focused on the initial mode of presentation of the patients, their stage of disease, the type of neo-adjuvent chemotherapy used and the type of surgery they underwent

Results: Majority of the patients presented at least six months after the onset of symptoms with pain and swelling being the most common modes of presentation. Majority of our patients had open biopsies done outside our hospital and received non-uniform neo-adjuvant chemotherapy. Distal femur was involved in 60% of the cases followed by proximal and distal tibia. Limb salvage surgery was performed in 90% of the cases, while the rest had primary amputation due to the extent of the disease. Autoclaved bone, allografts, free fibular grafts and custom made prostheses were used to reconstruct the intercalary defects left by the resection of the tumor. Polyuria was our main early post operative complication followed by wound infection. Only one patient had a local recurrence and 7/20 had distant metastasis in our follow-up (mean 2.5 years). Mortality rate was 25% in our study.

Conclusion: Limb salvage surgery was performed quite successfully with only one local recurrence in all of our patients with stage II b disease. Most of our patients who developed late distant metastasis had a non-uniform and uncontrolled chemotherapy protocol which could have adversely affected our final outcome.