Pelvic obliquity is a common finding in adolescents with cerebral palsy, however, there is little agreement on its measurement or relationship with hip development at different gross motor function classification system (GMFCS) levels.

The purpose of this investigation was to study these issues in a large, population-based cohort of adolescents with cerebral palsy at transition into adult services.

The cohort were a subset of a three year birth cohort (n = 98, 65M: 33F, with a mean age of 18.8 years (14.8 to 23.63) at their last radiological review) with the common features of a migration percentage greater than 30% and a history of adductor release surgery.

Different radiological methods of measuring pelvic obliquity were investigated in 40 patients and the angle between the acetabular tear drops (ITDL) and the horizontal reference frame of the radiograph was found to be reliable, with good face validity. This was selected for further study in all 98 patients.

The median pelvic obliquity was 4° (interquartile range 2° to 8°). There was a strong correlation between hip morphology and the presence of pelvic obliquity (effect of ITDL on Sharpe’s angle in the higher hip; rho 7.20 (5% confidence interval 5.59 to 8.81, p < 0.001). This was particularly true in non-ambulant adolescents (GMFCS IV and V) with severe pelvic obliquity, but was also easily detectable and clinically relevant in ambulant adolescents with mild pelvic obliquity.

The identification of pelvic obliquity and its management deserves closer scrutiny in children and adolescents with cerebral palsy.

Cite this article: Bone Joint J 2015;97-B:1435–40.

We report the results of Vulpius transverse gastrocsoleus recession for equinus gait in 26 children with cerebral palsy (CP), using the Gait Profile Score (GPS), Gait Variable Scores (GVS) and movement analysis profile. All children had an equinus deformity on physical examination and equinus gait on three-dimensional gait analysis prior to surgery. The pre-operative and post-operative GPS and GVS were statistically analysed. There were 20 boys and 6 girls in the study cohort with a mean age at surgery of 9.2 years (5.1 to 17.7) and 11.5 years (7.3 to 20.8) at follow-up. Of the 26 children, 14 had spastic diplegia and 12 spastic hemiplegia. Gait function improved for the cohort, confirmed by a decrease in mean GPS from 13.4° pre-operatively to 9.0° final review (p < 0.001). The change was 2.8 times the minimal clinically important difference (MCID). Thus the improvements in gait were both clinically and statistically significant. The transverse gastrocsoleus recession described by Vulpius is an effective procedure for equinus gait in selected children with CP, when there is a fixed contracture of the gastrocnemius and soleus muscles.

Cite this article: Bone Joint J 2015;97-B:564–71.

Lengthening of the conjoined tendon of the gastrocnemius aponeurosis and soleus fascia is frequently used in the treatment of equinus deformities in children and adults. The Vulpius procedure as described in most orthopaedic texts is a division of the conjoined tendon in the shape of an inverted V. However, transverse division was also described by Vulpius and Stoffel, and has been reported in some clinical studies.

We studied the anatomy and biomechanics of transverse division of the conjoined tendon in 12 human cadavers (24 legs). Transverse division of the conjoined tendon resulted in predictable, controlled lengthening of the gastrocsoleus muscle-tendon unit. The lengthening achieved was dependent both on the level of the cut in the conjoined tendon and division of the midline raphé. Division at a proximal level resulted in a mean lengthening of 15.2 mm (sd 2.0, (12 to 19), which increased to 17.1 mm (sd 1.8, (14 to 20) after division of the midline raphé. Division at a distal level resulted in a mean lengthening of 21.0 mm (sd 2.0, (18 to 25), which increased to 26.4 mm (sd 1.4, (24 to 29) after division of the raphé. These differences were significant (p < 0.001).

Cite this article: Bone Joint J 2014; 96-B:778–82.

Study Design: Prospective cohort study.

Objectives: To evaluate outcomes for back pain following primary single level spinal decompression for nerve root pain.

Subjects: All patients were managed in a single spinal unit with two spinal surgeons following the same management protocol. Any patient undergoing spinal fusion was excluded. Over a five-year period there were 217 patients, with a mean age of 39 years (15 to 78 years). The male to female ratio was 1:1. All had specific single level nerve root pain and definite nerve root compromise confirmed on MRI.

Outcome Measures: All patients were assessed preoperatively and followed at 3, 6, 12 and 24 months using a standard back pain questionnaire including visual analogue scores for leg and back pain, a pain diagram, Oswestry disability index (ODI), Zung depression index and somatisation scores.

Results: We report a statistically significant improvement in back pain post-operatively with 68.6% of patients improving their score (p < 0.001 sign test) with 19.5% reporting complete relief. This improvement was sustained over the follow-up period. Post-operative improvements in back pain correlated well with post surgical reduction in leg pain score, and ODI. Patients with increased back pain scores (> 5) at presentation, were more likely to report an improvement. In this group 80.5% reported a significant reduction in their back pain following surgery. No correlation could be identified between back pain scores and somatisation and Zung depression indices, age, gender or employment status.

Conclusions: These results are contrary to other reported series and suggest the prognosis for back pain following primary single level spinal decompression may be better than anticipated.

Study Design: A retrospective cross sectional cohort study of degeneration of the lumbar spine, using pre- and post-discography MRI scans of 28 patients, as compared to two consecutive MRI scans of an age and sex matched control group of 32 patients.

Objective: To determine whether injection of steroid into a lumbar intervertebral disc causes degeneration, as assessed by magnetic resonance imaging (MRI).

Methods: Twenty-eight patients with chronic discogenic low back pain were selected. Each had been investigated with an MRI, discography (with intradiscal injection of methylprednisolone), and a post-discography MRI scan. A randomly selected control group of thirty-two age and sex matched patients, having been examined on two occasions with MRI, was established. Two interpreters blinded to the patient groups assessed the degree of lumbar disc degeneration on the MRI scans on two separate occasions, using the Pfirrmann grading system.

Results: Kappa values proved interpretation consistency as compared with the published Pfirrmann paper. Variables of age and sex in the two groups showed no true variation in whether the discs improved, stayed the same or degenerated. The difference in the proportions for those with and without the injection gave a test statistic of 11.92 (p-value=0.002), indicating a discrepancy in the degeneration between those discs with and without an injection.

Conclusion: Previous studies on intradiscal steroid injections have shown variable results. Animal studies have shown that steroid administered intradiscally causes degeneration and primary calcification in discs. Two prospective double blind clinical trials using intradiscal steroids identified no significant benefit or improvement in the clinical outcome. This study indicates that intradiscal steroid injections cause MRI visible disc degeneration. In association with the results of the clinical trials, this study questions the indications for the use of intradiscal steroids in the management of discogenic low back pain.

Study Design: A retrospective study of the clinical outcome of patients with lumbar discogenic pain with Modic changes on MRI prior to intradiscal steroid injection.

Objectives: To determine whether the clinical outcome of patients with discogenic back pain who underwent intradiscal steroid injection could be predicted from MRI Modic changes.

Methods: The pre-operative scans were studied by two senior spinal surgeons. The lumbar vertebral end-plate changes were then classified according to the method described by Modic. The intra- and inter-observer ratings were satisfactory.

Subjects: 40 patients with discogenic back pain were recruited in this study. The mean age was 43.6 years (23 to 72 years). The male to female ratio was 1 to 1.

Outcome Measures: The clinical outcomes at six months post-intradiscal steroid injection were correlated with the Modic changes. The clinical outcomes were assessed using visual analogue scores for back pain as well as Oswestry disability index (ODI). At least a 2-point improvement in visual analogue score and a 20-point improvement in ODI were required to indicate significant symptomatic relief.

Results: We found that in those patients without Modic changes there was improvement of the low back pain in 9% (1/11). In those with Modic I changes there were significant relief in 64% (9/14), moderate relief in 29% (4/14) and no relief in 7% (1/14). In those with Modic II changes there were significant relief in 27% (4/15), moderate relief in 27% (4/15) and no relief in 47% (7/15). There were no cases with Modic III changes.

Conclusions: Previous studies on intradiscal steroid injections have shown variable results. Two prospective double-blind clinical trials, using intradiscal steroids, identified no significant benefit or improvement in the clinical outcome. Our results however suggest that patients with Modic I changes on MRI are most likely to benefit from intradiscal steroid injection in the short term.

12 GPs were invited to take part in a study in which the GPs would undertake training in out-patient techniques, to determine suitability of patients for arthroscopic surgery. The GPs would undertake to counsel the patients regarding the procedure itself and the post operative rehabilitation. They were then referred by means of a set referral form which included specific guidelines which allowed patients to be put directly onto the consultant’s waiting list. The patients would then be sent for surgery directly and be seen immediately pre-operatively by the operating consultant and consented. This group of direct access arthroscopy patients (36) were compared to a contemporaneous consecutive series of patients who had been referred in the normal manner and were undergoing operation at the time of the study period (October 1998 to April 2000.

In the group of patient submitted for direct access arthroscopy three patients had improved such that when they were offered admission dates they declined. A further three patients were deemed unsuitable for direct access arthroscopy and the referral was rejected by the consultant. Two patients declined three separate admission dates and were discharged, and a final patient did not attend his admission date. This left 27 patients who were admitted for direct access arthroscopy service. Of these, one patient was cancelled pre-operatively by the consultant as she had recently been admitted for investigation of cardiac abnormalities procedure and was therefore considered unfit for day case general anaesthetic procedure. Of the 26 patients who underwent arthroscopy all were discharged home the same day, and reviewed in the out-patient clinic at six weeks, and they were asked to complete a Patient Satisfaction Questionnaire, and were discharged from further review at that time.

When compared to a contemporaneous group of patients who had undergone arthroscopic surgery via the routine referral procedure, the group of patients admitted via the direct access route waited on average ten weeks (range 6 – 12) from GP consultation and referral to operation date. This compared to 41 week for the combined total out-patient and in-patient waiting times for the routine access group (range 18 – 132 weeks). Findings at arthroscopy were similar in the two groups with mostly meniscal lesions (18/26 direct access group compared to 15/26 routine access group). The therapeutic operation rate, i.e. procedures beyond simple diagnostic arthroscopy were undertaken, was high in both groups, 68% of the direct access group and 72% of the routine access group. Pre-operative diagnosis accuracy by the GPs was significantly higher in the direct access group of referrals. 65% of direct access referrals had the correct diagnosis made by the GP in the referral compared to 18% of correct diagnosis in the group undergoing routine referrals. Post operative recovery in terms of return to work , return to activities of daily living and discharge from clinic was the same in the two groups. Patient satisfaction was comparable in both groups.

In conclusion direct access arthroscopy reduces significantly the time the surgery and the number of visits by patients to primary or secondary care physicians. GP diagnostic rates were comparable to previously reported figures for registrar/middle grade pre-operative diagnostic rates for patients undergoing knee artrhoscopy. There was a high therapeutic operation rate suggesting few, if any inappropriate procedures were undertaken. The direct access arthroscopy service requires considerable time on the part of the consultant in both setting up the study and training the GPs to a reasonable standard and monitoring referrals and undertaking pre-operative screening of patients awaiting arthroscopy. There was a high inappropriate referral rate in that only 26 patients out of the 36 referred eventually underwent arthroscopic surgery. Although feasible we feel that direct access knee arthroscopy service needs refinement if it is to continue. We intend to introduce an orthopaedic practitioner who will accept referrals from GPs and then screen patients before placing patients on the consultant’s inpatient waiting list. Also the mechanism of extra lists needs to be put in place to ensure direct access patients do not “jump the queue” of patients who are already awaiting arthroscopic surgery.

Objective: To report a randomised controlled trial (RCT) of the therapeutic efficacy of intradiscal steroid injection for the treatment of discogenic back pain after two years.

Introduction: Discography remains the main method to assess whether a degenerate disc is the source of back pain. The treatment of such discogenic pain is difficult. There is only one previous RCT of the use intradiscal steroids, but with a short follow-up.

Patients and Methods: 120 consecutive patients with positive discography were randomised intra-operatively to receive an intradiscal injection of saline or 40mgs Depomedrone. Outcome was assessed using a back pain questionnaire at six weeks, three and six months, and at two years. Pain (using a visual analogue score), disability (the Oswestry Disability Index), and psychological status (DRAM score) were measured. The results were correlated with Modic changes and high intensity zones on MRI scan.

Results: An initial improvement of back pain in the steroid group is not maintained at two years, with no statistical difference between the two groups. Correlation of the results with the MRI findings will be presented.

Conclusion: This study demonstrates the need for long-term follow-up of such intradiscal therapeutic methods of treating discogenic pain.

12 General Practitioners (GP’s) were invited to take part in a study in which the GPs would undertake training in outpatient techniques, to determine suitability of patients for arthroscopic surgery. The GPs would undertake to counsel the patients regarding the procedure itself and the postoperative rehabilitation. They were then referred by means of a set referral form, which included specific guidelines, which allowed patients to be put directly onto the consultant’s waiting list. The patients would then be sent for surgery directly and be seen immediately pre-operatively by the operating consultant and consented. This group of direct access arthroscopy patients (36) were compared to a contemporaneous consecutive series of patients who had been referred in the normal manner and were undergoing operation at the time of the study period (October 1998 to April 2000.

In the group of patient submitted for direct access arthroscopy three patients had improved such that when they were offered admission dates they declined. A further three patients were deemed unsuitable for direct access arthroscopy and the referral was rejected by the consultant. Two patients declined three separate admission dates and were discharged, and a final patient did not attend his admission date. This left 27 patients who were admitted for direct access arthroscopy service. Of these, one patient was cancelled pre-operatively by the consultant as she had recently been admitted for investigation of cardiac abnormalities and was therefore considered unfit for day case general anaesthetic procedure. Of the 26 patients who underwent arthroscopy all were discharged home the same day, and reviewed in the out-patient clinic at six weeks, and they were asked to complete a Patient Satisfaction Questionnaire, and were discharged from further review at that time.

When compared to a contemporaneous group of patients who had undergone arthroscopic surgery via the routine referral procedure, the group of patients admitted via the direct access route waited on average ten weeks (range 6 – 12) from GP consultation and referral to operation date. This compared to 41 weeks for the combined total outpatient and in-patient waiting times for the routine access group (range 18 – 132 weeks). Findings at arthroscopy were similar in the two groups with mostly meniscal lesions (18/26 direct access group compared to 15/26 routine access group). The therapeutic operation rate, i.e. procedures beyond simple diagnostic arthroscopy were undertaken, was high in both groups, 68% of the direct access group and 72% of the routine access group. Pre-operative diagnosis accuracy by the GPs was significantly higher in the direct access group of referrals. 65% of direct access referrals had the correct diagnosis made by the GP in the referral compared to 18% of correct diagnosis in the group undergoing routine referral. Post operative recovery in terms of return to work, return to activities of daily living and discharge from clinic was the same in the two groups. Patient satisfaction was comparable in both groups.

In conclusion direct access arthroscopy reduces significantly the time to surgery and the number of visits by patients to primary or secondary care physicians. GP diagnostic rates were comparable to previously reported figures for registrar/middle grade pre-operative diagnostic rates for patients undergoing knee arthroscopy. There was a high therapeutic operation rate suggesting few, if any inappropriate procedures were undertaken. The direct access arthroscopy service requires considerable time on the part of the consultant in both setting up the study and training the GPs to a reasonable standard and monitoring referrals and undertaking pre-operative screening of patients awaiting arthroscopy. There was a high inappropriate referral rate in that only 26 patients out of the 36 referred eventually underwent arthroscopic surgery. Although feasible we feel that direct access knee arthroscopy service needs refinement if it is to continue. We intend to introduce an orthopaedic practitioner who will accept referrals from GPs and then screen patients before placing patients on the consultant’s inpatient waiting list. Also the mechanism of extra lists needs to be put in place to ensure direct access patients do not “jump the queue” of patients who are already awaiting arthroscopic surgery.