The safe surgical margin in Ewing's sarcoma.

INTRODUCTION: There is recent evidence advocating the use of post-chemotherapy MRI for safe resection of primary bone sarcoma in providing a clear margin of disease. This paper challenges this view by providing evidence obtained from comparing surgical resection margin measurements calculated off the pre- and post-chemotherapy MRIs to the post-operative histological analysis. METHOD: A retrospective patho-radiological analysis of 10 patients treated for long bone Ewing's sarcoma. The pre- and post-chemotherapy MRI radiological measurements were correlated with the post-operative gross and microscopic histological specimens with the principle aim of determining which represented the accurate histological extent of disease and therefore which image set should be used in determining the surgical resection margins. RESULTS: In the 10 cases there was a discrepancy in the extent of pathological disease on comparative histological and radiological assessment. The mean age at presentation was 19.5years [4-45 years], with a female bias (n = 7/10). The lower limbs were more commonly involved than the upper limb (femur n = 2/10, tibia n = 3/10, fibula n = 2/10, humerus n = 2/10, ulna n = 1/10). There was no correlation between the percentage reduction in measured volume/length of pathological bone on sequential MRI and the percentage necrosis on histology. The average discrepancy between the length of pathological bone on histology and on MRI was 2.7 cm. Using the baseline pre-chemotherapy MRI to plan the surgical resection margins, 7/10 patients had their surgical resection margins through radiologically clear but pathologically abnormal bone (without histological evidence of residual tumour). Had the post-chemotherapy MRI been used a further 3 patients would have had their tumour resected through pathologically abnormal bone. No patients had or would have had tumour resected through residual tumour. CONCLUSIONS: The use of the post-chemotherapy MRI for planning surgical resection margins increases the risk of resecting through histologically abnormal bone that may have been previously contaminated by tumour, without significant benefit of preserving sufficient bone to facilitate joint or physeal sparing surgery. The evidence from this study supports current guidelines recommending the use of pre-chemotherapy MRI to plan safe surgical resection margins in Ewing's sarcoma.

Remote monitoring of clubfoot treatment with digital photographs in low resource settings: Is it accurate?

BACKGROUND: Clinical examination and functional assessment are often the first steps to assess outcome of clubfoot treatment. Clinical photographs may be an adjunct used to assess treatment outcomes in lower resourced settings where physical review by a specialist is limited. We aimed to evaluate the diagnostic performance of photographic images of patients with clubfoot in assessing outcome following treatment. METHODS: In this single-centre diagnostic accuracy study, we included all children with clubfoot from a cohort treated between 2011 and 2013, in 2017. Two physiotherapists trained in clubfoot management calculated the Assessing Clubfoot Treatment (ACT) score for each child to decide if treatment was successful or if further treatment was required. Photographic images were then taken of 79 feet. Two blinded orthopaedic surgeons assessed three sets of images of each foot (n = 237 in total) at two time points (two months apart). Treatment for each foot was rated as 'success', 'borderline' or 'failure'. Intra- and inter-observer variation for the photographic image was assessed. Sensitivity, specificity, positive and negative predictive values were calculated for the photographic image compared to the ACT score. RESULTS: There was perfect correlation between clinical assessment and photographic evaluation of both raters at both time-points in 38 (48%) feet. The raters demonstrated acceptable reliability with re-scoring photographs (rater 1, k = 0.55; rater 2, k = 0.88). Thirty percent (n = 71) of photographs were assessed as poor quality image or sub-optimal patient position. Sensitivity of outcome with photograph compared to ACT score was 83.3%-88.3% and specificity ranged from 57.9%-73.3%. CONCLUSION: Digital photography may help to confirm, but not exclude, success of clubfoot treatment. Future work to establish photographic parameters as an adjunct to assessing treatment outcomes, and guidance on a standardised protocol for photographs, may be beneficial in the follow up of children who have treated clubfoot in isolated communities or lower resourced settings.

Paediatric and adolescent anterior cruciate ligament reconstruction surgery.

AIMS: Anterior cruciate ligament (ACL) surgery in children and the adolescent population has increased steadily over recent years. We used a national database to look at trends in ACL reconstruction and rates of serious complications, growth disturbance, and revision surgery, over 20 years. METHODS: All hospital episodes for patients undergoing ACL reconstruction, under the age of 20 years, between 1 April 1997 and 31 March 2017, were extracted by procedure code from the national Hospital Episode Statistics (HES). Population standardized rates of intervention were determined by age group and year of treatment. Subsequent rates of serious complications including reoperation for infection, growth disturbance (osteotomy, epiphysiodesis), revision reconstruction, and/or contralateral ACL reconstruction rates were determined. RESULTS: Over the 20 year period, 16,125 ACL reconstructions were included. The mean age of patients was 16.9 years (SD 2.0; 27.1% female, n = 4,374/16,125). The majority of procedures were observed in the 15 to 19 years age group. The rate of ACL reconstruction increased 29-fold from 1997 to 1998, to 2016 to 2017. Within 90 days of ACL reconstruction, the rate of reoperation for infection was 0.31% (95% confidence interval (CI) 0.23 to 0.41, n = 50/16,125) and the rate of pulmonary embolism was 0.037% (95%.CI 0.014 to 0.081, n = 6/16,125). Of those with minimum five-year follow-up following ACL reconstruction (n = 7,585), 1.00% of patients subsequently underwent an osteotomy (95% CI 0.79 to 1.25, n = 76/7,585), 0.09% an epiphysiodesis (95% CI 0.04 to 0.19, n = 7/7,585), 7.46% revision ACL reconstruction (95% CI 6.88 to 8.08, n = 566/7,585), and 6.37% contralateral ACL reconstruction (95% CI 5.83 to 6.94, n = 483/7,585). CONCLUSION: Rates of paediatric and adolescent ACL reconstruction have increased 29-fold over the last 20 years. Despite the increasing rate in the younger population, the risk of serious complications, including further surgery for growth disturbance is very low. The results of our study provide a point of reference for shared decision making in the management of ACL injury in the paediatric and adolescent population. Cite this article: Bone Joint J 2020;102-B(2):239-245.

Spontaneous Spinal Epidural Hematomas in Pregnancy: A Systematic Review.

BACKGROUND: Spontaneous spinal epidural hematomas (SSEH) are rare yet severe conditions. In pregnancy, this condition is challenging to diagnose and treat because of the risks to the mother and fetus. This study reviews the literature on SSEHs in pregnancy. METHODS: We performed a systematic review of the English literature on SSEHs from 1990 until 2018. Outcome measures were mode of presentation, risk factors, initial neurologic findings, diagnostic investigations, site and size of the SSEH, treatment, neurologic recovery, and survival. RESULTS: Fourteen publications (16 patients) were included. Two patients presented in the second trimester, with the remainder in the third trimester. All patients presented with back pain, and 15 subsequently developed spinal cord dysfunction. Magnetic resonance imaging (MRI) was performed in all cases. The cervicothoracic region was the most commonly affected, and the average hematoma size extended across 3.9 vertebral levels. All patients with neurologic dysfunction underwent surgical decompression. In women under 32 weeks' gestation, caesarean section was not routinely performed. In contrast, women of gestational age of 32 weeks or more underwent a caesarean section prior to spinal decompression. Women without neurologic dysfunction underwent a caesarean section and neurologic monitoring without decompression. All patients with abnormal neurology improved after surgery, except 1 patient. No patients died. CONCLUSIONS: In pregnancy, SSEHs typically present in the second or third trimesters with back pain, predominantly in the cervicothoracic region, followed by progressive neurologic dysfunction. MRI is diagnostic, and the treatment depends on the patient's neurologic dysfunction and gestational age.

How useful are Primary Trauma Care courses in sub-Saharan Africa?

INTRODUCTION: More than five million deaths occur each year from injury with the vast majority occurring in low and middle-income countries (LMICs). Africa bears the highest road traffic related mortality rates in the world. Despite this, formal training in trauma management is not widely adopted in these countries. We report our results of 10 consecutive Primary Trauma Care (PTC) courses delivered in seven East and Central African countries, as part of the COSECSA Oxford Orthopaedic Link (COOL) initiative. METHODS: Candidate's knowledge and clinical confidence in trauma management were assessed using a multiple-choice questionnaire and a confidence matrix rating of eight clinical scenarios. We performed descriptive statistical analysis on knowledge and clinical confidence scores of candidates before and after the course. We sub-analysed these scores, examining specifically the difference that exist between gender, job-roles and instructors versus non-instructors. RESULTS: We have trained 345 new PTC providers and 99 new PTC instructors over the 10 courses. Data sets were complete for 322 candidates. Just under a third of candidates were women (n=94). Over two-thirds of candidates (n=240) were doctors, while the remainder comprised of nurses, medical students and clinical officers. Overall, the median pre-course MCQ score was 70% which increased to 87% post course (p<0.05). Men achieved a higher MCQ score both pre- and post-course compared to women (p<0.05); however there was no significant difference in the degree of improvement of MCQ scores between gender. Instructors outperform non-instructors (p<0.05), and similarly doctors outperform non-doctors on final MCQ scores (post-course). However, it was the non-doctors who showed a statistically significant improvement in scores before and after the course (20% non-doctors vs 16% doctors, p<0.05). Candidate's clinical confidence also demonstrated significant improvement following the course (p<0.05). CONCLUSION: Our work demonstrates that COOL-funded PTC courses in the COSECSA region delivered to front-line health staff have helped improve their knowledge and confidence in trauma management, irrespective of their job-roles and gender. Further follow-up is needed to establish the long-term impact of PTC courses in this region.

Xenon mitigates isoflurane-induced neuronal apoptosis in the developing rodent brain.

BACKGROUND: Anesthetics, including isoflurane and nitrous oxide, an antagonist of the N-methyl-D-aspartate subtype of the glutamate receptor, have been demonstrated to induce apoptotic neurodegeneration when administered during neurodevelopment. Xenon, also an N-methyl-D-aspartate antagonist, not only lacks the characteristic toxicity produced by other N-methyl-D-aspartate antagonists, but also attenuates the neurotoxicity produced by this class of agent. Therefore, the current study sought to investigate xenon's putative protective properties against anesthetic-induced neuronal apoptosis. METHOD: Separate cohorts (n = 5 or 6 per group) of 7-day-old rats were randomly assigned and exposed to eight gas mixtures: air, 75% nitrous oxide, 75% xenon, 0.75% isoflurane, 0.75% isoflurane plus 35% or 75% nitrous oxide, 0.75% isoflurane plus 30% or 60% xenon for 6 h. Rats were killed, and cortical and hippocampal apoptosis was assessed using caspase-3 immunostaining. In separate cohorts, cortices were isolated for immunoblotting of caspase 3, caspase 8, caspase 9, and cytochrome c. Organotypic hippocampal slices of postnatal mice pups were derived and cultured for 24 h before similar gas exposures, as above, and subsequently processed for caspase-3 immunostaining. RESULTS: In vivo administration of isoflurane enhances neuronal apoptosis. When combined with isoflurane, nitrous oxide significantly increases whereas xenon significantly reduces apoptosis to a value no different from that of controls. In vitro studies corroborate the ability of xenon to attenuate isoflurane-induced apoptosis. Isoflurane enhanced expression of indicators of the intrinsic and common apoptotic pathways; this enhancement was increased by nitrous oxide but attenuated by xenon. CONCLUSIONS: The current study demonstrates that xenon prevents isoflurane-induced neonatal neuronal apoptosis.