1. The treatment of contractures at the hip secondary to poliomyelitis by Soutter's muscle slide or by Yount's fasciotomy gives excellent results. So does high femoral osteotomy, but it is not superior to the other two and should therefore be kept in reserve as a supplementary operation for the completion of correction of a deformity so gross as not to be wholly remediable by division of the soft parts.

2. Subluxation of the hip occurs only if the paralysis comes on during the first eighteen months of life and is a product not of severe paralysis but of unbalanced and often slight weakness of muscles. Correction of the invariable valgus deformity of the femoral neck by osteotomy is followed by relapse; acetabuloplasty too is unreliable. The most promising remedy seems to be some form of acetabuloplasty combined with transplantation of an iliopsoas of adequate strength into the greater trochanter. The indications for arthrodesis are few, but the results of this operation are good.

3. In the few patients with abductor weakness and little else the dipping gait may be abolished by iliopsoas transplantation.

1. Volkmann's ischaemia of the lower limb is more common in adults than in children and occurs with sufficient frequency after injuries of the femur, knee and leg to warrant a more determined effort to prevent it.

2. The first and most essential step is to recognise the early signs of ischaemic damage. Incision of the deep fascia may then save the threatened underlying muscle, though it may also be necessary to seek for and evacuate a haematoma beneath the muscle. When the femoral or popliteal artery is injured, exploration and repair may be imperative.

3. The treatment of established ischaemic contracture is by whatever measures are necessary to correct the deformity. These are lengthening of shortened tendons, or excision of them if they are involved in dense fibrosis at the periphery of the ischaemic mass; and excision of all totally destroyed muscle. Amputation may be necessary.

1 . Thirty-six patients with complete irrecoverable brachial plexus lesions have been studied.

2. Function has been compared after 1) arthrodesis of the shoulder with amputation through the arm, 2) so-called reconstructive procedures, and 3) no operative treatment.

3. The results of reconstructive operations have been so disappointing that we believe that this type of treatment should be abandoned.

4. Amputation-arthrodesis offers a better functional result than either reconstruction or no operation. Its value depends to a considerable extent on the manual dexterity of the patient.

5. A clerical worker who is not mechanically minded is less likely to use an artificial limb, and in this type of patient operation is perhaps best avoided.

1. The results of treatment of 134 patients with congenital dislocation of 167 hips are reviewed.

2. Late diagnosis is still a major problem.

3. Subluxations rarely give rise to poor results, but in dislocations first treated over the age of five years there is a one-in-three risk of failure.

4. Manipulative reduction is successful less often than reduction on a frame and carries a higher risk of avascular necrosis.

5. Closed reduction on a frame was satisfactory in 58 per cent of patients under the age of three years, and can succeed up to the age of five.

6. Open reduction was required in 20 per cent of cases under the age of three, and can be used successfully up to the age of six.

7. Seven anatomical barriers to closed reduction have been recognised and two or more are commonly found in one hip when open reduction is performed.

8. The acetabular roof may fail to develop after reduction, especially if this is delayed. A C.E. angle of under 20 degrees does not necessarily forebode this, unless measured on an arthrograph. Sclerosis of a sloping acetabular roof is an indication for operation. Acetabuloplasty is the proper operation for a sloping acetabulum and can be done successfully up to the age of twelve. Over this age, a shelf operation should be performed; this is appropriate also in younger patients in whom the curvature of the acetabulum is normal but does not extend far enough laterally. These operations were required in 38 per cent of hips treated in patients under the age of three, and in 64 per cent over this age. There is a one-in-three risk of avascular necrosis when acetabular reconstruction is done in patients under three.

9. Anteversion, if excessive, should be corrected by subtrochanteric osteotomy, and any valgus of the femoral neck should be corrected simultaneously.

10. Unilateral dislocations in patients over the age of six are best treated by Colonna's operation. In our few bilateral cases over this age our results have been disappointing.

11. Avascular necrosis is less common but more serious when it occurs over the age of three. Manipulative reduction and the use of frog-leg plasters are two avoidable factors which appear to increase its incidence. The more serious degrees are accompanied by stiffness of the hip, and when this sign is present weight bearing should be avoided.

12. Prolonged, though rarely permanent, limitation of movement occurs in some 10 per cent of cases. In a few, operative correction was required.

1. The results of repair of the sciatic nerve and of its main divisions have been analysed in a series of 118 cases, the patients having been under observation for three to eighteen years (average 11·7 years).

2. A result was satisfactory if there was some return of sensibility throughout the autonomous zone (the area of skin supplied exclusively by the damaged nerve) and if the more important muscles of the leg were capable of contraction against gravity and resistance.

3. When the whole of the sciatic nerve is damaged it is necessary to present the results separately for the lateral and medial popliteal divisions.

4. Of forty-seven cases of repair of the medial popliteal nerve 79 per cent showed useful motor and 62 per cent useful sensory recovery. In three out of four cases the correspondence between the degree of motor and of sensory recovery was fairly close.

5. Of seventy-two cases of repair of the lateral popliteal nerve 36 per cent showed useful motor and 74 per cent useful sensory recovery. The latter figure must be regarded with some reserve because sensory "recovery" in the lateral popliteal zone may be due to the ingrowth of nerve fibres from contiguous normally innervated skin. Thus it is not possible to correlate motor and sensory recovery.

6. In eighteen cases of repair of the posterior tibial nerve, there was useful sensory recovery in the sole in twelve. But although there was evidence of recovery in the plantar muscles in eleven cases it was functionally valueless.

7. In repair of the medial popliteal nerve the result was better if suture had been carried out early. In repair of the lateral popliteal nerve there was no evidence that delay was harmful; but the proportion of good results was so low (as judged by motor function alone, sensory recovery being often extraneous) that this exception to a general rule cannot be taken very seriously.

8. Gaps of up to twelve centimetres–estimated after resection of the damaged nerve ends–could be closed without difficulty by the usual technique, and the extent of the gap up to that limit had no influence on the prognosis. The closure of larger gaps, when the knee must be flexed beyond a right angle, is not compatible with good recovery because the post-operative stretching of the nerve causes serious intraneural damage.

9. Nerve grafting has given poor results in repair of the sciatic nerve.

1. We have described what happens to patients a number of years after injury of the sciatic nerve or of its divisions; there were 329 who had been under observation for periods ranging from three to eighteen years. The neurological recovery was recorded in every case and, more important, the behaviour of the limb as appreciated by the patient.

2. Although it was generally true that good neurological recovery and good function went together there were remarkable discrepancies. Isolated paralysis of the medial popliteal or of the lateral popliteal nerve was often compatible with good function, though patients with lateral popliteal paralysis usually needed toe-raising apparatus. Even total sciatic paralysis sometimes gave little trouble.

3. Of the various types of injury, clean wounds and traction lesions led to rather better than average return of function.

4. Some degree of pain was present in about half the cases, and over-response–exaggerated and painful response to an ordinary stimulus–was present in one-third of the cases.

5. Repair of the posterior tibial nerve was rarely worth while; no less than eight out of twelve patients with this type of injury exhibited over-response.

6. One-third of the patients showed vasomotor and trophic disorders: coldness of the affected limb, erythema, thinness or pigmentation of the skin, changes in the nails or oedema.

7. Pressure sores were the most serious consequence of sciatic nerve injury and at some time or other were present in 14 per cent of our patients. The cause was deformity rather than insensibility of the sole.

8. Of the various palliative operations Lambrinudi's tarsal arthrodesis gave such disappointing results that we doubt whether the operation is worth doing. Tenodesis, revived as a time-saving expedient during the war, was a failure. For lateral popliteal paralysis anterior transplantation of tibialis posterior is excellent.

9. Amputation was done in only ten cases. When it was performed for fixed deformity with secondary ulceration the result was satisfactory. When it was done because of pain there was no relief. Amputation is, therefore, avoidable provided that vigorous steps are taken to prevent or correct deformity; it should not be done for the relief of pain.

1 . Twenty-one cases of poliomyelitis and twenty cases of brachial plexus injury in which muscle transplantations had been performed to restore elbow flexion have been reviewed. The average follow-up period was four and a half years.

2. The results were graded objectively and subjectively. They were better when passive extension of the elbow was limited; such limitation always occurs after Steindler's operation, but infrequently after pectoral transplantation.

3. The results of pectoral transplantation are good when there is no significant shoulder paralysis; if there is shoulder weakness arthrodesis of the joint may be required to control medial rotation and adduction of the shoulder on flexion of the elbow. In brachial plexus lesions the results of pectoral transplantation may be marred by simultaneous contraction of the triceps. This can be overcome by transplanting triceps into the flexor apparatus. Triceps transplantation is rarely indicated because loss of active extension of the elbow is a grave disability.

4. Subjective results tended to be worse than objective results in brachial plexus lesions because impairment of sensibility in the hand often limited the usefulness of the limb. In striking contrast the subjective results were in general far better than the objective in patients who had had poliomyelitis. In them the smallest gain can be of functional value.

We believe that this technique has several advantages. After poliomyelitis recovery in the clavicular head of pectoralis major may exceed that in the sternal head; there may be considerable but incomplete recovery in both heads and it is then desirable to use all the active muscle available. Girls and women dislike conspicuous scars; the incisions used in this technique are unobtrusive when the arm is by the side.

1 . In the common type of Volkmann's ischaemic contracture affecting the forearm flexors, the infarct takes the form of an ellipsoid with its axis in the line of the anterior interosseous artery and with its central point a little above the middle of the forearm. The greatest damage is at the centre and usually falls most heavily on flexor digitorum profundus and flexor pollicis longus, which are often necrotic. Those muscles more superficially placed, and sometimes the deep extensors, are more likely to exhibit fibrosis.

2. The median nerve runs near the centre of the ellipsoid and may exhibit profound ischaemia. The ulnar nerve, lying at the edge of the ischaemic zone, tends to be less severely affected.

3. The treatment for this condition is excision of all tissues irreparably damaged by ischaemia. If this operation is performed within twelve months from the time of injury, correction of the contracture should be almost complete. The tendons of shortened but active muscles are lengthened or transplanted.

4. After such excision it is possible to carry out reconstructive procedures commonly used in the surgery of lower motor neurone disorders and of trauma. A wide variety of tendon transplantations is available. The median nerve may be repaired either by a free graft or, in cases where both nerves have been extensively damaged by ischaemia, by an ulnar to median nerve-pedicle graft.