The use of joint-preserving surgery of the hip has been largely abandoned since the introduction of total hip replacement. However, with the modification of such techniques as pelvic osteotomy, and the introduction of intracapsular procedures such as surgical hip dislocation and arthroscopy, previously unexpected options for the surgical treatment of sequelae of childhood conditions, including developmental dysplasia of the hip, slipped upper femoral epiphysis and Perthes’ disease, have become available. Moreover, femoroacetabular impingement has been identified as a significant aetiological factor in the development of osteoarthritis in many hips previously considered to suffer from primary osteoarthritis.

As mechanical causes of degenerative joint disease are now recognised earlier in the disease process, these techniques may be used to decelerate or even prevent progression to osteoarthritis. We review the recent development of these concepts and the associated surgical techniques.

Cite this article: Bone Joint J 2014;96-B:5–18.

Introduction and Objective. The patients with a total hip arthroplasty is growing in world manly in Europe and USA, and this solution present a high success at 10years in several orthopaedic registers. The application of total press-fit hip fixation presents the most used solution, but presents some failures associated to the acetabular component fixation, associated to the load transfer and bone loss at long term. The aim of this work is to investigate the influence of different acetabular bone loss in the strain distribution in iliac bone. To evaluate implant fixation, an experimental study was performed using acetabular press-fit component simulating different acetabular bone loss and measuring the strain distribution. Materials and Methods. The experimental samples developed was based in an iliac bone model of Sawbones supplier and a acetabular component Titanium (Stryker) in a condition press-fit fixation and was implanted according surgical procedure with 45º inclination angle and 20º in the anteversion angle. Were developed five models with same initial bone, one with intact condition simulating the cartilage between bones and four with different bone loss around the acetabular component. These four models representing the evolution of bone support of acetabular components presented in the literature. The evolution of bone loss was imposed with a CAD CAM process in same iliac bone model. The models were instrumented with 5 rosettes in critical region at the cortical bone to measure the strain evolution along the process. Results. The results of strain gauges present the influence of acetabular component implantation, reducing the bone strains and presented the effect of the strain shielding. The acetabular component works as a shield in the load transfer. The critical region is the posterior region with highest principal strains and the strain effect was observed with different bone loss around acetabular component. The maximum value of principal strain was observed in the intact condition in the anterior region, with 950μ∊. In the posterior superior region, the effect of bone loss is more important presenting a reduction of 500% in the strains. The effect of bone loss is presented in the strains induced with acetabular implantation, in the first step of implantation the maximum strain was 950μ∊ and in the last model the value was 50μ∊, indicating lower press-fit fixation. Conclusions. The models developed allows study the effect of bone loss and acetabular implant fixation in the load transfer at the hip articulation. The results presented a critical region as the anterior-superior and the effect of strain shielding was observed in comparison with intact articulation. The results of press-fit fixation present a reduction of implant stability along bone loss. The process of bone fixation developed present some limitation associated to the bone adhesion in the interface, not considered. Acknowledgement. This work was supported by POCI-01-0145-FEDER-032486,– FCT, by the FEDER, with COMPETE2020 - (POCI), FCT/M

Abstract. Multidisciplinary team (MDT) meetings in orthopaedic surgery are evolving. The goals include patient optimisation, surgical planning and discharge arrangements, individually on a patient specific basis. In line with British Association Surgery of the Knee and GIRFT guidelines, we report our regional experience on the implementation and evolution of our regional Revision Knee Arthroplasty MDT. We undertook a retrospective review of the process, cases discussed and quality assurance conducted in the weekly MDT. Since implementation of the MDT meeting in January 2019, 550 patients with painful joint replacements have been discussed. In May 2021, we formalised our ‘terms of reference’ and ‘standard operating procedures’ which are adhered to by the consultants operating within the network, all of whom attend the meeting. A proforma has been developed and is completed for all cases capturing all pertinent information. All cases are graded according to R1, R2, or R3 complexity scale. Since its inception, the MDT has looked at all post-operative imaging, we now describe a new classification system for grading the appearances. Confirmation of the pre-operative plan and actual surgical intervention is reviewed and audited. In addition, confirmation of indication of revision at the time of operation is reviewed and validated for accuracy with benefits to the unit, individual surgeon and the NJR. In conclusion, the implementation of the revision MDT facilitating pre-operative revision arthroplasty discussion and post-operative quality assurance processes enable surgeons to educate, reflect on their practice and ensure that the highest standards of care are being provided

Aims. The goal of closed reduction (CR) in the treatment of developmental dysplasia of the hip (DDH) is to achieve and maintain concentricity of the femoral head in the acetabulum. However, concentric reduction is not immediately attainable in all hips and it remains controversial to what degree a non-concentric reduction is acceptable. This prospective study is aimed at investigating the dynamic evolution of the hip joint space after CR in DDH using MRI. Methods. A consecutive series of patients with DDH who underwent CR since March 2014 were studied. Once the safety and stability were deemed adequate intraoperatively, reduction was accepted regardless of concentricity. Concentricity was defined when the superior joint space (SJS) and medial joint space (MJS) were both less than 2 mm, based on MRI. A total of 30 children, six boys and 24 girls, involving 35 hips, were recruited for the study. The mean age at CR was 13.7 months (3.5 to 27.6) and the mean follow-up was 49.5 months (approximately four years) (37 to 60). The joint space was evaluated along with the interval between the inverted and everted limbus. Results. Only three hips (8.6%) were fully concentric immediately after CR. During follow-up, 24 hips (68.6%) and 27 hips (77.1%) became concentric at six months and one year, respectively. Immediate SJS after CR decreased from 3.51 mm to 0.79 mm at six months follow-up (p = 0.001). SJS in the inverted group decreased from 3.75 mm to 0.97 mm at six months follow-up. SJS or MJS in the everted group were less than those in the inverted group at each time of follow-up (p = 0.008, p = 0.002). Conclusion. A stable, safe but non-concentric reduction achieved before the age of two years appears to improve over time with nearly 80% of hips becoming fully concentric by one year. Cite this article: Bone Joint J 2020;102-B(5):618–626

We present the outcomes in 38 consecutive patients who had total ankle replacement using the Ankle Evolution System with a minimum follow-up of four years. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score and regular standardised anteroposterior and lateral weight-bearing radiographs were obtained. Patient satisfaction and complications were recorded and the survival of the implants was demonstrated by the Kaplan-Meier method. The mean follow-up was for 57.8 months (48 to 80). The cumulative survival rate at six years was 94.7% (95% confidence interval 80.3 to 98.7). The mean total AOFAS score was 88.1 (53 to 100). The mean score for pain was 35.8 (20 to 40). Ten patients presented with edge-loading of whom nine had corrective surgery. Two ankles were revised, one to an arthrodesis and the other to replace the tibial component. Nine patients showed radiological evidence of osteolysis. They had minimal non-progressive symptoms and further surgery was not undertaken. Nevertheless, the concerns about osteolysis led to the implant being withdrawn by the manufacturer. The medium-term results of the ankle evolution system ankle replacement are satisfactory with high patient satisfaction, but the rate of osteolysis is of some concern. The long-term benefit of this procedure has yet to be determined

When removing femoral cement in revision hip surgery, creating an anterior femoral cortical window is an attractive alternative to extended trochanteric osteotomy. We describe our experience and evolution of this technique, the clinical and radiological results, and functional outcomes. Between 2006 and 2021 we used this technique in 22 consecutive cases at Whanganui Hospital, New Zealand. The average age at surgery was 74 years (Range 44 to 89 years). 16 cases were for aseptic loosening: six cases for infection. The technique has evolved to be more precise and since 2019 the combination of CT imaging and 3-D printing technology has allowed patient-specific (PSI) jigs to be created (6 cases). This technique now facilitates cement removal by potentiating exposure through an optimally sized anterior femoral window. Bone incorporation of the cortical window and functional outcomes were assessed in 22 cases, using computer tomography and Oxford scores respectively at six months post revision surgery. Of the septic cases, five went onto successful stage two procedures, the other to a Girdlestone procedure. On average, 80% bony incorporation of the cortical window occurred (range 40 −100%). The average Oxford hip score was 37 (range 22 – 48). Functional outcome (Oxford Hip) scores were available in 11 cases (9 pre-PSI jig and 2 using PSI jig). There were two cases with femoral component subsidence (1 using the PSI jig). This case series has shown the effectiveness of removing a distal femoral cement mantle using an anterior femoral cortical window, now optimized by using a patient specific jig with subsequent reliable bony integration, and functional outcomes comparable with the mean score for revision hip procedures reported in the New Zealand Joint Registry

Introduction. The viscoelastic cervical disk prosthesis CP-ESP is an innovative one-piece deformable but cohesive interbody spacer. It is an evolution of the LP-ESP lumbar disk implanted since 2006. The implant provides 6 full degrees of freedom including shock absorption. The design allows a limitation for rotation and translation with resistance to motion (elastic return property) aimed at avoiding overload of the posterior facets. The rotation center can vary freely during motion. It thus differs substantially from current prostheses. This study reports the clinical results of a prospective observational study series of 89 patients who are representative of the current use of the ESP implant since 2012. The radiological results are focused on the evolution of the mean center of rotation (MCR) as an additional information to the range of motion (ROM) for the evaluation of the quality of spine movement. Materials and Methods. 89 patients (33 males, mean age 45 years [28–60], 107 implants) were included for an open, prospective and non-randomized study between October 2012 and December 2015. One level patients were at C3C4 (3), C4C5 (3), C5C6 (41) C6C7 (24) C7T1 (1). Two levels patients were C4C5/C5C6 (3), C5C6/C6C7 (12), C6C7/C7D1 (1) and 3 levels C4C5/C5C6/C6C7 (1). Results. Clinical data were obtained preoperatively and at 3, 6, 12 and 24 months (mean ± SD): . Neck VAS:. 5,85±2,24. 2,34±1,95. 1,42±1,54. 2,25±1,75. 2,1±1,1. Arm VAS:. 6,5±1,95. 2,22±1,95. 1,5±2,0. 3±2,78. 1±2,5. NDI (%):. 55,8±15,2. 29,5±17. 18,9±15. 31±13. 21±11. SF 36 PCS (%):. 31±22,5. 50±14,9. 65±8,4. 44±12,8. 54±12. SF 36 MCS (%):. 32±13,9. 51±10,9. 69±8,5. 54±6,7. 59±8. We did not observe local ossifications. One case of side level degeneration was observed after 12 months in a C5C6 mono-segmental disk replacement (retrospectively this patient was a good case for a double initial implantation). To date the patient has not been re-operated. Two cases were revised (one C5C6 implant for bone ingrowth failure at 6 months and one C4C5 case for painful hypermobility in a globally stiff spine). Range of motion was obtained after 6 months and maintained at 24 months. Radiological study of the location of the mean center of rotation at the prosthesis level and adjacent disks demonstrated the adaptation ability of the implant. Conclusion. The concept of the ESP prosthesis is different from that of the “first generation” articulated devices currently used in the cervical spine. This study reports encouraging clinical results about pain, function and kinematic behavior. An interesting point is the evolution of the Mean Centers of Rotation in the. post-operative course. This adaptation ability is one of the main features as we need to consider the mean and long term evolution of the global cervical posture and mobility after a cervical disc replacement. Additional studies and longer patient follow-up are needed to assess long-term reliability of this innovative implant

Osteoarthritis is extremely common and many different causes for it have been described. One such cause is abnormal morphology of the affected joint, the hip being a good example of this. For those joints with femoroacetabular impingement (FAI) or developmental dysplasia of the hip (DDH), a link with subsequent osteoarthritis seems clear. However, far from being abnormal, these variants may be explained by evolution, certainly so for FAI, and may actually be normal rather than representing deformity or disease. The animal equivalent of FAI is coxa recta, commonly found in species that run and jump. It is rarely found in animals that climb and swim. In contrast are the animals with coxa rotunda, a perfectly spherical femoral head, and more in keeping with the coxa profunda of mankind. This article describes the evolutionary process of the human hip and its link to FAI and DDH. Do we need to worry after all?

Background: Long-term results after fusion for cervical disc disease show evidence of adjacent segment disease, mainly in young and active population. This led to the development of new techniques, i.e. cervical mobile prostheses. 8yr-follow-up of Cervidisc. ®. semi-constrained prosthesis documented motion preservation, but its design required minor adjustments to assess optimal outcome leading to an optimized version – Discocerv. ®. Cervidisc Evolution. Purpose: To evaluate the intermediate outcome in patients operated with Discocerv. ®. . Study design: Multicenter prospective non comparative study. Patient sample: Since April 2006, 77 consecutive patients (41m/36w: mean age 45.2[27–65]) were enrolled in the study so far in 7 centers in France and Switzerland. Mean follow up was 6(0–12) months. Outcome measures: Clinical evaluation criteria: VAS 1 to 100mm self-reported cervical and radicular pain, NDI (1–50 scale), symptoms evolution (ODOM score), work status, patient satisfaction were recorded pre–and post-operatively. Radiographic criteria: operated levels’ flexion-extension mobility. Methods: Patients underwent one (C3C4 n=2, C4C5 n= 7, C5C6 n=37, C6C7 n= 28) or multiple level (C5C6/ C6C7 n=2; C4C5/C5C6/C6C7 n=1) cervical arthroplasty with Discocerv for degenerative disc diseases (disc hernia, stenosis, discopathy). Results: Per-operative complications occurred in 4 patients (5%) without further consequences. No post operative complications were reported. 67% of active patients resumed their previous work within the first 6 months after surgery. The ODOM score showed 100% excellent and good results at 6 to 12mths follow-up. Mean cervical and radicular VAS-reported pain decreased from 60 [4–84] and 65 [2–96] pre-operatively to 21[0–45] and 21[0–36] at 0–6 months and to 15 [0–40] and 16 [0–40] respectively at 6–12 months. Similarly mean NDI decreased from 25 [9–45] to 10 [0–35] at 0–6 months and to 6[0–36] at 6–12mths. All patients were satisfied with the results so far. Quantitative radiographic analysis showed satisfactory restoration of cervical mobility at the operated levels with mean flexion-extension mobility 6.4°[1–11°] at 0–3mths and 7.1°[4–12°] at 6–12mths respectively. The adjacent level mobility was found within normal ranges at 6–12mths post-operatively. At the same follow-up period, the regional lordosis was within physiological ranges for 65% of patients at the last follow-up. Discusssion and conclusion: Our results with Discocerv. ®. Cervidisc Evolution prosthesis confirm the long term 96% mobility obtained at 7 years follow-up with the first generation of the device, i.e. Cervidisc. ®. . Both clinical and radiological findings in this study support the effectiveness of the Discocerv. ®. Cervidisc Evolution prosthesis at mid-term. However further follow-up at long term is necessary in order to confirm these findings

Aims. There has been an evolution recently in the management of unstable fractures of the ankle with a trend towards direct fixation of a posterior malleolar fragment. Within these fractures, Haraguchi type 2 fractures extend medially and often cannot be fixed using a standard posterolateral approach. Our aim was to describe the posteromedial approach to address these fractures and to assess its efficacy and safety. Patients and Methods. We performed a review of 15 patients with a Haraguchi type 2 posterior malleolar fracture which was fixed using a posteromedial approach. Five patients underwent initial temporary spanning external fixation. The outcome was assessed at a median follow-up of 29 months (interquartile range (IQR) 17 to 36) using the Olerud and Molander score and radiographs were assessed for the quality of the reduction. Results. The median Olerud and Molander score was 72 (IQR 70 to 75), representing a good functional outcome. The reduction was anatomical in ten, with a median step of 1.2 mm (IQR 0.9 to 1.85) in the remaining five patients. One patient had parasthaesiae affecting the medial forefoot, which resolved within three months. Conclusion. We found that the posteromedial approach to the ankle for the surgical treatment of Haraguchi type 2 posterior malleolar fractures is a safe technique that enables good visualisation and reduction of the individual fracture fragments with promising early outcomes. Cite this article: Bone Joint J 2017;99-B:1496–1501

Purpose: Prospective randomized clinical and radiological study to compare the evolution of instrumented posterolateral lumbosacral fusion using either coralline hydroxyapatite(CHA), or iliac bone graft(IBG) in three comparable groups of patients. Methods: 56 randomly selected adult patients with spinal stenosis were divided into three groups(A,B,C) included 17, 19 and 20 patients respectively and underwent decompression and fusion. The spines of Group A received IBG ; Group B IBG on the left side and CHA mixed with local bone and bone marrow on the right side; Group C CHA mixed with local bone and bone marrow bilaterally. The patients’s age was 61+11, 64+8 and 58+8 years for groups A, B and C respectively. SF-36, Oswestry Disability Index, and Roland-Morris surveys were used. Visual Analog pain Scale was used for pain. Roentgenograms (AP, lateral and oblique plus bending views) and CT-scans were used to evaluate the evolution of fusion. Two independent observers tested variability in evolution of the dorsolateral bony fusion 3 to 48 months postoperatively with the Christiansen’s and CHA resorption in Groups B and C. Results: Intraobserver and interobserver agreement (r) for radiological fusion was 0.71 and 0.69 respectively, and 0.83 and 0.76 for evaluation of CHA resorption. There was no visible pseudarthrosis. Fusion was achieved one year postoperatively. CHA resorped 6 months postoperatively at the intertransverse spaces. Bone bridging started 3 months postoperatively in all levels posteriorly as well as between the transverse processes where IBG was applied. SF-36, Oswestry Disability Index, and Roland-Morris Score improved > 20 postoperatively in all groups. There was one pedicle screw breakage at the lowermost-instrumented level in group A and two in group C without pseudarthrosis. There was no deep infection. Operative time and blood loss were less in group C, while donor site complaints were observed in the patients of the groups A and B only. Discussion & Conclusion: This study showed that autologous IBG remains the gold standard for posterior instrumented lumbar fusion to which each new graft should be compared. CHA was proven in this series not appropriate for intertransverse posterolateral fusion because the host bone in this area is little

Background. The discussion over the duration, type of therapy and regimen to be used in osteoarticular tuberculosis is losing importance in all orthopaedic gathering. Still little consensus is there over the universality of a treatment regime for osteoarticular tuberculosis. Material and Method. 340 new cases of osteoarticular tuberculosis were included in the study that were medically treated in the department of orthopaedics in a tertiary care center between 2001 and 2011. Out of which 202 cases were of spinal tuberculosis and 138 cases of extraspinal tuberculosis. 88 cases of spinal tuberculosis were treated by conventional method and 114 cases by short course chemotherapy. 60 cases of extraarticular tuberculosis were treated by conventional chemotherapy and 78 cases by short course and intermittent therapy. Results. All cases were evaluated on clinical, radiological and haematological basis. Cases who received conventional therapy received 18–24 months of treatment irrespective to the clinical, radiological and haematological parameters. Whereas those who received short course (2HRZE+4 HR) and intermittent therapy (DOTS) were evaluated for clinical improvement. Maximum follow up was of 12.8 years (conventional) minimum follow of 8 years (intermittent). The trend of fall in ESR, clinical and radiological parameters showed improvement beyond 2 years of initiation of treatment in cases that had stopped treatment at 6 months. But the improvement was slow after six months even in cases who received 24 months of chemotherapy. There were no relapses in all the three groups. Conclusion. This study reinforces that chemotherapy tailored to the response of treatment (6-9months) is the rational therapy. This study gives an insight over the evolution of different regimes as well as gives an understanding of the clinical treatment. Level of Evidence. Level 1. No relevant financial disclosures or conflicts of interest from any of the authors

Introduction. Tribological studies have described a characteristic wear pattern of metal-on-metal hip resurfacings (MoMHRAs) with a run-in period followed by a ‘bedding-in’ phase minimising wear or by an increasing wear patch with edge loading. The use of metal ions as surrogate markers of in-vivo wear is now recommended as a screening tool for the performance of MoMHRAs. The aims of this retrospective, single-surgeon study were to measure ion levels in unilateral MoMHRAs at different stages during the steady-state in order to study the evolution of wear and factors affecting it. Methods. 218 consecutive patients with minimum two serum ion measurements were included. The mean age at surgery was 52.3 years, the first assessment was made at a mean of 2.5 years (11 months–8 years) and the last assessment at a mean of 4.6 years post resurfacing (2– 12 years). Ion level change was defined as Ion level at last assessment minus Ion level at first assessment. Ten different resurfacing designs were implanted, the majority being BHR (n=104), Conserve plus(n=55) and ASR (n=25). The median femoral component size was 50 mm (38–59mm). Radiological assessment of acetabular component orientation was made with EBRA. Results. For the whole cohort a significant reduction in Chromium (Cr) levels between initial [2.6 μg/ml (SD: 6.8)] and last assessment [1.9 μg/ml (SD: 8.3)] was found (p= 0.004). Cobalt (Co) levels were similar at initial [1.7 (SD: 7.7)] and last [1.8 (SD: 10.6)] follow-up (p=0.78). Cr levels increased in 31% and Co increased in 46% of patients. There was a significant ion level increase in 5% of patients. There was no significant difference between genders (p= 0.4) or implant designs (p = 0.07), but a trend of higher ions at last follow up with the ASR implants in comparison to BHR and C+. Neither component size (p=0.4) nor acetabular orientation (p=0.46) correlated with change in ion levels. However, a CPR distance (contact patch-rim) of <10mm was associated with an increase in Cr levels over time (p= 0.042). Patients with increasing ion levels had significantly lower Harris Hip Scores (p=0.038). Discussion. The analysis of the evolution of ion levels in unilateral hip resurfacing after the run-in phase demonstrates an overall decrease of Cr levels but no significant change in Co levels. This in vivo finding is consistent with tribocorrosion studies showing the formation of a passive protective film on the articulating surfaces after the initial wear-in, preventing further corrosion. From that point on, provided there is no edge loading causing increased surface wear, ions are mainly formed by corrosion of the particulate debris generated during the run-in phase. In vitro studies have shown a higher dissolution of the more soluble Co from the debris while Cr remains in solid form with less ion formation. In a number of cases in our study, ion levels continued to increase, indicating ongoing surface wear. These increasing ion levels were correlated with a lower coverage angle more prone to edge loading and with the development of clinical symptoms

The success of total knee replacement depends on several factors, however, surgical technique is particularly important. In fact mistakes in alignment of prosthtic components are common causes of aseptic loosening. Serious improper alignment (more than 3°) was found out, according to several papers, in about 10% of the implants; this appears not correlated with surgeon’s experience when they use mechanical alignment devices either extra medullary or intra medullary. The development of computer-based systems to achieve correct prosthetic components alignement has the purpose to solve the problems of traditional mechanical alignement systems. At present computer-assisted navigation systems, either they areimage-free or imege-based, are widely empolied while robotic systems are not so commonly used. The Authors describe in this paper the features of the computer-assisted navigation system they at present employ. They moreover emphasize its precision and the reproducibility of the results they can achive. The features of this system (it is based on an image-free navigation method; it allows quantification of the kinematics of the knee; it allows the use of either specially designed cutting bolcks or standar instruments), are an intresting evolution of computer-assisted navigation systems for knee replacement

Background: Current treatment for Perthes disease aims at preventing deformation of the femoral head during the active stage of the disease by obtaining containment of the femoral head. To effectively pre-empt femoral head deformation, one needs to know, when during the disease irreparable femoral head deformation occurs. This study was undertaken to attempt to clarify this. Methods: Records and 2634 pairs of radiographs (AP and lateral) of 610 patients with Perthes’ disease were reviewed. The evolution of the disease was divided into seven stages (Stages Ia, Ib, IIa, IIb, IIIa, IIIb & IV) based on plain radiographic appearances. Intra-observer and inter-observer reproducibility of this new classification system was assessed. The duration of each stage of the disease was noted. The stage at which epiphyseal extrusion and widening of the metaphysis occurred and the stage at which metaphyseal and acetabular changes appeared were identified. The shape and the size of the femoral head, the extent of trochanteric overgrowth and the radius of the acetabulum were assessed in hips that had healed. Results: The reproducibility of the new classification system of the evolution Of Perthes’ disease was good. The median duration of each stage varied between 95 and 326 days. Epiphyseal extrusion and metaphyseal widening was modest in Stages Ia, Ib and IIa but increased dramatically after Stage IIb. > 20% extrusion occurred in 70% of the hips by Stage IIIa. Metaphyseal changes were most frequently encountered in Stage IIb, while acetabular changes were most prevalent in Stage IIIa. At healing, only 24% of untreated patients had spherical femoral heads, while 52% had irregular femoral heads. Conclusions: The new classification of the stages of evolution of Perthes’ disease helps to identify when crucial events occur during the course of the disease. The timing of epiphyseal extrusion, metaphyseal widening and the appearance of adverse metaphyseal and acetabular changes suggest that femoral head deformation occurs by Stage IIIa in untreated hips. Hence, if containment were to succeed, it should be achieved before this stage

Aim. To review the evolution of the orthopaedic surgical care offered at a small rural hospital in western Nepal. The United Missions Hospital of Tansen (UMHT) was established in 1954 and has progressed substantially over the past 55 years. Located in the hills 300 km west of Kathmandu, it services not only Palpa District but also the surrounding nine districts and Indian patients from across the nearby border. The hospital has progressed from a simple medical clinic to a 165-bed hospital with four operating theatres, a new emergency department and multiple outpatient clinics. Orthopaedics in particular has come a long way from solely non-operative care such as plasters, splints and traction, to plating and intra-medullary nailing with intra-operative imaging facilities. This talk will review the progression of services in the region and highlight how western intervention has drastically improved the health care and lives of people in and around Tansen. Methods. UMHT is a 165-bed hospital with medical staff covering paediatrics, general medicine, general surgery and orthopaedics. Exact specialty coverage can vary depending on expatriate cover and locally trained staff expertise. There are around 315 Nepali employees, and eight mission appointees, mainly from the UK, USA, Australia and Sweden. There are six resident medical officers who are post internship and usually completing GP training schemes. The hospital is accredited to train 10 interns per year and frequently takes local and international medical students on rotation. Surgical facilities include daily outpatient surgical clinics of 30–60 patients, two minor operation theatres and two operating theatres. Generally, these are run as one orthopaedic and one general surgical theatre. This review is based on the experiences of Dr John Bosanquet, Dr Sandy Bosanquet and Dr Lachlan Host in their outreach trips to this hospital and in particular will focus on the progression over the last 10 years of the orthopaedic services available. Major advances have been in the provision of x-ray and CT facilities, improved supply of sterile equipment, introduction of IM nailing using the SIGN nail, and the training of local staff to continue the work. Conclusions. UMHT is a work in progress and is only made possible by the contributions of the many doctors, nurses, teachers and other professionals who willingly offer their services to help those less fortunate. Even more importantly is the funding provided from multiple organisations to sustain this outreach. The challenge remains, as in any outreach offered, of providing a service that is sustainable long-term. To date, UMHT has stood the test of time and there is much to be learnt from its example in the establishment of similar outreach projects. Future challenges for Tansen include the need for improved sterile facilities, the challenges of introducing elective surgery, particularly arthroplasty, provision of spine and neurosurgical facilities, and retention of skilled personal in what can be an isolating environment

Objective: To document an unusual pattern of clinical presentation simulating cerebral palsy and investigate the evolution of spinal deformity in relation to patients’ growth and responsiveness to levodopa therapy. Study Design-Material: A retrospective study was performed including 3 pediatric patients with dopa-responsive dystonia who developed in the course of their disease spinal curvatures. Summary of Background Data: Dopa-responsive dystonia has been recognized as a separate type of idiopathic dystonia with early onset, gradual generalized involvement, diurnal fluctuation of symptoms, spinal malalignment, and remarkable response to levodopa. Nevertheless, it can present with atypical features including prominent spastic elements and intrafamilial variability of expression. Methods: The medical records and radiographs of the 3 patients were reviewed. Results: All 3 siblings were normal at birth and had negative family history of neurological disease or spinal imbalance. Soon they developed progressive neurological impairment with exaggerated spasticity, underestimated dystonic patterns, and marked phenotypic variation, leading to the initial misdiagnosis of spastic-dystonic cerebral palsy of familial inheritance. With further growth, patient 1 and 3 developed spinal deformity, which responded dramatically to levodopa treatment and resolved spontaneously, while the neurological symptoms persistently ameliorated. Patient 2 developed a rigid C-shaped thoracolumbar scoliotic curve measuring at age 10 years 88o; even though she demonstrated considerable overall improvement with levodopa, the spinal curvature remained unresponsive and necessitated surgical correction through a combined anterior-posterior instrumented spinal fusion extending to the sacrum. However, her ambulatory function was preserved. Conclusions: Spinal decompensation is a common manifestation of dopa-responsive dystonia with excellent prognosis if adequate diagnosis and initiation of levodopa treatment are made early. On the contrary, if diagnosis and levodopa treatment are delayed, spinal deformity may progress following the rapid evolution pattern of neuromuscular curves, necessitating surgical intervention. When spinal arthrodesis is required, inclusion of the lumbosacral joint does not preclude latter ambulatory function

This is the first time that the principle of the mould—the principle of guiding the repair of nature for the purpose of recreating a destroyed or damaged structure, has been applied to surgery. The evolution of the method to its present encouraging stage is the result of the co-operative, professional family spirit of the Massachusetts General Hospital. We all share in it. We share it with the general surgeon because of his contributions to surgical technique. We share it with the "medical man" because of his pre-operative and post-operative care of the patient; because of his guidance as to when, and when not, to operate; and because of the many friendly arguments which are productive of so much good. We share it with the anaesthetist because of his clinical judgment of the patient, his selection of anaesthetic agent, and his continuous, conscientious administration of the anaesthetic throughout the operation. I am going to change from "we" to "I." I owe so much to my assistants, from the first to the last: Bill Rogers, Eddie Cave, George Van Gorder, Paul Norton, Milton Thompson, Otto Aufranc, and Carroll Larson. I want to thank them all for helping to carry the load, for remembering the things that I forgot, and for making helpful suggestions which often led to improvement in surgical technique or to the construction of a useful instrument. I want to pay tribute to the staff of the Orthopaedic Service of the Massachusetts General Hospital and to thank its members for kindly scepticism, constructive criticism, and neverfailing loyal support. The subject of this lecture, "Evolution of Mould Arthroplasty of the Hip Joint," is appropriate for a Moynihan lecture. It is not the work of one man alone. It is the work of one man, supported by a co-operative, helpful, and friendly hospital staff. This is what Lord Moynihan strove so hard to bring about at a time when surgeons viewed one another as rivals. To quote Dr William Mayo: "It is to Lord Moynihan's everlasting credit that, largely as a result of his unceasing efforts, surgeons came to consider themselves as fellow-workers in a cause."

Purpose: The purpose of our study was to evaluate, in a context of laxity, the incidence of meniscal lesions and their treatment on the osteoarthritic evolution after more than ten years. In 1986 and 1987, we operated 230 knees with tears of the anterior cruciate ligament using a patellar graft. Among these knees, 184 (80%) were reviewed clinically and radiographically for this study. Material and methods: Ninety patients (49%) had healthy menisci at the operation and did not have a secondary meniscal procedure; 94 patients (51%) had a meniscal procedure before, during or after the plasty. Among these, 13 (14%) had had an earlier meniscectomy, 18 (19%) had had meniscectomy at the time of the plasty (two revisions), 35 (37%) had had sutures (five secondary failures), ten (11%) had had a long injury left in place (four revisons), and 18 (19%) with normal knees at the time of the plasty had a secondary meniscectomy. Results: We compared the radiological results in these different populations (osteoarthritis with remodelling compared with normal images). There was a significant difference between the population with normal knee images and the population with meniscal lesions irrespective of the time of treatment (prior meniscectomy, concomitant meniscectomy and plasty, healthy menisci at the time of plasty but secondary meniscectomy). There was no significant difference between the knees with normal menisci and those with sutured menisci. Conclusion: Saving the meniscus has a major effect on the radiological evolution of the knee. Thus isolated meniscectomy should not be performed for laxity in young patients; meniscal lesions should be sutured at the time of ligamentoplasty