We present a 25-year-old patient with juvenile rheumatoid arthritis and ankylosis of both hips and both knees treated by staged bilateral hip and knee arthroplasty. She was followed up for 18 months. We discuss the pre-operative planning, surgical details and post-operative rehabilitation

Between June 1993 and December 1994, we performed total knee arthroplasty (TKA) on 27 knees in 24 patients with spontaneous bony ankylosis in severe flexion. The mean age at operation was 43.5 years (30 to 60). No patient had preoperative pain. Three were unable to walk and 21 could manage less than five blocks. The mean duration of the ankylosis was 18.7 years (13 to 25) and its mean position was 105° flexion (75 to 135). The preoperative Hospital for Special Surgery Knee Score of 60 points was improved to 87 at the final follow-up three to five years later. All knees were free from pain. The mean range of active flexion in 24 knees was 97° (78 to 115) and the mean arc of movement 91° (78 to 98). The mean fixed flexion deformity was 6° (0 to 25) and the extension lag 8° (0 to 25). Angular deformity was corrected to between 0° and 10° of valgus. Four patients were able to walk one block and 20 five to seven blocks. Thirteen knees (48%) showed some necrosis at the skin edge; one knee required arthrodesis and another resection arthroplasty. One had a recurrence of tuberculous infection requiring arthrodesis. One patient had a rupture of the quadriceps tendon. To date no prosthesis has required revision for loosening. Radiolucency of 1 mm or less about the tibial prosthesis was observed at follow-up in four of the 24 knees. Our results have shown that one-stage TKA and skeletal traction after operation can achieve correction of severe flexion deformity of the knee with marked improvement in the function and quality of life

Ten patients with 13 ankylosed elbows after burns are described. Six elbows, fixed in nearly full extension, had almost total functional disability; the other seven had varying amounts of deformity. In five of the 13 elbows there was a continuous bony mass with loss of the joint space; these were treated by a modified excision arthroplasty which restored good movement and useful function, though there was some lateral laxity. Six elbows had a posterior bony block; this was excised, which restored a useful arc of movement. The literature on bony ankylosis after burns is reviewed and the management of these cases in a developing country is described

Eighteen hip fusions were converted to total hip replacements. A constrained acetabular liner was used in three hips. Mean follow up was five years (two to 15). Two (11%) hips failed, requiring revision surgery and two patients (11%) had injury to the peroneal nerve. Heterotopic ossification developed in seven (39%) hips, in one case resulting in joint ankylosis. No hips dislocated. . Conversion of hip fusion to hip replacement carries an increased risk of heterotopic ossification and neurological injury. We advise prophylaxis against heterotropic ossification. When there is concern about hip stability we suggest that the use of a constrained acetabular liner is considered. Despite the potential for complications, this procedure had a high success rate and was effective in restoring hip function

From 1984 to 1995, 68 ankylosed elbows and 11 which were unstable after trauma were replaced in India by Baksi sloppy hinge prostheses. The mean age of the patients was 28.6 years (17 to 70) and the mean follow-up 9.6 years (2 to 13.5).

Of the 68 ankylosed elbows, 59 (87%) regained a mean arc of painless movement of 88.5° (27 to 115). The mean improvement of supination was 24° and of pronation 16.5°. There were 54 good results (80%), eight fair and three poor. There were two complete failures due to infection, and one due to a broken humeral stem.

Of the 11 unstable elbows, the nine with good results had a mean arc of 125° (15 to 140) of painless stable movement, with a mean improvement in supination of 26° and of pronation of 19.5°. There was one fair result and one failure due to loosening with subsequent late infection.

There were significant complications in 14 cases with infection in seven and aseptic loosening in four. Patients with loosening or late removal of the prosthesis often retained reasonably stable elbow movement because periprosthetic fibrosis had connected the approximated bone ends, and muscle balance had been restored.

A number of causes have been advanced to explain the destructive discovertebral (Andersson) lesions that occur in ankylosing spondylitis, and various treatments have been proposed, depending on the presumed cause. The purpose of this study was to identify the causes of these lesions by defining their clinical and radiological characteristics. We retrospectively reviewed 622 patients with ankylosing spondylitis. In all, 33 patients (5.3%) had these lesions, affecting 100 spinal segments. Inflammatory lesions were found in 91 segments of 24 patients (3.9%) and traumatic lesions in nine segments of nine patients (1.4%). The inflammatory lesions were associated with recent-onset disease; a low modified Stoke ankylosing spondylitis spine score (mSASSS) due to incomplete bony ankylosis between vertebral bodies; multiple lesions; inflammatory changes on MRI; reversal of the inflammatory changes and central bony ankylosis at follow-up; and a good response to anti-inflammatory drugs. Traumatic lesions were associated with prolonged disease duration; a high mSASSS due to complete bony ankylosis between vertebral bodies; a previous history of trauma; single lesions; nonunion of fractures of the posterior column; acute kyphoscoliotic deformity with the lesion at the apex; instability, and the need for operative treatment due to that instability. It is essential to distinguish between inflammatory and traumatic Andersson lesions, as the former respond to medical treatment whereas the latter require surgery

Heterotopic ossification (HO) of the hip after injury to the central nervous system can lead to joint ankylosis. Surgery is usually delayed to avoid recurrence, even if the functional status is affected. We report a consecutive series of patients with HO of the hip after injury to the central nervous system who required surgery in a single, specialised tertiary referral unit. As was usual practice, they all underwent CT to determine the location of the HO and to evaluate the density of the femoral head and articular surface. The outcome of surgery was correlated with the pre-, peri- and post-operative findings. In all, 183 hips (143 patients) were included of which 70 were ankylosed. A total of 25 peri-operative fractures of the femoral neck occurred, all of which arose in patients with ankylosed hips and were associated with intra-articular lesions in 18 and severe osteopenia of the femoral head in seven. All the intra-articular lesions were predicted by CT and strongly associated with post-operative complications. The loss of the range of movement before ankylosis is a more important factor than the maturity of the HO in deciding the timing of surgery. Early surgical intervention minimises the development of intra-articular pathology, osteoporosis and the resultant complications without increasing the risk of recurrence of HO

1. Fifty cases of arthrodesis of the hip joint in tuberculous arthritis are analysed; in forty cases the late end-result has been ascertained two or more years after operation. 2. The indications for arthrodesis are discussed. The operation should not be performed when disease is active; it should not be undertaken before the age of twelve to thirteen years; it is not advisable in elderly patients; it may be contra-indicated when there are multiple foci of infection. Subject to these limitations every patient with unsound ankylosis after adequate conservative treatment should be treated by arthrodesis; painful fibrous ankylosis and late onset of deformity are definite indications. 3. Three types of operation have been used: intra-articular arthrodesis; extra-articular ilio-femoral arthrodesis; combined intra- and extra-articular arthrodesis. Extra-articular ilio-femoral arthrodesis is preferred, deformity being first corrected by traction or osteotomy. 4. Post-operation complications were few; the mortality rate was low (2 per cent.). 5. There was bone ankylosis with solid incorporation of the graft in 87·5 per cent., failure of union of the graft (to the trochanter) in 10 per cent., and destruction of the graft in 2·5 per cent. 6. Late end-results show full working capacity in 87·5 per cent. of patients, part working capacity in 2·5 per cent. and inability to work in 7·5 per cent. The writer wishes to express his thanks to Professor Harry Platt and Professor T. P.. McMurray for criticism and advice in the preparation of this paper, and to Dr F. C. S. Bradbury, Central Consultant Tuberculosis Officer of the Lancashire County Council, for permission to publish these cases

Between July 1986 and August 1996, we performed 32 total knee arthroplasties (TKA) on 32 patients with partially or completely ankylosed knees secondary to infection. Their mean age at surgery was 40 years (20 to 63) and the mean follow-up was ten years (5 to 13). The mean post-operative range of movement was 75.3° (30 to 115) in those with complete and 98.7° (60 to 130) in those with partial ankylosis. The mean Hospital for Special Surgery knee score increased from 57 to 86 points post-operatively. There were complications in four knees (12.5%), which included superficial infection (one), deep infection (one), supracondylar femoral fracture (one) and transient palsy of the common peroneal nerve (one). Although TKA in the ankylosed knee is technically demanding and has a considerable rate of complications, reasonable restoration of function can be obtained by careful selection of patients, meticulous surgical technique, and aggressive rehabilitation

Neurogenic myositis ossificans is a disabling condition affecting the large joints of patients with severe post-traumatic impairment of the central nervous system. It can result in ankylosis of the joint and vascular or neural compression. Surgery may be hazardous with potential haemorrhage, neurovascular injury, iatrogenic fracture and osteochondral injury. We undertook pre-operative volumetric CT assessment of 45 ankylosed hips with neurogenic myositis ossificans which required surgery. Helical CT with intravenous contrast, combined with two- and three-dimensional surface reconstructions, was the only pre-operative imaging procedure. This gave good differentiation of the heterotopic bone from the adjacent vessels. We established that early surgery, within 24 months of injury, was neither complicated by peri-operative fracture nor by the early recurrence of neurogenic myositis ossificans. Surgical delay was associated with a loss of joint space and a greater degree of bone demineralisation. Enhanced volumetric CT is an excellent method for the pre-operative assessment of neurogenic myositis ossificans and correlates well with the operative findings

Cervical spinal disc replacement is used in the management of degenerative cervical disc disease in an attempt to preserve cervical spinal movement and to prevent adjacent disc overload and subsequent degeneration. A large number of patients have undergone cervical spinal disc replacement, but the effectiveness of these implants is still uncertain. In most instances, degenerative change at adjacent levels represents the physiological progression of the natural history of the arthritic disc, and is unrelated to the surgeon. Complications of cervical disc replacement include loss of movement from periprosthetic ankylosis and ossification, neurological deficit, loosening and failure of the device, and worsening of any cervical kyphosis. Strict selection criteria and adherence to scientific evidence are necessary. Only prospective, randomised clinical trials with long-term follow-up will establish any real advantage of cervical spinal disc replacement over fusion

1 . The results of compression arthrodesis of the hip have been studied in fifty-six patients. There was one post-operative death from pulmonary embolism on the tenth day. 2. Bony union for the whole series (fifty-five patients) was achieved in 76·4 per cent. Sound fibrous ankylosis, indistinguishable from bony union clinically and functionally, was achieved in 10·9 per cent. Residual movement occurred in 12·7 per cent. 3. Thirty-five patients were treated by the standard technique of eight weeks in plaster, followed by full weight bearing, irrespective of whether any movement was detected on clinical testing. 82·8 per cent achieved sound bony union; 5·7 per cent achieved sound fibrous ankylosis, and residual movement occurred in 11·4 per cent. 4. Ten patients were treated without plaster protection; six achieved bony union; three had sound fibrous ankylosis and one had residual movement. Healing was delayed in this group and there was more residual deformity. 5. 67·5 per cent of all patients recovered full knee range. Only one patient with reduced range had knee flexion of less than 90 degrees. Twenty-four of the thirty-five patients treated by the standard technique of eight weeks in plaster were examined. Fifteen had full knee movement; in only four was knee flexion less than 120 degrees and in no case was it less than 90 degrees. 6. Return to full activity was rapid. Sixty per cent of patients returned to work within six months and 80 per cent within nine months of surgery. Five of the six patients examined with residual movement in the hip joint were back at work within six months of surgery. 7. This study lends support to the view that arthrodesis of the hip, in the presence of normal function in the opposite hip, is compatible with vigorous and full activity

1. Arthroplasty of the knee joint should be performed only in carefully selected cases. Criteria for the operation are outlined. 2. In our experience, 70 per cent. of properly selected patients secure good or fair results. An additional 12 per cent., whose anatomical or functional results were classified as poor, preferred the movement which had been gained to ankylosis of the joint. 3. The major functional adaptation of the knee joint takes place during the first five years after arthroplasty. Several patients who had a poor range of movement after one or two years developed an excellent range by the end of five years. 4. Instability, when present, usually became apparent within the first five years. 5. Joints which were still stable at the end of five years usually remained so over a long period of time. Four patients have been traced for twenty to twenty-five years, and three have been traced for over twenty-five years. 6. Since the incidence of ankylosis of the knee joint from gonococcal and pyogenic infections has been reduced by the use of antibiotics, fewer patients are suitable subjects for arthroplasty

1. Almost all patients with osteoarthritis of the hip who consult the surgeon do so because they wish to be relieved of pain. They all have limitation of movement in varying degrees but most of them will be either unaware of it or will have accepted it. What is more important, they would not have sought medical advice because of stiffness if there had been no pain. The primary objective of operative treatment must therefore be to relieve pain. 2. Displacement osteotomy will give substantial relief from pain in a high proportion of cases and the relief is lasting. Perhaps that explains why this operation, advocated by McMurray and Malkin twenty-five years ago, is being practised more widely than ever to-day while its competitors (neurectomy, capsulectomy, arthroplasty) have steadily diminished in popularity. 3. The disadvantages of the operation are all related to post-operative immobilisation in plaster, which may induce further stiffness of the hip, even to the extent of ankylosis, or stiffness and pain in the knee. These disadvantages may be overcome to a considerable degree by internal fixation followed by sling suspension and early active movement. But when, under anaesthesia, the range of hip flexion is reduced to 45 degrees or less, the operation is always liable to result in ankylosis, and it is wise in these circumstances to take this possibility into account and warn the patient beforehand

1. Three hundred and twenty cases of tuberculosis of the hip joint have been analysed and the late results assessed three or more years after discharge from hospital. 2. The primary bone focus involved the acetabulum alone in 39·3 per cent; the acetabulum and femoral head in 34·1 per cent; the head of femur alone in 19·2 per cent, and the femoral neck alone in 7·4 per cent. In 101 cases widespread destruction of the joint had taken place by the time the patient first came under observation. 3. Premature epiphysial fusion round the knee joint of the affected side occurred in 23 per cent of all patients under the age of fifteen years. 4. When hip disease was complicated by multiple foci of active tuberculosis or by secondarily infected abscesses and sinuses, the prognosis was seriously worsened. 5. Significant late deformity occurred in 38·3 per cent of patients discharged with "sound" fibrous ankylosis, and in 60·5 per cent of those with an unstable fibrous ankylosis. 6. Of 187 patients observed for more than three years after discharge from hospital 174 returned to full activity, seven were partly incapacitated and six were totally incapacitated. 7. Analysis of the late results suggests that the prognosis is best when an adequate period of conservative treatment is followed by some form of arthrodesis operation

Aims

The aim of this study was to reassess the rate of neurological, psoas-related, and abdominal complications associated with L4-L5 lateral lumbar interbody fusion (LLIF) undertaken using a standardized preoperative assessment and surgical technique.

Aims

To examine the long-term outcome of arthrodesis of the hip undertaken in a paediatric population in treating painful arthritis of the hip. In our patient population, most of whom live rurally in hilly terrain and have limited healthcare access and resources, hip arthrodesis has been an important surgical option for the monoarticular painful hip in a child.

Pre-operative planning for total hip replacement (THR) is challenging in hips with severe acetabular deformities, including those with a hypoplastic acetabulum or severe defects and in the presence of arthrodesis or ankylosis. We evaluated whether a Rapid Prototype (RP) model, which is a life-sized reproduction based on three-dimensional CT scans, can determine the feasibility of THR and provide information about the size and position of the acetabular component in severe acetabular deformities. THR was planned using an RP model in 21 complex hips in five men (five hips) and 16 women (16 hips) with a mean age of 47.7 years (24 to 70) at operation. An acetabular component was implanted successfully and THR completed in all hips. The acetabular component used was within 2 mm of the predicted size in 17 hips (80.9%). All of the acetabular components and femoral stems had radiological evidence of bone ingrowth and stability at the final follow-up, without any detectable wear or peri-prosthetic osteolysis. The RP model allowed a simulated procedure pre-operatively and was helpful in determining the feasibility of THR pre-operatively, and to decide on implant type, size and position in complex THRs. Cite this article: Bone Joint J 2013;95-B:1458–63

We performed arthrodesis of the ankle in eight patients by arthroscopic joint excision and fixation with crossed tibiotalar compression screws. Two patients had rheumatoid arthritis and six had post-traumatic osteoarthritis. None had a serious deformity of the ankle. Clinical ankylosis was achieved in all cases and there was radiological evidence of bone fusion in four

Aims

The aim of this study was to develop and internally validate a prognostic nomogram to predict the probability of gaining a functional range of motion (ROM ≥ 120°) after open arthrolysis of the elbow in patients with post-traumatic stiffness of the elbow.

We report a new method of ankle arthrodesis which combines an anterior approach with a dowel technique of bone grafting and screw fixation. In 20 ankles of 20 patients, ten with osteoarthritis, eight with rheumatoid arthritis and two others, we achieved 19 solid bony fusions and one painless fibrous ankylosis. The average time to union was 12.5 weeks. Patient satisfaction was high and the functional results were as good as for other reported methods, with fewer complications

Plasmin, a proteolytic enzyme derived from the blood, may be activated in synovial fluid both by trauma to synovial tissue and cartilage, and by kinases produced by streptococci and staphylococci. Plasmin normally removes fibrin, but, when in excess, attacks the protein of cartilage matrix. Conversely, excess inhibitor favours the persistence of fibrin and subsequent fibrosis. The relationship of excess protease to the chondrolysis of suppurative arthritis and of excess inhibitor to pannus formation and fibrous ankylosis in tuberculous and rheumatoid arthritis are discussed

1. The usual methods of posterior arthrodesis of the lumbo-sacral joint are not satisfactory in cases in which laminectomy has been performed. 2. Estimation of fusion by mobility radiographs is unreliable and cannot distinguish between fibrous ankylosis and bony fusion. 3. Bone grafts inserted from behind between the vertebral bodies almost invariably fail to become incorporated. 4. Intertransverse arthrodesis has given promising results and is probably the best method available at present

The results of Charnley stabilisation of the hip in forty-three patients observed for one to four and a half years are reported. The operation readily produced a bony fusion in young patients and also in some of the older ones. Fibrous ankylosis, with or without some movement in the joint, gave an excellent result. Even when a pseudarthrosis or a stress fracture occurred, the clinical result often showed a definite improvement. Only three patients did not benefit from the operation, though none of these showed any significant increase in their disability

Arthrodesis after the removal of a knee prosthesis is often hampered by the small area of contact of the bony surfaces and by pre-existing infection. Conventional systems of external fixation and compression frequently fail to achieve stability but the addition of the Wagner leg-lengthening apparatus applied anteriorly and adjusted to give compression ensures rigid external fixation. Four knees in four patients were treated using this technique; the treatment followed the removal of infected prostheses in three knees and painful fibrous ankylosis after the removal of the prosthesis in the other. All obtained a sound arthrodesis

1. Experience in the treatment of tuberculous disease of the spine, hip and knee by combined constitutional, antibiotic and operative measures is described. 2. In patients with tuberculosis of the spine, especially in the thoracic region and when perispinal abscess formation is a prominent feature, the treatment helps to ensure stable ankylosis in the type of case in which it otherwise might not occur. 3. In children with tuberculosis of the hip and in adults and children with tuberculosis of the knee it is usually possible to save the joint and to restore function, provided the joint has not been destroyed before treatment is begun

Operation on the hips of patients with myelomeningocele is often followed by stiffness or ankylosis. Excision of the upper end of the femur for this condition frequently fails because of extensive new bone formation. Twelve excisions in eight patients are reported. Six of these patients had recently had spinal fusion operations; the consequent loss of ability to compensate for hip stiffness by spinal flexion had made sitting difficult or impossible. Excision or even re-excision of the upper femur failed in most cases. Careful assessment of hip mobility before spinal operations in these patients is essential and osteotomy rather than excision of the upper femur is advised

Talectomy was performed on 10 patients (15 feet) for club foot deformity in arthrogryposis multiplex congenita. These were reviewed after an average follow-up of eight years. At follow-up nine feet were plantigrade, and six had less than 15 degrees residual equinus at the ankle. All the feet were asymptomatic but had mild residual adduction of the forefoot and marked stiffness of the hindfoot. Seven feet developed spontaneous bony ankylosis in the tibiotarsal joint. The common technical errors were incomplete removal of the talus and incorrect positioning of the calcaneus in the ankle mortise

The Stanmore hinged total knee replacement was introduced in 1969 for severe destructive arthropathy of the knee, and the results of one hundred consecutive operations are presented after an average interval of two and a half years. Insertion of the prosthesis relieved pain in 94 per cent, improved the range of movement in 67 per cent, invariably restored stability and corrected valgus or varus deformity. Gross flexion contractures were improved but not always fully corrected. Serious complications were few, though of three cases of deep infection two came to amputation and one to fibrous ankylosis. There were no mechanical failures of components of the prosthesis

1. This paper describes the macroscopic and microscopic changes that are seen in posterior intervertebral joints after anterior vertebral fusion. 2. We now have a reasonably clear view of the types of change seen under these circumstances. The type varies from case to case and in different parts of the same specimen. So far we have no clear idea of the sequence or the pattern that leads from the normal to complete fibrosis or osseous ankylosis. 3. Further experimental work is needed in order to build up a clear concept of the sequence of events and of their relative importance. To do this it will be necessary to immobilise joints for longer than before

Fifty-four hips converted to low friction arthroplasty between 1965 and 1975 have been reviewed one to eleven years after operation. In many cases malposition had led to degenerative changes in the opposite hip, the lumbar spine or the knee, often with severe loss of function due to pain. It was found that total replacement could give useful relief of pain and improved function, though the range of movement obtained was not as good as in primary replacement. An outstanding feature was the correction of inequality of leg length. In general, the results were much better in cases of ankylosis acquired in adult life than in cases of spontaneous fusion after sepsis in childhood. The most important complication was a single case of sciatic palsy

Splitting fractures of the humeral head are rare; part of the humeral head dislocates and the unfractured part remains attached to the shaft. We report eight cases in young patients. In five the diagnosis was made at presentation: three had minimal internal fixation using a superior subacromial approach, one had a closed reduction and one a primary prosthetic replacement. All five patients regained excellent function with no avascular necrosis at two years. In three the injury was initially unrecognised; two developed a painless bony ankylosis and one is awaiting hemiarthroplasty. It is important to obtain the three trauma radiographic views to diagnose these unusual fractures reliably. CT delineates the configuration of the fracture. In young patients open reduction and internal fixation seems preferable to replacement of the humeral head, since we have shown that the head is potentially viable

1. After almost seventeen years the three metal prostheses remain in approximately the original position in which they were inserted. 2. All three patients are ambulatory and two of them pleased with the result. 3. The youngest patient, now fifty-six, has a solid ankylosis of the hip and leads an active life free of pain. 4. In view of the attritional changes which have been seen to occur as a result of the reaction of bone to metal, it is suggested that resection replacement operations should be reserved for the primary treatment of certain fractures in the elderly and in those patients who are expected to be mostly inactive for the rest of their life. As a rough guide, it is considered that the operation should not be carried out under the age of seventy

In fifty-six patients with ankylosing spondylitis three types of arthroplasty had been performed in ninety-nine hips. Forty-one of the patients were men and fifteen were women, their average age at operation being forty-two years. Primary pseudarthrosis produced well-satisfied patients, but only a fair result in five hips, whereas cup arthroplasty resulted in a poor outcome for eight hips, all of which needed revision. Total replacement of eighty-six hips, however, led to 73 per cent being graded as good or excellent up to ten years later. The main complications were deep infection of five hips, para-articular ossification around nine hips (six leading to bony ankylosis), and fibrous ankylosis of six hips

1. One hundred and forty-two cases of extra-articular arthrodesis of quiescent tuberculous hips with fibrous ankylosis have been reviewed. 2. The methods used were the ilio-femoral graft with and without osteotomy, and the ischio-femoral graft by the Brittain or Foley technique. 3. Success occurs more frequently when the grafting operation is combined with or followed by a femoral osteotomy. 4. It is suggested that this success is due largely to the increased immobilisation afforded by the osteotomy. 5. It appears that equally good results can be obtained with either an ilio-femoral or an ischio-femoral graft in these cases provided that an upper femoral osteotomy is also carried out, preferably at or soon after the grafting operation. 6. An upper femoral osteotomy will frequently convert an unsuccessful extra-articular hip graft into a successful one without further grafting

Eighty elbows in 65 patients with an average age of 57 years have had two-part non-constrained Liverpool elbow arthroplasties performed since 1974. Fifty-five had rheumatoid arthritis, eight osteoarthritis or ankylosis secondary to injury, one osteochondritis dissecans and one pyknodysostosis. The average preoperative range of movement was 42 degrees to 112 degrees with 47 degrees of pronation and 42 degrees of supination. There was significant gain in the arc of movements at follow-up: 32 degrees in the extension-flexion range (average range 32 degrees to 134 degrees of flexion) and 42 degrees in forearm rotation (average pronation 69 degrees and supination 62 degrees). Before operation severe pain was the predominating symptom in 43 elbows (53.8%) but after replacement there was only moderate pain in five elbows (6.2%). The results were excellent in 42 (52.5%), good in 15 (18.7%), fair in 9 (11.3%) and unsatisfactory or poor in 14 (17.5%). Eight elbows required revision of the arthroplasty: three were post-traumatic, disorganised or osteoarthritic joints, three rheumatoid and both elbows in the patient with pyknodysostosis. Loosening of the prosthesis (particularly the humeral component) was the common factor necessitating revision. Of six rheumatoid elbows needing removal of the implant, four had deep infection, one had a dislodged humeral component as a result of injury and in one a divided olecranon had developed non-union. Rheumatoid elbows benefited more than post-traumatic arthritic elbows from the operation. (ABSTRACT TRUNCATED AT 250 WORDS)

Aims

Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants.

1. A review of 204 cases of prolapsed intervertebral disc treated by the author by operation ten to twenty-five years before is presented. Injury was an etiological factor in only 14 per cent. 2. The decision to operate should be made after a clearly defined and controlled, but limited, period of closed treatment. The patients should not have to wait for operation. Treatment by closed methods should not be continued in the absence of detectable signs of improvement. Continuation under such circumstances delays recovery from paralysis, prolongs convalescence and delays return to work. Persistence of paraesthesia and numbness are other probable consequences of such delay. 3. A central disc prolapse is an indication for urgent operation if persistent sphincter disturbance or incomplete bladder evacuation is to be avoided. 4. A recurrence rate of sciatica less frequent than that associated with treatment by closed methods is noted in this and other reported series. True recurrence, as opposed to a prolapse at another level, is rare and is most probably due to continuation of the biochemical process of degeneration leading to further sequestration of disc tissue. On the other hand, the altered spinal mechanics, particularly local rigidity resulting from enucleation of a deranged intervertebral disc, may predispose to prolapse at a higher level or may themselves be the cause of symptoms of "recurrence". 5. Operation gives early and lasting relief of sciatic pain, reduces the need for the subsequent use of a corset and assists the patient to an early return to work. 6. Operation does not affect the decision to change work. This is decided by the length of history before operation and the amount of disc degeneration; and the need to change work is the same whether the patient is treated by closed means or by operation. 7. Apart from simple back raising exercises to strengthen the spinal extensor muscles, no physiotherapy need be given because it is not likely to improve the prognosis. 8. Backache is the most frequent disability after operation (17 per cent) and is related to the degree of degenerative change present before and after operation. Injury precipitated the onset of backache in three cases. Operation does not by itself produce backache. The amount of bone removed has no demonstrable effect on the late results of operation, nor on the subsequent development of degenerative changes. 9. Enucleation of the nucleus is not followed by fibrous ankylosis across the intervertebral space

1. Ectopic ossification is commonest in, but not confined to, traumatic paraplegia. It occurs also in many other neurological disorders which have in common a gross disturbance of spinal cord reflex activity. It is a true ossification and must be distinguished from calcification. 2. The neurological lesion may lie anywhere from the cerebral cortex to the mixed peripheral nerve. It may involve motor tracts, sensory tracts or a mixture of both. 3. The ossification is localised and self-limiting. It occurs mainly in the lower limbs and is restricted to certain muscles or muscle groups, the nerve supply of which is always below the level of the central neurological lesion. 4. The blood chemistry is usually normal. 5. A true arthropathy is rare except as part of a secondary suppurative arthritis. 6. The resemblance to myositis ossificans progressiva or to ossifying haematoma is only superficial, although the pathological process at cellular level may be the same. 7. The period of onset after paraplegia is variable. The earliest recorded example is in one of our own cases in which ossification occurred nineteen days after injury. Other patients have developed ossification after several years. 8. The condition is commonest in acquired nervous disease rather than in congenital disorders, and so far as we know it has not been described in the myopathies. The presence of muscular spasticity or flaccidity is relevant only in that it indicates a disturbance of reflex activity. 9. Soft-tissue ulceration appears to be frequently associated with ectopic ossification. The type of new bone formation associated with large chronic ulcers is not to be compared with the new bone formation in the muscles of a paraplegic patient in otherwise good general condition. 10. The occurrence of urinary tract infections with calculi and generalised sepsis is not specifically related to the onset of new bone formation. 11. Localised soft-tissue oedema often precedes the formation of new bone. Its appearance is undoubtedly important, but the mechanism of its origin is obscure. 12. It is not yet known what initiates ectopic ossification, what limits its spread and what finally causes it to stop. 13. We have described 100 examples of ectopic ossification in 603 paraplegic patients. 14. Surgery has been required in only eight patients. The only indication for surgery is bony ankylosis of the hip in an unacceptable position

When large daily doses of vitamin D were administered to rats endochondral growth was inhibited and bone resorption occurred; later in the process uncalcified matrix (osteoid) like that seen in rickets formed on trabecular margins. When vitamin D was given only for a short period and then discontinued, little resorption of bone was seen during the withdrawal period and wide seams of osteoid material appeared which eventually calcified in an irregular manner. When normal endochondral growth was resumed a wide transverse band of dense bone with enclosed cartilaginous cores was left in the marrow cavity. If, after a few days, a second large dose of the vitamin was given resorption again occurred and calcification of osteoid material was accelerated, the first microscopic sign being a dense, wide, granular, deeply staining line at the junction of the bone and new osteoid. After a second withdrawal period a second layer of osteoid formed; eventually another transverse band appeared in the metaphysis. If this hypervitaminosis D cycle (+4 -12) was continued rats continued to form new bone with relatively little remodelling, so that after three such cycles bones became dense and hard. Histological study showed that little marrow cavity remained in either skull, vertebrae or epiphyses and a dense mass of bone enclosing cartilage cores filled the metaphysial part of the long bones. In addition, ankylosis ofteeth, calcification of spinal ligaments and widespread metastatic calcification were present. When hypervitaminosis D cycles (+1 -12, +1 -21) were adjusted to produce minimal resorptive changes a wide range of bone change was observed. This varied from uniform dense metaphysial bone containing abnormal cartilage matrix arranged in longitudinal striations, dense transverse bands parallel to the epiphysial cartilage, to remnants of dense trabeculae extending into the marrow cavity. Bone changes in osteopetrosis structurally closely resembled the induced bone changes in the rat. It is concluded that an important mechanism in the production of osteopetrosis is an accentuated rhythm of bone change like that shown experimentally to be produced in these animals. It is emphasised that these changes are but part of a range of bone disorders associated with abnormalities of cycles of resorption and deposition of bone, the type of change differing with the nature of the cycles

General remarks–Comparison of the two reviews shows that patients with good results return more readily for a review than those with poor results. In middle-aged patients with some disability for walking an attendance of 80 per cent at least is necessary in order to obtain a representative follow-up five to ten years after operation. An outstanding feature of all the operations reviewed is the degree of lasting relief of pain. It is rare to find that a patient with severe hip pain before operation has pain of the same severity after any of these operations at least up to ten years afterwards, and probably for much longer. Generally speaking, although in advancing years stiffness of the hip is undoubtedly a handicap, it is preferable to instability, particularly if this is progressive. A patient can adapt himself to and accept a disability that is permanent and unaltering, but instability increasing in later years can be distressing mentally and incapacitating physically. Cup arthroplasty–There is an element of unpredictability in the results, especially the late results, of cup arthroplasty. Movement decreases and there is a tendency for pain and instability to increase after four or five years. There is little to indicate which case will be successful although the results vary according to the condition for which operation is performed. The operation gives good results, on the whole, for osteoarthritis, particularly when the operation is done on one hip only. Stability is much more important when both hips are involved, and, unless this is good in at least one hip, the results of bilateral operations are poor. "Excellent" results are not obtained in rheumatoid arthritis but few results are "poor." Operations for congenital dislocation of the hip give the most disappointing results. In operations for ankylosing spondylitis there is a high incidence of stiffening of the hip, but many patients are greatly improved in comparison to their state before operation. Displacement osteotomy–The hazard in displacement osteotomy is ankylosis, particularly when internal fixation is not used. Relief of pain and stability are well maintained. The results in general, and for pain in particular, are less good when internal fixation is used. Adduction of the upper fragment of the femur appears to be of value in the production of a good result. In the series examined it was less often achieved when internal fixation was the method of immobilisation. The best results were obtained in cases of congenital dislocation of the hip and there were few "poor" results in cases of congenital subluxation. Excision of the head and neck of the femur and Batchelor's operation–Rehabilitation may take a long time, but the late results are more predictable than in the other operations reviewed. A "fair" result is more likely than an "excellent" one, but late "poor" results are few. Relief of pain is better after excision of the head and neck than after any other operation reviewed

Aims

To report the surgical outcome of patients with severe Scheuermann’s kyphosis treated using a consistent technique and perioperative management.

Aims

Increasingly, patients with bilateral hip arthritis wish to undergo staged total hip arthroplasty (THA). With the rise in demand for arthroplasty, perioperative risk assessment and counselling is crucial for shared decision making. However, it is unknown if complications that occur after a unilateral hip arthroplasty predict complications following surgery of the contralateral hip.

Aims

Heterotopic ossification (HO) occurs after arthroplasty, especially total hip arthroplasty. In this study we describe the incidence, evolution, morphology and clinical consequences of HO following reverse shoulder arthroplasty.

Aims

The crucial role of the radial head in the stability of the elbow in terrible triad injury is acknowledged. This retrospective study aims to compare the results of resection of a severely comminuted radial head with or without prosthetic arthroplasty as part of the reconstruction for this injury.

In this paper we propose a new classification of neurogenic peri-articular heterotopic ossification (HO) of the hip based on three-dimensional (3D) CT, with the aim of improving pre-operative planning for its excision.

A total of 55 patients (73 hips) with clinically significant HO after either traumatic brain or spinal cord injury were assessed by 3D-CT scanning, and the results compared with the intra-operative findings.

At operation, the gross pathological anatomy of the HO as identified by 3D-CT imaging was confirmed as affecting the peri-articular hip muscles to a greater or lesser extent. We identified seven patterns of involvement: four basic (anterior, medial, posterior and lateral) and three mixed (anteromedial, posterolateral and circumferential). Excellent intra- and inter-observer agreement, with kappa values > 0.8, confirmed the reproducibility of the classification system.

We describe the different surgical approaches used to excise the HO which were guided by the 3D-CT findings. Resection was always successful.

3D-CT imaging, complemented in some cases by angiography, allows the surgeon to define the 3D anatomy of the HO accurately and to plan its surgical excision with precision.

Cite this article: Bone Joint J 2015; 97-B:899–904.

Aims

The aims of this study were to measure sagittal standing and sitting lumbar-pelvic-femoral alignment in patients before and following total hip arthroplasty (THA), and to consider what preoperative factors may influence a change in postoperative pelvic position.

Aim

The primary aim of this retrospective study was to identify the incidence of heterotopic ossification (HO) following elective and trauma elbow arthroplasty. The secondary aim was to determine clinical outcomes with respect to the formation of heterotopic ossification.

Aims

The aim of this study was to report the mid-term clinical outcome of cemented unlinked J-alumina ceramic elbow (JACE) arthroplasties when used in patients with rheumatoid arthritis (RA).

Aims

The purpose of this study was to compare the clinical and radiographic outcomes of total ankle arthroplasty (TAA) in patients with pre-operatively moderate and severe arthritic varus ankles to those achieved for patients with neutral ankles.