A boy aged three with indifference to pain was followed up until his death from amyloid disease some twenty-one years later. A full necropsy was done and the neuropathology suggested a sensory neuropathy.

1. The fibrillar networks of adult human articular cartilage, taken from femoral and acetabular specimens, have been systematically examined by scanning electron microscopy. The internal structures revealed by rupturing the tissue were compared with published findings from transmission electron microscope studies.

2. Though this technique demonstrated the internal fibrillar appearance of cartilage to a remarkable degree, it had several attendant limitations. On final drying, specimens generally exhibited shrinkage which varied within wide limits; this could have altered the internal architecture to some extent. In addition, the rupturing technique, which at the time of this investigation was the only satisfactory method of revealing the fibrillar cartilage structure, may well have had a great influence on the fibril orientations.

3. The fibrils revealed no characteristic collagen periodicity and were considerably thicker than those observed by transmission electron microscopy. It is suggested that a coating of mucin on the collagen fibrils might account for this.

4. At low magnifications the torn layers in the fractured surfaces extended radially from the calcified zone and turned obliquely at or near the articular surface to merge with the distinctly layered superficial zone, thus forming arcade-like structures. That these were not artefacts produced by the fracturing technique was shown by their similarity to the classical arcade pattern of light microscopy. However, the factor which governed the direction of these planes of weakness, be it collagen, mucopolysaccharides or cells, could not be satisfactorily determined.

5. At higher magnifications only three regions of distinct fibrillar organisation could be identified: 1) a surface layer consisting of a random fibrillar network; 2) a superficial zone composed of layers of fibrillar network, intersecting and overlapping in planes parallel to the surface; and 3) elsewhere below the superficial zone a network of virtually random fibrils which extended to the calcified region with apparently little variation in thickness or density. There was little variation from this pattern even in aged fibrillated specimens.

6. At the lower magnification range the scanning electron microscope has revealed the arcade pattern described by light microscopy, while at the higher magnifications the fibrillar organisation as seen by scanning electron microscopy correlated well with the concepts developed by transmission electron microscopy, that is, a random network of fibrils overlaid at the articular surface by a membrane-like system of bundled fibrils.

7. A possible role in the transmission of joint forces is outlined for the above fibrillar organisation.

We report a prospective study of 55 patients with acute primary patellar dislocation, all treated by operation and followed up for at least two years. Diagnosis was based on the history of a lateral displacement, with medial tenderness and a positive apprehension test; redislocations were excluded. Before operation, the difference in lateral shift on skyline views of the injured and control patellae was highly significant. At operation, rupture of the medial retinaculum of the patella was seen in all but one case. There were medial marginal fractures of the patella in 23 cases. Subjective results of the operation were excellent or good in 44 of the 55 at two years with a redislocation rate of only 9%. Most patients were able to return to the same level of sporting activity as before the injury.

Electromyographic and clinical studies were performed on patients undergoing total hip replacement by the modified direct lateral (29 hips), the direct lateral (29 hips) and the posterior approaches (21 hips). Assessments were made three months after operation. The Trendelenburg test was positive (Grade II) in eight cases operated upon by the direct lateral route, but in only one of each of the other two groups. Denervation occurred in only five of the 28 hips with abductor weakness without statistical difference between the groups. In the modified direct lateral group, radiological evidence of union of the trochanteric sliver was associated with significantly better abductor function than in those with malunion or non-union.

A retrospective study of 260 industrial amputees was undertaken to determine the long-term functional results of partial foot amputations following trauma. Follow-up ranged from 1 to 68 years with a mean of 16 years. Of 113 partial foot amputees (118 amputations) who had retained their original amputation, the functional end-results were 43% good, 38% fair and 19% poor. Lisfranc and Chopart amputations were better than those at transmetatarsal or digital levels. Of 260 initial amputations 49 (19%) were revised to a Syme's or a below-knee amputation.

A prospective study was made over a three-year period of 900 consecutive unilateral Colles' fractures. The radiographic features at the time of fracture, after reduction and one week later were measured and correlated with grip strength and range of movement at three years. The most significant radiographic feature to influence the outcome was the presence of shortening of the radius one week after reduction of the fracture. Persistent dorsal tilt, radiocarpal joint involvement and ulnar styloid fracture were each associated with reduced range of movement, but had no effect on grip strength. Extension of the fracture into the distal radio-ulnar joint was associated with reduced grip strength but had no effect on range of movement. Radial tilt of the radial fragment did not correlate with any aspect of the result after three years.

The clinical and pathological findings in a case of early avascular necrosis of the femoral head following renal transplantation are described. Regions of subchondral bone distant from the principal lesions showed increased numbers of empty osteocytic lacunae. This has been quantified and it is suggested that a loss of osteocytes is perhaps one of the earliest lesions leading to established avascular necrosis.

Idiopathic osteolysis is characterised by a spontaneous onset without previous causative factors, followed by rapid destruction and resorption of the involved bones. This process can result in severe deformities with joint subluxation and instability. In certain forms an associated malignant nephropathy may develop. A case report is presented which illustrates the destructive nature of the process.

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)

Eighteen patients with acute dislocation of the patella had associated osteochondral fractures. This fracture complicates approximately 5% of all acute dislocations of the patella occurring in children. Three types of fracture patterns were noted. All patients who were treated by immediate arthrotomy and excision or replacement of the osteochondral fragment and repair of the acute dislocation of the patella made an uneventful recovery with no recurrence of the dislocation. In those patients in whom the osteochondral fragment was removed but with no repair the dislocation recurred.

We treated 39 patients with fractures of the humeral shaft by closed retrograde locked intramedullary nailing, using Russell-Taylor humeral nails. The mean healing time of all fractures was 13.7 weeks. After consolidation, shoulder function was excellent in 92.3% and elbow function excellent in 87.2%. Functional end-results were excellent in 84.6% of patients, moderate in 10.3% and bad in 5.1%. One patient had a postoperative radial nerve palsy, which recovered within three months. There was additional comminution at the fracture site in three patients (7.7%) which did not affect healing, and slight nail migration in two older patients (5.1%). Two patients (5.1%) needed a second procedure because of disturbed fracture healing. One screw breakage was seen in a patient with delayed union. Retrograde locked humeral nailing appears to be a better solution for the stabilisation of fractures of the humeral shaft than anterograde nailing or plate and screw fixation. We found the complication rate to be acceptable and shoulder and elbow function to recover rapidly in most cases.

The Norwegian Arthroplasty Register recorded 24,408 primary total hip replacements from 1987 to 1993; 2907 of them (13%) were performed with uncemented femoral components. We have compared the results of eight different designs, each used in more than 100 patients. Survivorship of the components was estimated by the Kaplan-Meier method using revision for aseptic loosening of the femoral component as the end-point. At 4.5 years, the estimated probability of revision for aseptic loosening for all implants was 4.5%, for the Bio-Fit stem 18.6% (n = 210) and for the Femora stem 13.6% (n = 173). The PM-Prosthesis and the Harris/Galante stem prostheses needed revision in 5.6% and 3.6%, respectively. The clockwise threaded stem of the Femora implant needed revision in 20% of right hips, but in only 4% of left hips. The short-term results of the four best uncemented femoral components (Corail, LMT, Profile and Zweimuller) were similar to those for cemented stems, with revision for loosening in less than 1% at 4.5 years. The importance of the control of innovative designs and the registration of early results is discussed.

In the literature 21 children have been reported with haematogenous osteomyelitis involving only the epiphyses of long bones; in 20 the epiphyses of the knee were involved and the radiographs showed a lytic lesion. Most patients gave a history of pain, limp or refusal to walk for weeks or months without general illness. The erythrocyte sedimentation rate and white cell count were of little diagnostic value, but a bone scan was usually positive. All the patients were cured by antibiotics alone or in combination with curettage.

For equinus deformity in spastic hemiplegia, correction by the White slide technique has been studied in a group of 35 patients followed up for 14 to 20 years. It is a simple, effective method of lengthening the calcaneal tendon, and is free from significant complications with an acceptable rate of recurrent deformity. The majority of patients achieved a heel-toe gait.

The modified Magnuson-Stack procedure of lateral and distal transfer of the insertion of the subscapularis muscle was used in 38 consecutive patients with recurrent anterior dislocation of the shoulder, all of whom have been followed-up for a minimum of three years. There was only one failure; the other 37 patients had an excellent or satisfactory result with an adequate range of movement. Bankart and Hill-Sachs lesions were not a constant finding but subscapularis laxity was detected in almost every case, an observation that helps to confirm its central role as a cause of recurrence.

Seventy resistant club feet in 46 patients were treated within the first six months of life by posterior release as an incident in continuing conservative care and were later assessed at an average age of 15 years. Assessment was made upon strict clinical criteria, including appearance, function and degree of pain during activity; the results were excellent in 22 feet, good in 19, and poor in 29. We also studied the correlation between the radiographs and the final outcome. From these data we propose certain indications for the timing and technique of this type of management, and also discuss the relative merits of this approach compared with more conventional radical release operations.

Five patients with long-standing, severe rheumatoid arthritis who developed cervical myelopathy at the subaxial levels are presented. In each patient the myelopathy occurred in the absence of major subluxation. At laminectomy the cause of the cord compression was found to be a band-like mass of ligamentous and granulation tissue in the posterior half of the extradural space, extending to the underlying portion of the dura and forming a constricting ring. In three patients this constricting ring was released by longitudinal division of the dura followed by application of a fascial patch graft. This release seems to be essential for effective decompression of the cord and good neurological recovery was achieved in these three patients. Of the other two patients, the result was fair in one and poor in the other, this latter result being due to severe intra-operative bleeding with a massive wound haematoma.

Thirty years' experience of excision of the trapezium for osteoarthritis of the trapeziometacarpal joint has shown that this simple operation is entirely satisfactory.

1. In a series of one hundred personal cases of "painful shoulder" rupture of the musculotendinous cuff was proved by operation in eighteen cases and was presumed in eight further cases, namely, in about one quarter of the series.

2. Of the eighteen cases treated by operation through the transacromial approach, perfect results were obtained only in four. The other results were unsatisfactory. In five, movement was good but there was pain or weakness of the limb. In nine the condition was unaltered or made worse.

3. Conservative treatment of traumatic lesions of the supraspinatus tendon is therefore advocated. The advisability of rest of the shoulder joint in an abduction splint for five or six weeks is stressed. Operative exposure, through a transacromial approach, is recommended only when conservative measures have failed.

4. When there is rupture of the cuff there is evidence that simple longitudinal suture of the gap after freshening of the margins is likely to give better results than attempts to suture the medial end of the rupture to the greater tuberosity. Most ruptures have a longitudinal extension of the initial transverse tear, and direct suture of the medial edge of the gap to the greater tuberosity may lead to shortening of the tendon and interference with its function.

5. Ruptures of the supraspinatus tendon may cause no symptoms, lead to complete loss of function, or cause a painful arc of movement during mid-elevation. The clinical state depends upon whether or not the condition of the ruptured tendon is causing pain, and whether the other short rotator muscles of the shoulder can compensate in tensor and fixator actions for the loss of action of the supraspinatus.

6. Capsulitis is a convenient term by which to describe inflammatory lesions of the capsule and bursae around the shoulder joint. The initial stage of irritative capsulitis may develop to the later stage of adhesive capsulitis. Differentiation is important because treatment in the first stage is by rest, and in the second by manipulation and exercise.

7. The subdeltoid bursa is the "peritoneum" of the spinatus tendons; like the peritoneum it shares the pathology of the organs it protects and is itself seldom the site of primary pathological processes.

8. The management of the "frozen shoulder," whether loss of movement is protective or adhesive, calls for time and patience but the ultimate outlook is good.