Twenty-seven children with progressive infantile idiopathic scoliosis have been reviewed after long-term management. Twenty-two children had single thoracic curves which were diagnosed at an early age and treated in a modified Milwaukee brace until the age of ten years when the spine was corrected and fused. The mean correction after operation was 40 per cent of the initial degree of curvature seen in early childhood before treatment. Solid spinal fusion led to a further moderate loss in correction due to bending of the fusion mass before the spine became stable several years later. Five children had double structural curves and were treated only in a brace. This provided less satisfactory control of these curves but because of the minimal cosmetic deformity, extensive spinal fusion was avoided

Aims

The first death in the UK caused by COVID-19 occurred on 5 March 2020. We aim to describe the clinical characteristics and outcomes of major trauma and orthopaedic patients admitted in the early COVID-19 era.

We have developed a simple technique for demonstrating the sagittal profile of each rotated level of a scoliotic spine and used it to determine the patterns of lordosis and kyphosis in each of six clinical types of idiopathic scoliosis. The currently accepted classification of scoliosis is inaccurate and a modification is proposed. The three main types of scoliosis were shown to have sagittal profiles distinctly different from each other and from normal. Single structural curves had short lordotic sections at their apices, limited above and below by kyphosis. Double curves showed longer lordotic sections limited only by one area of kyphosis. Lordosis throughout the thoracic and lumbar spine was associated with triple curve patterns. The biomechanical effects of the abnormal sagittal profiles provide a simple explanation for the genesis and progression of the different types of scoliosis, and the recognition of the pattern of the sagittal abnormalities permits treatment to be designed on a sound anatomical basis for individual cases

We describe 100 consecutive patients with osteoid osteoma. Of the 97 who had operations, 89 were treated by intralesional excision and eight by wide resection. The three remaining patients were not operated on because the osteoid osteoma was almost painless, or was found in the pedicle of the 12th thoracic vertebra at the site of entrance of the artery of Adamkjewicz. The diagnosis was confirmed histologically in all specimens. No local recurrences were observed at a minimum follow-up of one year. All except one patient were mobilised two to four days after surgery. A precise preoperative diagnosis of the lesion is mandatory, based on clinical findings, standard radiographs, thin-section CT and a bone scan. We compared our operative technique with 247 cases in which the percutaneous technique of removal or coagulation of the nidus had been performed. The latter procedure has a less constant rate of primary cure (83% v 100%). Its principal indication appears to be for osteoid osteomas in the proximal femur and the pelvis

Twenty young men with displaced fractures of one or more long bones in the lower limb, but with no evidence of cranial, thoracic or abdominal injury, were studied prospectively. Although all the patients became hypoxaemic, the six who developed signs of respiratory distress (Group 1) were found to have a significantly lower arterial oxygen tension and a significantly higher rate of urinary urea excretion than the remaining 14 patients whose pulmonary function appeared to be clinically normal (Group 2). Circulating fat macroglobules were identified in three cases, only one of whom was in Group 1, and hence the tests for fat embolism were not of prognostic value. Although an immunodeficient state is considered to contribute to the pulmonary insufficiency which occurs after major trauma, convincing evidence of a lymphocyte-suppressive agent was found in only one patient

Moire topography was added to school scoliosis screening in Singapore in 1982. The results from 1342 topographs, assessed in isolation, were used to study the accuracy of the method in predicting the radiographic location and magnitude of scoliotic curves. Accuracy in identifying the site of the curve was 68% in the thoracic spine, 54% in the thoracolumbar spine, and 15% in the lumbar region. There were 12.7% false-positive results and 4.3% false negatives. Of patients with a deviation of one moire fringe, 76.5% had a curve of 15 degrees or less; of those with a deviation of four moire fringes, 69% had a curve greater than 26 degrees. The prediction of the Cobb angle was less accurate when there was a deviation of two or three fringes. It is suggested that moire topography as a screening device should be reserved for use in the second tier of screening, since the forward-bending test is an effective and cheap method for the first tier of a mass school-screening programme

Aims

Spinal tuberculosis (TB) remains an important concern. Although spinal TB often has sequelae such as myelopathy after treatment, the predictive factors affecting such unfavourable outcomes are not yet established. We investigated the clinical manifestations and predictors of unfavourable treatment outcomes in patients with spinal TB.

From 1981 to 1986 we treated 413 patients for acute spinal-cord injuries. We reviewed 356 patients followed for a minimum of two years of whom 71 (20%) developed heterotopic ossification around one or more joints. Heterotopic ossification occurred more often in male patients (23%) than in female (10%), and was most frequent in the 20- to 30-year age group. It was also more common after injuries of the lower cervical or thoracic spine than after those of the lumbar spine. Patients with severe neurological deficits (Frankel grades A and B) showed significantly more heterotopic ossification but there was no correlation with the number or severity of associated head and limb injuries. Serum calcium levels did not change significantly in either group for 30 weeks after injury, but the erythrocyte sedimentation rate and the alkaline phosphatase level were significantly increased at six weeks in patients with heterotopic ossification

We report the management of two children and 11 adults with paraplegia secondary to vertebral hydatidosis. Destruction of pedicles, posterior vertebral elements and discs as well as the vertebral bodies was common and all six patients with thoracic disease had involvement of adjacent ribs. The 13 patients had a total of 42 major surgical procedures; two patients died from postoperative complications and four from complications of the disease and paraplegia. All eight patients initially treated by laminectomy or anterior decompression alone relapsed within two years and seven required further surgery. Circumferential decompression and grafting gave the best results, six of nine patients being in remission an average of three years and six months later. The prognosis for such patients is poor; remission is the aim, rather than cure. Anthelminthic drugs may improve the prognosis, but radical surgery is likely to remain the keystone of treatment in the foreseeable future

1. Forty patients with solitary eosinophilic granuloma of bone from the Hospital for Sick Children, Toronto, have been reviewed. They had clinical and laboratory findings similar to those reported by others except for the erythrocyte sedimentation rate, which was raised in nearly half the patients tested. 2. Radiographs in all cases showed the lesion to be osteolytic. In the skull and cervical spine there was no bony reaction ; in the thoracic and lumbar spine the typical picture of Calvés disease was produced; in long bones the cortex commonly showed endosteal erosion and periosteal reaction. 3. In one patient the lesion progressed so rapidly that the body of a cervical vertebra was destroyed within ten days. 4. The differential diagnosis includes sarcoma. Biopsy is essential. 5. All the patients improved regardless of the treatment they received. Complications were due either to the site of the lesion or to its treatment. 6. Expansion of the lesion after biopsy indicates a more widespread manifestation of histiocytosis X

The systemic arterial pressure has been used as a guide for determining the susceptibility to surgical bleeding during controlled hypotensive anaesthesia. Arterial hypotension is not, however, necessarily accompanied by venous or intraosseous hypotension. The main source of bleeding during posterior spinal surgery is the bone and is venous rather than arterial. The intraoperative blood loss, the intraosseous pressure (IOP) within the first thoracic vertebral body, and the systemic arterial pressure were measured in 27 patients during cervical laminoplasty for spondylotic myelopathy. The intraoperative blood loss correlated significantly with the vertebral IOP (p = 0.0073, r = 0.499), but not with systemic arterial pressure, age, or body-weight. The systemic arterial pressure did not correlate with the vertebral IOP. The mean value of the mean arterial pressure throughout the operation varied between 74 and 110 mmHg. The findings suggest that the vertebral IOP parallels surgical bleeding during posterior spinal surgery under normotensive anaesthesia and that patients with a low arterial pressure do not necessarily have a low IOP

Aims

Computer-based applications are increasingly being used by orthopaedic surgeons in their clinical practice. With the integration of technology in surgery, augmented reality (AR) may become an important tool for surgeons in the future. By superimposing a digital image on a user’s view of the physical world, this technology shows great promise in orthopaedics. The aim of this review is to investigate the current and potential uses of AR in orthopaedics.

One hundred and nine children with myelodysplasia were evaluated and classified according to the level and type of paralysis and its effect on functional ability. Thirty-one per cent of the patients were paralysed at the thoracic level, 26% at the upper lumbar level, 30% at the lower lumbar level and 13% at the sacral level. Fifty-four per cent of these patients demonstrated the classic flaccid paralysis in the lower limbs with normal upper limbs; 9% were flaccid in the lower limbs, but were spastic in the upper; 24% were spastic in the lower limbs; 13% were spastic in the upper and lower limbs. Patients with spastic lower limbs required more orthopaedic procedures, more days in hospital and in casts, and were less likely to walk than those with flaccid paralysis. Patients with spastic upper limbs were less likely to be independent in activities of daily living and were more likely to require special schools than patients with normal upper limbs. In addition to the spinal cord level of the lesion, the degree of spasticity is important in the evaluation, treatment and prognosis of myelodysplastic patients

A radiological study of 50 patients with thoracic Scheuermann's disease revealed two types of lateral spinal curvature. A total of 43 lateral curves was present in 35 of the patients. Thirteen were apical at the same level as the Scheuermann's kyphosis and were due to vertebral-body wedging in the coronal plane; these curves had a mean Cobb angle of 15 degrees, occurred with equal prevalence in boys and girls and were directed equally to right and left. Thirty curves occurred in regions of compensatory lordosis (mean 5.6 degrees) situated above or, more commonly, below the Scheuermann's kyphosis. These scolioses had a mean Cobb angle of 16 degrees, were more often convex to the right than to the left and were significantly more prevalent in girls than in boys. The presence of these kyphoses and scolioses in the same spine, separated by only a few vertebrae, emphasises the importance of the sagittal plane in idiopathic spinal deformities and strongly suggests that idiopathic scoliosis and Scheuermann's disease share a common pathological process

A girl aged ten, of Cape Coloured stock, with typical features of parastremmatic dwarfism has been investigated. The clinical manifestations included disproportionate dwarfism, limb deformity, a short stiff neck, and marked thoracic kyphosis. The radiographic changes were dramatic, the skeleton having a "flocky" appearance due to patches of radiolucency in an irregular lattice of sclerosis. The metaphyses and epiphyses of the long bones were grossly expanded, and the vertebrae were flattened and distorted. The clinical and radiographic features of five other previously reported individuals with parastremmatic dwarfism were very similar to those of our patient. The differential diagnosis of this condition includes metatrophic dwarfism, diatrophic dwarfism and the spondylo-epiphysial dysplasias. However, the unique "flocky" radiographic appearance of the bones permits diagnostic precision. There is some evidence to indicate that parastremmatic dwarfism might be transmitted as an autosomal dominant, although this is by no means certain. The fact that our patient had seven normal siblings and unaffected parents would be compatible woth autosomal recessive inheritance

Aims

Early cases of cauda equina syndrome (CES) often present with nonspecific symptoms and signs, and it is recommended that patients undergo emergency MRI regardless of the time since presentation. This creates substantial pressure on resources, with many scans performed to rule out cauda equina rather than confirm it. We propose that compression of the cauda equina should be apparent with a limited sequence (LS) scan that takes significantly less time to perform.

Spinal accessory nerve palsy leads to painful disability of the shoulder, carrying an uncertain prognosis. We reviewed the long-term outcome in 16 patients who were treated for pain, weakness of active elevation and asymmetry of the shoulder and the neck due to chronic paralysis of the trapezius muscle, as a result of nerve palsy. Of four patients who were treated conservatively, none regained satisfactory function, although two became pain-free. The other 12 patients were treated operatively with transfer of the levator scapulae to the acromion and the rhomboid muscles to the infraspinatus fossa (the Eden-Lange procedure). At a mean follow-up of 32 years, the clinical outcome of the operatively treated patients was excellent in nine, fair in two, and poor in one patient, as determined by the Constant score. Pain was adequately relieved in 11 and overhead function was restored in nine patients. Pre-operative electromyography had been carried out in four patients. In two, who eventually had a poor outcome, a concomitant long thoracic and dorsal scapular nerve lesion had been present. The Eden-Lange procedure gives very satisfactory long-term results for the treatment of isolated paralysis of trapezius. In the presence of an additional serratus anterior palsy or weak rhomboid muscles, the procedure is less successful in restoring shoulder function

1 . Young Wistar rats fed on a diet containing 0·3 per cent semicarbazide hydrochloride developed the characteristic lesions of osteolathyrism. This consisted of kyphoscoliosis, displacement of epiphyses and dislocations of joints. A pathological study of the skeletal lesions showed widening, disorganisation and tears of the epiphysial plate with the zone of maturing cartilage showing the greatest increase in width. The severe kyphoscoliosis was due to a derangement and displacement at and through the epiphysial plates of the twelfth thoracic or first lumbar vertebra. 2. Some of the compounds that are known to produce osteolathyrism in laboratory animals are beta aminopropionitrile, amino acetonitrile, mercaptoethylamine and semicarbazide. The mode of action of the lathyrogenic compounds was analysed in the light of a number of experiments done in this laboratory. 3. lt is possible that they interfere with the metabolism of the epiphysial plate. There appears to be a decreased polymerisation of the ground substance of the epiphysial cartilage, but the exact metabolic reaction involved is not known. Other chemicals of similar structure, with the same reactive groups, did not show lathyrogenic properties. It is concluded that it is not a particular chemical structure, configuration or specific reactive group that is responsible for the production of osteolathyrism. The chemistry of the lesions still remains to be solved

1. Radiography of the spines of thirty-three West African patients recently recovered or dead from tetanus revealed vertebral fractures in nineteen. These fractures occurred most frequently in the fourth to eighth thoracic vertebrae. 2. The spines of 111 Nigerians from the same area of West Africa were examined, measurement of the areas and shape of the vertebral bodies carried out, and the proportional incidence of articular shelves and laminar spicules was calculated. 3. The upper mid-thoracic vertebral bodies are relatively long and narrow and have but little greater cross-sectional area than those immediately above them; possessing no neural arch supports to sustain longitudinal compressive forces in flexion, they are at greatest hazard during tetanic spasms. 4. Analyses of these factors and of the clinical features, together with experimental observations drawn from the literature, are used to explain the prevalence of upper mid-thoracic vertebral fractures as a complication of tetanus in West Africans, and in particular the greater degree of compression and higher incidence found in children. 5. Vertebral fracture is not usually an important complication of tetanus; it causes little pain, does not prolong the illness, gives rise to no permanent disability and has no effect on the mortality