We describe 74 patients with disabling instability of the knee due to isolated anterior cruciate deficiency. None responded to conservative measures or correction of internal derangements. All patients were treated by replacement of the anterior cruciate ligament with the medial third of the patellar tendon as a free graft, supplemented by an extra-articular MacIntosh lateral reconstruction. A satisfactory outcome was found in 93% of knees after an average of 70 months follow-up. Cast immobilisation after operation, the interval between injury and reconstruction, the age of the patient and the severity of symptoms before reconstruction had no significant effect on the final outcome

A six-year-old girl with congenital sensory neuropathy with anhidrosis (CSNA) presented with bilateral hip dysplasia and subluxation on the right side. Conservative treatment of the hips by closed reduction and a plaster cast was unsuccessful. When aged seven years the patient had an intertrochanteric varus rotation osteotomy on the right side, but subluxation was again evident after five months. A Salter-type pelvic osteotomy was carried out followed by immobilisation, but one year later subluxation was present in the right hip and dislocation in the left. At the age of nine years, the right femoral head resembled a Charcot joint, although walking ability was preserved. In patients with CSNA, surgery may not always be advisable

We report eight cases of fracture of the cuboid in seven children under four years of age, collected during a two-year period. There was no history of trauma in five of the patients. This fracture is rarely diagnosed and has probably been under-reported. Small children are poor historians and difficult to examine, and early radiographs may be normal or have only subtle abnormalities. Cuboid fracture should be considered in the differential diagnosis of limping toddlers, and a bone scan may be needed to confirm the diagnosis earlier than radiography. These fractures heal completely, without sequelae. Treatment in a short-leg walking cast is recommended, primarily for reasons of comfort

Aims

The consensus is that bipolar hemiarthroplasty (BHA) in allograft-prosthesis composite (APC) reconstruction of the proximal femur following primary tumour resection provides more stability than total hip arthroplasty (THA). However, no comparative study has been performed. In this study, we have compared the outcome and complication rates of these two methods.

Aims

This study is a prospective, non-randomized trial for the treatment of fractures of the medial malleolus using lean, bioabsorbable, rare-earth element (REE)-free, magnesium (Mg)-based biodegradable screws in the adult skeleton.

Hindfoot (subtalar) movement and disability after fracture of the tibial shaft have been studied. One hundred patients with soundly healed fractures of the tibial shaft treated by immobilisation in a long leg plaster cast were examined at least one year after the fracture had healed. Subtalar movement was accurately measured by a special technique and the patients were questioned specifically about any disability associated with their hindfoot. Subtalar movement was limited to some degree in 72% of patients. Forty-three per cent of patients complained of symptoms related to their subtalar joint and 12% found these symptoms troublesome

We performed a prospective, randomised trial in 39 patients with open tibial fractures treated initially by external fixation to compare cast immobilisation (group A) and intramedullary nailing (group B) as a sequential protocol planned from the onset of treatment. The results showed that group B achieved faster union (p < 0.05) than group A with less malunion or shortening and a greater range of movement. Patients treated by intramedullary nailing required fewer radiographs and outpatient visits (p = 0.0015) and had a more predictable and rapid return to full function. We feel that these severe fractures are better treated by delayed intramedullary nailing and that this has an acceptable rate of complications

Unilateral Colles' fractures in 187 patients over the age of 55 years were studied in a randomised prospective trial: 97 fractures were minimally displaced and were treated either conventionally or in a crepe bandage; 90 displaced Colles' fractures were reduced and of these 47 were treated conventionally while 43 were encouraged to mobilise the wrist in a cast which restricted extension. Early wrist movement hastened functional recovery and led to earlier resolution of wrist swelling. Discomfort was no greater than in patients who were treated conventionally. The bony deformity, which recurred irrespective of the method of treatment, was not adversely affected by early mobilisation

Aims

Infected and deformed neuropathic feet and ankles are serious challenges for surgical management. In this study we present our experience in performing ankle arthrodesis in a closed manner, without surgical preparation of the joint surfaces by cartilaginous debridement, but instead using an Ilizarov ring fixator (IRF) for deformity correction and facilitating fusion, in arthritic neuropathic ankles with associated osteomyelitis.

Forty-seven patients over the age of 55 years with a displaced fracture of the ankle were entered into a prospective, randomised study in order to compare open reduction and internal fixation with closed treatment in a plaster cast; 36 were reviewed after a mean of 27 months. The outcome was assessed clinically, radiologically and functionally using the Olerud score. The results showed that anatomical reduction was significantly less reliable (p = 0.03) and loss of reduction significantly more common (p = 0.001) in the group with closed treatment. Those managed by open reduction and internal fixation had a significantly higher functional outcome score (p = 0.03) and a significantly better range of movement of the ankle (p = 0.044) at review

We measured pressures in the anterior and deep posterior compartments continuously for up to 72 hours in 20 patients with closed fractures of the tibial shaft treated primarily in plaster casts. All were examined independently after periods of three to 14 months. Pressures above 40 mmHg occurred in seven (35%) and above 30 mmHg in 14 (70%). No patient had the symptoms of compartment syndrome during monitoring. Abnormalities at review did not correlate with the maximum consecutive time periods during which the compartment pressures were raised. Thus, in the absence of symptoms the monitored pressures did not relate to outcome. Routine monitoring in this type of patient is therefore of doubtful benefit

Twenty complex tibial deformities due to anterior poliomyelitis in 18 patients were corrected by a modified O’Donoghue osteotomy. This technique allowed correction of the deformity in three planes. This was achieved by widening the rectangular window distally to correct both rotation and valgus and by trimming the anterior edges of the step cuts to correct flexion deformity. An above-knee cast was applied for eight to 13 weeks and the patients followed up for a mean of 3.2 years. One of the 18 patients developed delayed union because of fracture of the medial limb of the step cut. The results showed excellent correction of the three-plane deformity and there was no recurrence. This method of osteotomy is a safe and simple procedure which does not require internal fixation and allows correction of torsional and angular deformity

We report a prospective study of the causes and treatment of 26 long-standing neuropathic ulcers of the foot in 21 patients. The most important causal factor, well illustrated by pressure studies, was the presence of a dynamic or static deformity leading to local areas of peak pressure on insensitive skin. All but one of the 26 ulcers had healed after an average of 10 weeks of treatment in a light, skin-tight plaster cast, with the prohibition of weight-bearing. Recurrent ulceration was prevented in all but one foot by early operation to correct the causative deformity; this was performed after the ulcer had healed and before allowing weight-bearing on the limb. Pressure studies after operation confirmed that pressure points had been relieved

The integrity of the periosteum and the interosseous membrane determine the stability of fractures of the distal ulna; this is indicated by the initial displacement. In fractures displaced by less than 50% the periosteum and interosseous membranes are largely intact; these fractures are stable and require only below-elbow immobilisation for protection and relief of pain. In fractures displaced by more than 50% the membranes are disrupted; these fractures are unstable and require above-elbow immobilisation for stability. As most fractures are displaced by less than 50%, immobilisation of the elbow, which significantly increases morbidity, is usually unnecessary. I report the results of a cadaveric study on the pathomechanics of fractures of the distal ulna, and of a prospective clinical trial in which the type of cast used for immobilisation was determined by the stability of the fracture

We carried out a randomised, prospective, multicentre clinical trial of the treatment of Colles’ fractures. A total of 339 patients was placed into two groups, those with minimally displaced fractures not requiring manipulation (151 patients) and those with displaced fractures which needed manipulation (188 patients). Treatment was by either a conventional Colles’ plaster cast (a control group) or with a prefabricated functional brace (the Aberdeen Colles’ fracture brace). Similar results were obtained in both groups with regard to the reduction and to pain scores but the brace provided better grip strength in the early stages of treatment. This was statistically significant after five weeks for both manipulated and non-manipulated fractures. At the tenth day the results were statistically significant only in manipulated fractures. There was no significant difference in the functional outcome between the two treatment groups. However, younger patients and those with less initial displacement had better functional results

We evaluated the long-term results of 109 tibial plateau fractures, 61 treated by skeletal traction and early knee movement and 48 treated by surgery, at an average follow-up of 70 months. The functional results were much the same, though meniscectomy had been performed in almost half of the surgical patients. Time in bed and duration of hospital stay were clearly shorter after surgery (p less than 0.0001). We concluded that conservative management is a valid alternative to surgery, but should probably be reserved for cases where operation is undesirable. Future studies should compare surgery without meniscectomy and conservative treatment using cast braces to reduce the time in traction

The management of an anterior supracondylar fracture by closed reduction, traction, percutaneous pinning or open reduction is seldom satisfactory, especially for adults and the aged with a lesser ability to remodel and a slower functional recovery. A new, safe, and simple technique is described in which the condylar mass is pushed posteriorly along the axis of the forearm and the hand is rotated to full supination while the elbow is held in flexion to correct deformities. Fixation is divided into two parts: the circular cast around the upper arm provides a firm buttress onto which the lower fragment is reduced and then the arm is immobilised in a plaster which includes the wrist. Four cases of delayed, comminuted, compound fractures have been fully evaluated clinically and radiologically and the results assessed as good or excellent