1. Nine out of ten patients who undergo McMurray osteotomy may expect lasting relief of pain. Seventy-five per cent should have a satisfactory functional result. It is rare for a patient to be made worse. 2. Osteoarthritis of the hip and ununited fracture of the femoral neck are good reasons for operation; avascular necrosis after fracture is not. 3. Internal fixation shortens the time in plaster and in hospital, and reduces the incidence of stiffness of the knee. 4. The common observation that the joint space may be increased after osteotomy is due often to the altered position of the femoral head. Occasionally there occurs a true increase in joint space, presumably indicating regeneration of articular cartilage, and an accompanying regression in the changes of osteoarthritis

Objectives

Previously, we reported the improved transfection efficiency of a plasmid DNA-chitosan (pDNA-CS) complex using a phosphorylatable nuclear localization signal-linked nucleic kinase substrate short peptide (pNNS) conjugated to chitosan (pNNS-CS). This study investigated the effects of pNNS-CS-mediated miR-140 and interleukin-1 receptor antagonist protein (IL-1Ra) gene transfection both in rabbit chondrocytes and a cartilage defect model.

We reviewed, retrospectively, 13 patients who had undergone open anterograde autologous bone grafting of the talus for symptomatic osteochondral defects of the dome of the talus. The mean age of the seven men and six women was 38.4 years. The defects included the full thickness of articular cartilage, extended through the subchondral plate and were associated with subchondral cysts. Six patients (46%) were clinical failures requiring further surgery. Of the remaining seven, functional outcome results were obtained at a mean of 51.9 months after surgery. The mean outcome scores for the Musculoskeletal Outcomes Data Evaluation and Management System foot and ankle questionnaire and the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale were 87.0 and 84.3, respectively. There was an overall 46.2% patient satisfaction rate. We believe that the technique of autologous bone grafting presented should be used with extreme caution, when considered as the primary treatment for the adult patient with a symptomatic advanced osteochondral defect of the talus

1. Degenerative arthritis has been produced consistently in adult rabbits by the injection of the proteolytic plant enzyme papain into the hip joint. Arthritic changes were recognisable radiographically after six weeks. 2. A progression of changes occurred, from loss of acid mucopolysaccharide staining in the matrix, fibrillation, fissuring and erosion of articular cartilage with death of chondrocytes in the weight-bearing areas, to secondary bony changes of subchondral sclerosis, occasional cysts and osteophyte formation. 3. Synovial inflammation occurred with accumulation of cartilage and bone debris in the inferior capsule and later capsular thickening. 4. It is suggested that this arthritis is sufficiently similar to human osteoarthritis to be useful as a model for further studies of the pathogenesis of the disease and the effects of different methods of treatment

1. Grafts of joint cartilage from immature lambs were used to repair articular cartilage defects in other lambs and in adult sheep. 2. Stability of these grafts in a functional state was found in most for periods up to fourteen months. Although a limited homograft reaction occurred this did not lead to destruction of the cartilage, even though parts of it were well vascularised. 3. The results suggest that the process of endochondral ossification is associated with the liberation of antigenic material leading to sensitisation of the host. Destruction ofthe cartilage is prevented by an inhibitory action which the matrix appears to exert on the destructive elements themselves and which is itself dependent on the vitality of the chondrocytes. 4. The avascularity of cartilage is not a sufficient explanation for its privileged position in relation to the homograft reaction

1. The source of nutrition of articular cartilage still remains a subject of controversy. 2. Experiments are described in which an attempt to demonstrate the direct transfer of fluid from the subchondral bone has been made using 355 and an autoradiographic technique. These experiments were based on ones originally performed by Ekholm (1951), except that two distinct groups of animals were used : immature rabbits and adult rabbits whose skeletons were mature. 3. The transfer of fluid to the cartilage could be demonstrated only in the immature rabbits. 4. It is suggested that some of the conflicting opinions which have been advanced on this subject stem from a failure to distinguish between mature and immature joint cartilage. Subchondral nutrition is a feature only of the immature animal

1. The form and distribution of the blood vessels within the adult human femoral head are described. 2. It has been found possible to delimit the proximal femoral epiphysis in mature years by reference to arterial form alone. 3. Two morphologically different sets of vessels are described interposed between the arterioles and venules of the bone marrow. One, a true capillary bed, lies mainly within the fat marrow; the other, constituted by sinusoids, lies within the red marrow. The departure of these findings from current views is noted. 4. A capillary system is described in relationship to the calcified zone of the articular cartilage. 5. No evidence has been found in support of the common belief that the circulation within the femoral head decreases quantitatively with advancing age

We assessed arthroscopically 22 young athletes with an isolated acute posterior cruciate ligament (PCL) injury. Four had significant damage to the articular cartilage of the medial femorotibial compartment and were advised not to resume sports. Three underwent PCL reconstruction because of a reparable meniscal tear or instability. The other 15 were treated conservatively and resumed sport. At an average follow-up of 51 months, one had developed arthritic symptoms due to newly-developed severe chondral damage to the medial femoral condyle, but none of the other 14 had developed arthritic symptoms and most remained athletically active. Severe chondral damage should be seen at an early arthroscopy. Knees with an isolated injury to the PCL with concomitant articular damage may be successfully managed by conservative treatment

A new technique of shoulder fusion is presented using a posterior approach. After removal of the articular cartilage, a Rush pin is introduced from the spine of the scapula, through the glenoid into the medullary canal of the humerus. This is supplemented by tension-band wiring from the acromion to the neck of the humerus and a muscle pedicle graft attached to the acromion. A shoulder spica is applied for four to six weeks. Four patients with injuries to the upper brachial plexus and 14 with paralysis of the upper arm due to anterior poliomyelitis have been followed for three years. One of the 18 patients developed nonunion; she had removed her own cast prematurely. This method of fixation provides high shear resistance and low axial stiffness without deforming plastically. It does not affect bone growth in young patients, is effective in patients with osteoporosis, and gives a high rate of union

Destruction of the articular cartilage is the first change seen on gross examination of the knee in osteoarthritis. Weight-bearing radiographs are conventionally taken with the knee in full extension. Biomechanical studies have shown, however, that the major contact stresses in the femorotibial articulation occur when the knee is flexed about 28 degrees. Arthroscopy has confirmed that cartilage loss occurs in a more posterior portion of the femoral condyles than is revealed by radiographs taken in full extension. The 'standing tunnel view' is a weight-bearing postero-anterior radiograph taken with the knee in 30 degrees of flexion. The radiographs of 64 patients have been used to compare the conventional with the standing tunnel view. In 10 knees in which the conventional view suggested normal cartilage the standing tunnel view revealed severe degeneration

A biomechanical study has been carried out on 20 cadaveric knees to investigate their load-absorbing mechanism. The impact load was applied using a weight falling onto the transected proximal femur and the force transmitted through the knee was measured at the transected distal tibia using a load transducer. The peak force transmitted increased as, sequentially, meniscus, articular cartilage and subchondral bone were damaged or removed. The most striking result was found in an implanted knee replacement where the transmitted force reached 180% of that in the intact knee. The results show that the joint has an impact-absorbing property in each segment and that in the osteoarthritic knee there is less absorption of shock than in the normal knee. The high impact force in an implanted knee suggests that microfractures of the cancellous bone might be expected and may produce loosening

Patellofemoral joint degeneration is often considered a contraindication to medial unicompartmental knee replacement. We examined the validity of this preconception using information gathered prospectively on the intra-operative status of the patellofemoral joint in 824 knees in 793 consecutive patients who underwent Oxford unicondylar knee replacement for anteromedial osteoarthritis. All operations were performed between January 1998 and September 2005. A five-point grading system classified degeneration of the patellofemoral joint from none to full-thickness cartilage loss. A subclassification of the presence or absence of any full-thickness cartilage loss was subsequently performed to test selected hypotheses. Outcome was evaluated independently by physiotherapists using the Oxford and the American Knee Society Scores with a minimum follow-up of one year. Full-thickness cartilage loss on the trochlear surface was observed in 100 of 785 knees (13%), on the medial facet of the patella in 69 of 782 knees (9%) and on the lateral facet in 29 of 784 knees (4%). Full-thickness cartilage loss at any location was seen in 128 knees (16%) and did not produce a significantly worse outcome than those with a normal or near-normal joint surface. The severity of the degeneration at any of the intra-articular locations also had no influence on outcome. We concluded that, provided there is not bone loss and grooving of the lateral facet, damage to the articular cartilage of the patellofemoral joint to the extent of full-thickness cartilage loss is not a contraindication to the Oxford mobile-bearing unicompartmental knee replacement

Osteoarthritis of the medial compartment of the knee often shows a specific pattern of anterior wear. Review of our revisions from a series of medial metal-backed Brigham unicondylar knee replacements performed between 1983 and 1989 showed that this wear pattern was common on the tibial polyethylene surface. We reviewed these cases retrospectively to compare the pattern of preoperative erosion with the wear of the prosthesis. In all 14 knees with severe anterior wear in a unicompartmental replacement, the prearthroplasty radiographs showed similar patterns, suggesting that the implanted tibial component may continue to be subjected to the same localised stresses that precipitated the failure of the original articular cartilage. Many tibial components implanted during the 1980s had an unacceptably thin anterior rim of polyethylene and it seems that greater thickness is essential at the anterior and peripheral margins of the tibial plateau

We have carried out a prospective, longitudinal 30-year review of 95 adolescents who underwent total meniscectomy in one knee, and have compared the results with those observed 13 years earlier. All the medical records were scrutinised. Of the 63 patients reviewed clinically, 47 reported decreased sporting activity, although subjective satisfaction rose by 3% to 71%. The scores on the WOMAC osteoarthritis index differed significantly between patients grouped by subjective global assessment. Satisfactory function scores increased from 48% to 60%. In the 53 patients consenting to bilateral radiography of the knee, the incidence of narrowing of the articular cartilage in the operated knee increased significantly between the reviews (19% to 36%). Progression of degenerative change paralleled reduction in activity. Outcome measures were best after medial, intermediate after lateral and worst after double meniscectomy

To study the anatomy of subarticular bone and cartilage, fresh specimens of cartilage on bone from the human shoulder, hip and knee were treated with bleach or papain, or were fixed and decalcified. All were compared using scanning electron microscopy. Papain digestion selectively removed cartilage to the tidemark. The tidemark contour was highly variable; irregularities were indirectly related to degenerative lesions and were most prominent in peripheral non-weight-bearing areas of joints with central fibrillation. Decalcification exposed the interface between the bone and calcified cartilage. Collagen fibrils in articular cartilage did not interdigitate with those of bone. The subchondral bone was appositional, avascular, smooth and very thin in most areas of human joints. Perforations through subchondral bone or calcified cartilage were rare. Bleach maceration destroyed important details

Two distinct lesions affect the articular cartilage of the patella. Surface degeneration occurs particularly on the odd facet; it is age dependent, often present in youth and it becomes more frequent with increasing age. It probably does not occasion patello-femoral pain in youth, but may predispose to degenerative arthritis in that joint in later years and is regarded as a consequence of habitual disuse. The term "basal degeneration" is used to describe a lesion in which there is a fasciculation of collagen in the middle and deep zones of cartilage without, at first, affecting the surface. It was found astride the ridge separating the medial from the odd facet in twenty-three adolescents who had complained of prolonged patello-femoral pain. They were treated by excision of the disc of affected cartilage, with relief of pain in most cases. The pathogenesis of basal degeneration is related to the functional anatomy of the patella

We examined macroscopically and microscopically 55 cadaver rotator-cuff tendons attached to their humeral heads to determine the distance between the edge of the articular cartilage and the tendon insertion of the supraspinatus (the width of the sulcus) and the score of regressive changes at the sulcus. In 33 specimens we measured the tensile strength. The width of the sulcus was correlated with the score of regressive changes and with the ultimate tensile strength of the supraspinatus tendon. The width of the sulcus correlated positively with the score of regressive changes (r = 0.66, p < 0.0001), but there was a negative correlation between the latter and the ultimate tensile strength (r = −0.81, p = 0.001) and between the width of the sulcus and the ultimate tensile strength (r = −0.74, p = 0.004). We believe that the width of the sulcus is a simple and useful clinical indicator of the integrity and the tensile strength of the supraspinatus tendon

We have investigated the factors which affect the progression of osteoarthritis after rotational acetabular osteotomy (RAO). Between 1984 and 1998, we treated 60 dysplastic hips by RAO. The mean age at surgery was 31.6 years (13 to 51) and the mean period of follow-up was 4.6 years (2 to 9.5). The thickness of the articular cartilage on the weight-bearing area, pre- and postoperative acetabular cover, and the sphericity of the femoral head were used for radiological assessment. The osteoarthritis did not progress in 39 hips. Significant factors which affected the radiological grade included sphericity of the femoral head and the postoperative acetabular cover. The surgical approach and preoperative acetabular cover did not affect the progression of osteoarthritis. Patients were divided into two groups according to the surgical approach used, either conventional (23 hips) or modified (37 hips). Significant factors included the postoperative acetabular cover in the modified approach, and the sphericity of the femoral head in the conventional approach. It is critical that the postoperative cover is sufficient, especially when RAO is carried out using our modified technique

We have developed a novel, two-layered, collagen matrix seeded with chondrocytes for repair of articular cartilage. It consists of a dense collagen layer which is in contact with bone and a porous matrix to support the seeded chondrocytes. The matrices were implanted in rabbit femoral trochleas for up to 24 weeks. The control groups received either a matrix without cells or no implant. The best histological repair was seen with cell-seeded implants. The permeability and glycosaminoglycan content of both implant groups were nearly normal, but were significantly less in tissue from empty defects. The type-II collagen content of the seeded implants was normal. For unseeded implants it was 74.3% of the normal and for empty defects only 20%. The current treatments for articular injury often result in a fibrous repair which deteriorates with time. This bilayer implant allowed sustained hyaline-like repair of articular defects during the entire six-month period of observation

We have divided Severin group-V severely dysplastic hips with a false into three subtypes, based on the height and shape of the socket. We performed rotational acetabular osteotomy (RAO) in 19 hips in 17 young adults with a type-1 ‘low’ false acetabulum which had direct contact with the true acetabulum. This is a periacetabular osteotomy which gives acetabular coverage with articular cartilage and produces a nearly normal position of the head. Concomitant osteotomies of the proximal femur were carried out in 11 hips. We reviewed the patients clinically and radiologically at a mean of ten years (6 to 18) after operation. Of the 19 hips, 15 showed very good or good results. This operation is indicated in young adults with a dysplastic hip and a type-1 low false acetabulum. Subclassification of Severin group V is a convenient way of defining those patients who would benefit from the procedure