Surgical exposure of the ankle is usually obtained by an anterior approach, especially for replacement arthroplasty. The transfibular approach has been popular for arthrodesis. We describe a new posterior approach to the ankle and posterior subtalar joint based on an extra-articular vertical calcaneal osteotomy behind the subtalar joint. The posterior flap so formed is hinged medially and offers wide exposure of the back of the ankle and posterior subtalar joint. This hinge allows safe and stable reduction of the osteotomised calcaneum, and the plane of dissection follows an ‘internervous plane’ behind the fibula. We have had good results after using this incision in 12 patients with osteoarthritis or rheumatoid arthritis and there have been no difficulties with wound healing

1. A study is presented of 286 extra-articular subtalar arthrodeses done during the years 1958 to 1965 on 258 patients with pes calcaneo-valgus, pes planovalgus, pes varus or flail foot. 2. Certain changes in the surgical technique originally presented by Grice have been made. We have applied the arthrodesis not only to valgus feet but also to varus feet, and we have described the details of the surgical technique as used on the varus foot. 3. In none of our cases was there failure of fusion or reabsorption of the graft. The unsatisfactory results (239 per cent) were caused by residual varus or valgus deformity of the foot

1. Forty-five arthroplasties of the knee with the Walldius prosthesis are reported in forty-two patients, thirty-seven with rheumatoid arthritis and five with osteoarthritis. 2. There has been no structural failure of the prosthesis. 3. Sepsis required removal of the prosthesis in three cases, but arthrodesis was obtained in two of the three. 4. Serious loosening of the prosthesis occurred in one case only. Varus deformity occurred in one patient. 5. Radiological evidence of some movement of the prosthesis was present in six other cases but this did not seem to affect function. 6. It is concluded that this operation has a place in the treatment of the more seriously disabled patient, but should not be used when heavy demands are likely to be made on the joint

After brachial plexus injuries, and other forms of paralysis of the upper limb, even when residual paralysis is very grave indeed, and even when the limb is almost flail—a forearm which can project forwards by the construction of a bone-block behind the elbow, with arthrodesis of the shoulder when necessary; a hand with fingers in the form of a claw and a thumb which opposes them; and a wrist which may perhaps be arthrodesed, but which still better can flex or extend when the forearm is pronated or supinated; together with the wise use of such muscles as are likely to gain function; may enable a patient to do very much more than he can with an artificial limb

Aims

Cigarette smoking has a negative impact on the skeletal system, causes a decrease in bone mass in both young and old patients, and is considered a risk factor for the development of osteoporosis. In addition, it disturbs the bone healing process and prolongs the healing time after fractures. The mechanisms by which cigarette smoking impairs fracture healing are not fully understood. There are few studies reporting the effects of cigarette smoking on new blood vessel formation during the early stage of fracture healing. We tested the hypothesis that cigarette smoke inhalation may suppress angiogenesis and delay fracture healing.

We studied the natural history of Perthes’ disease in 62 children in whom the onset of symptoms was in adolescence. Three patterns of disease were noted, namely, late-onset pattern, segmental collapse, or destructive with failure of revascularisation. In the late-onset pattern, the disease followed the sequence of healing seen in younger children, but adequate epiphyseal remodelling did not occur. Consequently, the femoral head was never spherical after revascularisation. With segmental collapse, early and irreversible collapse of part of the epiphysis occurred with gross deformation of the femoral head. The destructive pattern was characterised by a failure of revascularisation and repair of the avascular epiphysis. The radiological outcome was poor in all three patterns. The poorest clinical results were found in the destructive type which was frequently associated with incapacitating pain requiring arthrodesis or excision arthroplasty within three years of onset of the disease

1 . Thirty-six patients with complete irrecoverable brachial plexus lesions have been studied. 2. Function has been compared after 1) arthrodesis of the shoulder with amputation through the arm, 2) so-called reconstructive procedures, and 3) no operative treatment. 3. The results of reconstructive operations have been so disappointing that we believe that this type of treatment should be abandoned. 4. Amputation-arthrodesis offers a better functional result than either reconstruction or no operation. Its value depends to a considerable extent on the manual dexterity of the patient. 5. A clerical worker who is not mechanically minded is less likely to use an artificial limb, and in this type of patient operation is perhaps best avoided

1. A medial approach is preferred for arthrodesis of the wrist in reconstructive surgery because there is no interference with the extensor tendons. 2. The value of pre-operative assessment by a trial period in plaster is mentioned. 3. The technique of operation is described. 4. In the absence of active pronation, screwing the ulna to the radius in 45 degrees of pronation is advised. 5. The necessity for securing haemostasis before closing the wound is emphasised. 6. Thirty-four cases are reviewed. The shortest follow-up was one year and the longest twelve years. The result was satisfactory in all cases. Most patients were discharged from hospital after the plaster had been changed two weeks after operation. Union occurred in about sixteen weeks

We reviewed 33 children with tuberculosis of the knee treated during the period from 1979 to 1991. All were treated with triple chemotherapy, using rifampicin, isoniazid and pyrazinamide for nine months. No patient had a synovectomy; surgery was limited to open biopsy or salvage procedures such as posterior release and arthrodesis for late stages of the disease. The radiological appearance of the knee at presentation predicted the outcome. The 30 patients with stage-1 (normal) or stage-2 (osteomyelitic) disease had excellent or good results; the three with narrowed joint spaces in stage 3 or stage 4 (arthritic) had fair or poor results. Early active mobilisation, as against long-term immobilisation, seemed to have no effect on the outcome of stage-1 or stage-2 disease

Our study establishes a rabbit model of disc degeneration which requires neither a chemical nor physical injury to the disc. Disc degeneration similar to that seen in man was created at levels proximal (L4-L5) and caudal (L7-S1) to a simulated lumbar fusion and was studied for up to nine months after arthrodesis. Loss of the normal parallel arrangement of collagen bundles within the annular lamellae was observed in intervertebral discs adjacent to the fusion at three months. By six months there was further disorganisation as well as loss of distinction between the lamellae themselves. By nine months the structure of the disc had been replaced by disorganised fibrous tissue, and annular tears were seen. There was an initial cellular proliferative response followed by loss of chondrocytes and notochordal cells in the nucleus pulposus. Degeneration was accompanied by a decrease in the monomer size of proteoglycans. Narrowing of the disc space, endplate sclerosis and the formation of osteophytes at adjacent disc spaces were observed radiologically

Osteoarthritis of the wrist is a complication of a number of common traumatic conditions. Arthrodesis of the radiocarpal joint, proximal row carpectomy and excision of the scaphoid, combined with midcarpal arthrodesis, have all been reported as surgical options. There have been no randomised studies comparing these procedures, and the feasibility of conducting this type of trial is limited. We used decision analysis to compare the three surgical techniques. The variables for the model used were based principally on data from the literature. Extensive sensitivity analyses were carried out to test the impact of the values given to these variables on the outcome of the model. The model indicated that the preferred treatment is proximal row carpectomy. Decision analysis allows a comparison between alternative treatments, when evidence from a randomised trial is lacking or unobtainable. The decision-analysis model may also provide insight into aspects of a problem which would be difficult, or impossible, to evaluate by a cohort study

Shoulder arthrodesis is often used to treat flail shoulder after a brachial plexus injury, but has a high complication rate and entails loss of passive mobility. We have reviewed 27 patients with brachial plexus injury treated by transfer of the trapezius to the proximal humerus at an average time from injury of 31.3 months. Pre-operatively, all 27 shoulders were subluxated, with an average abduction of 3.5 degrees. Postoperatively, shoulder abduction averaged 45.4 degrees, and subluxation was abolished. All patients were satisfied with their improvement in function. Trapezius transfer is recommended as a simple procedure that requires only a brief period in hospital, allows early rehabilitation, and gives a satisfactory outcome, while retaining passive mobility of the shoulder

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

Aims

Total ankle arthroplasty (TAA) has become the most reliable surgical solution for patients with end-stage arthritis of the ankle. Aseptic loosening of the talar component is the most common complication. A custom-made artificial talus can be used as the talar component in a combined TAA for patients with poor bone stock of the talus. The purpose of this study was to investigate the functional and clinical outcomes of combined TAA.

Aims

The modified Dunn procedure has the potential to restore the anatomy in hips with severe slipped capital femoral epiphyses (SCFE). However, there is a risk of developing avascular necrosis of the femoral head (AVN). In this paper, we report on clinical outcome, radiological outcome, AVN rate and complications, and the cumulative survivorship at long-term follow-up in patients undergoing the modified Dunn procedure for severe SCFE.

We have reviewed at an average period of ten years the results of 71 consecutive primary arthroplasties with the Insall-Burstein total condylar knee prosthesis in patients with rheumatoid arthritis. Their mean age at surgery was 52 years (24 to 72). At follow-up the overall results (Hospital for Special Surgery knee rating score) were excellent or good in 77%, fair in 11% and poor in 11%. There was residual pain in only 5% of patients with prostheses in situ; 58% could walk more than 500 m, and the median range of motion was 108 degrees. Eight knees had been revised. Five underwent arthrodesis because of deep infection and three needed revision arthroplasty for mechanical loosening. The crude survival rate of the arthroplasties was 89%. The presence of radiolucency around the tibial component correlated significantly with the severity of residual pain

We have examined whether the rotatory subluxation of the scaphoid which is seen in patients with advanced Kienböck’s disease is associated with scapholunate advanced collapse (SLAC) wrist. We studied 16 patients (11 men, 5 women) who had stage-IV Kienböck’s disease with chronic subluxation of the scaphoid. All had received conservative treatment. The mean period of affection with Kienböck’s disease was 30 years (14 to 49). No wrist had SLAC. In eight patients, 24 years or more after the onset of the disease, the articular surface of the radius had been remodelled by the subluxed scaphoid with maintenance of the joint space. The wrists of six patients were considered to be excellent, nine good, and one fair according to the clinical criteria of Dornan. Our findings have shown that rotatory subluxation of the scaphoid in Kienböck’s disease is not a cause of SLAC wrist and therefore that scaphotrapezio-trapezoid arthrodesis is not required for the management of these patients

After severe poliomyelitis, which is still relatively common in some developing countries, lateral rotation deformity of the tibia may occur. We have reviewed 51 patients treated by O'Donoghue's rotation osteotomy of the tibia. An average lateral rotation deformity of 57 degrees was fully corrected in all the patients, and in 38 of them the graft obtained during the osteotomy was used for a simultaneous Grice-Green subtalar arthrodesis in one or both feet. All the osteotomies united in an average of 11 weeks, some with relatively minor and unintentional posterior angulation. There was no posterior angulation when the length of the step cut osteotomy was 4.5 cm or more. O'Donoghue's osteotomy is a simple and safe operation, being particularly advantageous if a Grice-Green procedure is also required

We have reviewed the results of 106 intertrochanteric osteotomies performed for osteonecrosis of the femoral head. The average age at operation was 47.5 years. At two years from operation 71% of the hips had a clinically satisfactory result and at final follow-up, an average of 8.2 years after operation, 58% continued to have excellent or good rating. Twenty-four hips had needed total replacement or arthrodesis because of pain. Patients aged less than 55 did better than those operated on after that age, and hips with an idiopathic or post-traumatic aetiology did considerably better than alcohol-induced or steroid-induced cases. In view of these findings we believe that in the younger adult, in the absence of metabolic bone disease or advanced joint destruction, intertrochanteric osteotomy should be considered for the treatment of osteonecrosis

1. A modification of the McLaughlin technique of lag screw fixation of the fractured scaphoid is described. 2. Fifty-six patients operated upon between 1956 and 1966 have been reviewed and their fractures classified under the headings recent, delayed union and non-union. 3. Plaster casts were avoided and early return to work encouraged; 95 per cent did so within two months. 4. Of twenty-two recent fractures, including three perilunar trans-scaphoid dislocations, nineteen united; of fifteen showing delayed union, eight united: and of nineteen cases of non-union, only two united. 5. The function of the wrist in the seventeen cases of persistent non-union stabilised by lag-screw was surprisingly good; only one patient has required arthrodesis to date. 6. The indications and contra-indications for the operation are discussed