We dissected 105 cadaveric shoulders to study the origin of the tendon of the long head of biceps, and examined histologically the interrelationship between the tendon, the supraglenoid tubercle and the superior labrum of the glenoid. In all specimens approximately 50% of the biceps tendon arose directly from the superior glenoid labrum with the remainder attached to the supraglenoid tubercle. The main labral origin was from the posterior labrum in more than half of the specimens, and in a quarter this was the only labral attachment. On the basis of the biceps attachment to the anterior or posterior labrum, we distinguished four types of origin. These normal anatomical variations are significant for arthroscopic diagnosis and may help to explain the various patterns of injury seen in partial or complete detachment of the tendon, the labrum or both

This work studied the fibre bundle anatomy of the anterior cruciate ligament. Three functional bundles--anteromedial, intermediate, and posterolateral--were identified in cadaver knees. Their contributions to resisting anterior subluxation in flexion and extension were found by repeated tests after sequential bundle transection. Changes of length in flexion and extension and in tibial rotation were measured. None of the fibres were isometric. The posterolateral bundle was stretched in extension and the anteromedial in flexion, which correlated with increased contributions to knee stability and the likelihood of partial ruptures in these positions. Tibial rotation had no significant effect. The fibre length changes suggested that the 'isometric point' aimed at by some ligament replacements lay anterior and superior to the femoral origin of the intermediate fibre bundle and towards the roof of the intercondylar notch

We have investigated the effect of joint tamponade and of traction in extension on the oxygen and carbon dioxide tensions in the femoral head of the immature goat, using mass spectrometry. Tamponade of 75 mmHg caused the oxygen tension in the femoral head to drop from 48 +/- 4 mmHg to 29 +/- 3 mmHg. Traction in extension further decreased the oxygen tension. Both these changes were highly significant. The partial pressure of carbon dioxide increased, but to a lesser extent and only effusion together with traction gave a statistically significant effect. Our study showed that joint effusion can produce hypoxia in the bone as a result of impaired blood flow to the femoral head. The application of traction increases this haemodynamic effect

We have reviewed 32 patients who sustained a substantial knee ligament injury during adolescence when their knee epiphyses were open. They were all treated non-operatively and re-examined and evaluated in detail after an average of eight years. There were 25 Grade II partial tears and seven Grade III complete tears. After Grade II injuries the functional results were excellent or good, though static instability had not improved from the initial post-traumatic examination. The long-term results of Grade III injuries were poor, because of chronic functional instability, with continuous symptoms and some post-traumatic osteoarthritis. The results of non-operative treatment for Grade III ligament injuries were not acceptable

We have studied the formation of collagen fibrils in ‘activated fibroblasts’ of tendo Achillis of rabbits. The tendon was in the process of regeneration after experimental partial tenotomy. Samples were taken from the peri-incisional region and analysed by transmission electron microscopy. Ultrastructural examination showed the presence of a ‘fine dense granular substance’ inside the rough endoplasmic reticulum and procollagen filaments. These come together to form collagen fibrils in the dilated vacuoles of the rough endoplasmic reticulum. The possible intra- and extracellular origin of collagen fibrils is suggested. Within the cell biosynthesis of collagen fibrils take place with the formation of collagen substance which gives rise to procollagen filaments. These make contact in parallel apposition to produce striated ‘spindle-shaped bodies’ which elongate by the longitudinal attachment of more procollagen filaments and form intracellular nascent collagen fibrils

The spinal stenosis syndrome is a potential hazard when congenital or developmental narrowing of the bony canal, particularly in its lateral recesses where it can be demonstrated by axial tomography, places the emergent nerve root and its blood supply at risk to further small compressive elements. When lumbar disc degeneration allows rotatory and lateral instability, posterolateral bulging of the annulus fibrosus into the root canal occurs when weight is taken on the ipsilateral lower limb. Symptoms of the spinal stenosis syndrome do not arise until the development of this instability. To relieve the symptoms, the nerve root must be freely mobilised and decompressed by full lateral decompression, with partial or total facetectomy if necessary, by enucleation of the intervertebral disc and by removal of the posterolateral portions of the annuli fibrosi

Forty-three patients with unilateral congenital short tibia with partial or complete absence of the fibula are reviewed. The factors influencing the degree of leg shortening at maturity are considered. Serial radiographic measurements of leg length in fourteen patients covering an average observation period of 9-3 years support the hypothesis that the relative difference in growth between the two limbs remains remarkably constant. By estimating the percentage difference between the normal and abnormal leg lengths on the first measurable radiograph it is therefore possible to predict the likely shortening at maturity. This method of prediction allows the surgeon to make the decision to proceed to Syme's amputation or to the use of an extension prosthesis at about one year of age when the child starts to walk

1. The management of severe kyphosis of the lumbar spine in association with myelomeningocele is discussed. 2. Neonatal spinal osteotomy-resection has been performed in six patients with partial correction of the deformity and a greatly improved ease of closure and healing of the skin defect. The severity of lower limb paralysis has been diminished compared with the complete paraplegia that almost always results from conservative management of closure of the defect without osteotomy. 3. In an older child who has not had the benefit of neonatal osteotomy and who has complete lower limb paralysis, transverse spinal osteotomy or excision of the prominent laminae and pedicles on each side of the midline makes possible the fitting of apparatus for walking and diminishes the liability to recurrent ulceration of the skin

Posterior fixation of intervertebral discs is used to treat, and occasionally diagnose, discogenic pain since it is thought that it will reduce the internal loading of the discs in vitro. We measured the internal loading of ten intervertebral discs using stress profilometry under simulated physiological loads and then after posterior fixation. Partial discectomies were performed to simulate advanced disc degeneration and the sequence repeated. Posterior fixation had very little effect on the magnitude of the loads acting on the disc and none when disc degeneration was simulated. It did, however, reduce bulging of the anterior annulus under combined bending and compression (p < 0.03). Recent experiments in vivo have shown that discogenic pain is associated with abnormal bulging of the annulus which suggests that the clinical benefit of fixation may be due to this

In a prospective study, 41 consecutive patients with a partial tear of the anterior cruciate ligament, diagnosed by arthroscopy, were reviewed after an average of 17 months, having been in plaster for six weeks after injury. Their average age was 29 years and review included clinical examination, measurement of anterior and posterior laxity with the Stryker knee laxity tester as well as evaluation of knee function and activity level. Twenty-one patients had unstable knees at follow-up; the mean total anteroposterior laxity for these patients was 12.6 +/- 3.9 mm compared with 7.1 +/- 4.3 mm for the normal knee. Most patients had few symptoms, but there was a significant reduction in the mean level of activity in the unstable group

1. Pain in the elbow in javelin throwers is a common complaint. 2. The commonest type is caused by recurrent strain of the medial ligament. It develops in individuals who employ an incorrect throwing technique. The symptoms are cumulative, increasing with throwing and decreasing and resolving with rest. Treatment consists in improving the throwing technique. Local anaesthetic injected into the tender area produces complete but temporary relief. Hydrocortisone may produce partial or complete relief. 3. A second type of "javelin elbow" occurs in expert throwers and is the result of hyperextension of the elbow at the end of the throw, causing an injury to the tip of the olecranon. The symptoms are the result of a single throw or "mal-throw" and are completely disabling. They resolve with rest but tend to recur. If the tip of the olecranon is fractured excision of the fragment completely relieves the symptoms

We report a prospective study of 46 patients with acute complete dislocation of the acromioclavicular joint. They were all treated by suture of the deltoid and trapezius over the clavicle with no repair of the coracoclavicular ligaments, using only temporary fixation with two wires. At operation 43 patients (93.5%) had damage to the trapezius or deltoid or both. The coracoclavicular ligaments were intact in six (13%). Follow-up was from 2 to 7.9 years (mean 5.8), and at the latest review only five patients (10.9%) had redisplacement, due to premature removal of wires for infection in one, to migration of the wires in another and to partial failure of the muscle repair in three. We consider that the deltoid and trapezius attachments are important clinical stabilizers of the clavicle and that their repair, with reinforcement, is a useful addition to any method of surgical treatment

Limb lengthening is used to correct leg length discrepancy and to increase stature. The reported frequency of peripheral nerve complications varies from 5% to 30%, but is probably underestimated. Damage may be direct or be caused by overstretching of the nerves. We have used electrophysiological tests to evaluate five patients during bilateral tibial lengthening by the Ilizarov method. Results after 24 to 107 days of lengthening showed electromyographic evidence of partial muscle denervation in all 10 limbs, with reduced motor conduction velocities in two tibial nerves and three common peroneal nerves. The sensory conduction velocity in the sural nerve was always unchanged. A clear relationship was shown between the amount of tibial lengthening and the degree of electrophysiological abnormality. Our results suggest that subclinical nerve damage is a very frequent complication of tibial lengthening

We present a study of 30 fusion operations in 26 rheumatoid arthritics with cervical spine instability. Atlanto-axial instability was present in 15, of whom 12 were fused; three had cord involvement and all made a partial or complete recovery following fusion. Cranial settling necessitated cranio-cervical fusion in four patients; all fused, and one with myelopathy was relieved. Subaxial instability required fusion in seven cases; two postoperative deaths followed the only two anterior interbody fusions. Posterior fusion was successful in the other five, with remission of neurological compromise in the three with myelopathy and one with radiculopathy. We conclude that neurological compromise in an unstable but mobile rheumatoid cervical spine can usually be brought to remission by immobilisation alone, so decompressive procedures are unnecessary in the first instance

The British Orthopaedic Association assessment questionnaire for knee replacements was adapted to allow comparison of the severity of underlying polyarthritis with the benefits of geometric knee replacement in a retrospective study of 150 knees between six months and six years after operation. Total or partial relief of pain was achieved in 81 per cent of the operation, and changes in mobility occurred in fewer patients. Late sepsis remained a serious complication of nine per cent of the operations and one patient died from septicaemia. Late sepsis was associated with previous synovectomy or osteotomy. Retropatellar pain rarely interfered with the mobility of the patient. There was no association of operations that failed with a high erythrocyte sedimentation rate, a high platelet count, a low haemoglobin level or with a strongly positive rheumatoid factor but pain in the contralateral knee was associated with a diminished functional capacity

Objectives

MicroRNAs (miRNAs) have been reported as key regulators of bone formation, signalling, and repair. Fracture healing is a proliferative physiological process where the body facilitates the repair of a bone fracture. The aim of our study was to explore the effects of microRNA-186 (miR-186) on fracture healing through the bone morphogenetic protein (BMP) signalling pathway by binding to Smad family member 6 (SMAD6) in a mouse model of femoral fracture.

We reviewed 74 partial medial meniscectomies in 57 patients with stable knees, to assess the long-term functional and radiological outcome. The International Knee Documentation Committee score and the residual laxity were assessed in both knees. At the time of surgery the mean age of the patients was 36 ± 11 years and the mean follow-up was 12 ± 1 years. All had a limited medial meniscectomy. The anterior cruciate ligament was intact in all cases. The meniscal tear was vertical in 95% and complex in 5%. The posterior part of the meniscus was removed in 99%. A peripheral rim was preserved in all cases. After 12 years 95% of the patients were satisfied or very satisfied with their knee(s). Objectively, 57% had grade A function and 43% were grade B. The outcome correlated only with the presence of anterior knee pain at final follow-up. In the 49 cases of arthroscopic meniscectomy for which there was a contralateral normal knee there was narrowing of the ‘joint-space’ in 16% of the operated knees. There was no correlation between this and other parameters such as age or different meniscal pathologies

Aims

There are comparatively few randomized studies evaluating knee arthroplasty prostheses, and fewer still that report longer-term functional outcomes. The aim of this study was to evaluate mid-term outcomes of an existing implant trial cohort to document changing patient function over time following total knee arthroplasty using longitudinal analytical techniques and to determine whether implant design chosen at time of surgery influenced these outcomes.