From 1974 to 1989, we treated 50 patients with a simple dislocation of the hip: 38 were posterior dislocations and 12 were anterior. All dislocations primarily treated at our hospital were reduced by closed methods within three hours (mean 85 minutes (10 to 180)) and 43 were reviewed after an average follow-up of 8 years (2 to 17). It is widely held that isolated hip dislocation reduced within six hours gives an excellent outcome, but we found a significant number of complications. There were radiological signs of partial avascular necrosis in two, mild osteoarthritis in seven, and moderate degeneration in two. Heterotopic ossification was seen in four patients, but 29 of 33 MRI examinations were normal. Objective evaluation according to the Thompson and Epstein (1951) criteria showed fair and poor results in 3 of 12 anterior dislocations, but in 16 of 30 posterior dislocations. In six of the seven patients with no other severe injury, the hip had an excellent or good result; in only three of the eight patients with severe multiple injuries was this the case. The important factors in the long-term prognosis appear to be the direction of the dislocation and the overall severity of injuries

Comminuted and displaced fractures of the inferior pole of the patella are not easy to reduce and it is difficult to fix the fragments soundly enough to allow early movement of the knee. We have evaluated the clinical effectiveness of the separate vertical wiring technique in acute comminuted fractures of the inferior pole of the patella. A biomechanical study was also performed using ten pairs of embalmed cadaver knees. A four-part fracture was made on the inferior pole of the patella and fixed by two separate vertical wires on one side and two pull-out sutures after partial patellectomy on the other. The ultimate load to failure in the first group was significantly higher than in the second (250.1± 109.7 N v 69.7 ± 18.9 N, p< 0.002), as was the stiffness (279.9 ± 76.4 N/mm v 23.2 ± 11.4 N/mm, p< 0.001). The separate wire technique was used in 25 patients with comminuted fractures of the inferior pole of the patella who were followed up for a mean period of 22 months (10 to 50). All the fractures healed at a mean of seven weeks (6 to 10). No breakage of a wire or infection occurred. The mean grading at the final follow-up was 29.5 points (27 to 30) using the Böstman method. This technique preserved the length of the patella, fixed the comminuted fragments of the inferior pole and avoided long-term immobilisation of the knee

1. The operation of spinal fusion combined with Harrington rod instrumentation is often accompanied by severe blood loss. Factors affecting the degree of blood loss are discussed with emphasis on the adverse effects of partial or complete obstruction of the inferior vena cava during operation. 2. A new scoliosis operating frame is described which is designed to encourage normal venous return during spinal fusion with the patient prone. In addition, it stabilises the patient during the procedure. 3. A standard anaesthetic technique and method of supporting the patient have been used in forty major corrective operations in thirty-eight consecutive cases of scoliosis in the past nine months. The measured blood loss at operation encountered in this series compares favourably with the quantities lost in a previously reported series of cases in which alternative methods of anaesthesia and of support for the patients were used. 4. All operations in both series were performed by the same surgeon (J. E. H.). Although further experience with the surgical technique has helped in reducing the blood loss in the later series, the same basic method of exposure and performance of the instrumentation and fusion has been used in all cases

We performed a prospective study to assess the long-term outcome of 57 arthroscopic debridement procedures carried out to treat anterior impingement in the ankle. Using preoperative radiographs, we grouped patients according to the extent of their osteoarthritis (OA). The symptoms of those with grade-0 changes could be attributed to anterior soft-tissue impingement alone. Patients with grade-I disease had both anterior soft-tissue and osteophytic impingement, but no narrowing of the joint space. In those with grade-II OA, narrowing of the joint space was accompanied by osteophytic impingement. Radiographs taken before and after operation and at follow-up were compared to assess the recurrence of osteophytes and the progression of narrowing of the joint space. At a mean follow-up of 6.5 years (5 to 8) all patients without OA had excellent or good results. There were excellent or good results in 77% of patients with grade-I OA, despite partial or complete recurrence of osteophytes in two-thirds. In most patients with grade-II OA, narrowing of the joint space had not progressed at follow-up. There was a notable improvement in pain in these patients, 53% of whom had excellent or good results. Although some osteophytes recurred, at long-term follow-up arthroscopic excision of soft-tissue overgrowths and osteophytes proved to be an effective way of treating anterior impingement of the ankle in patients who had no narrowing of the joint space

Aims

In order to determine whether and for whom serial radiological evaluation is necessary in one-part proximal humerus fractures, we set out to describe the clinical history and predictors of secondary displacement in patients sustaining these injuries.

We made a prospective arthroscopic study of 106 skeletally mature male sportsmen with an average age of 28.35 years (16.8 to 44) who presented with an acute haemarthrosis of the knee due to sporting activities. We excluded those with patellar dislocations, radiographic bone injuries, extra-articular ligamentous lesions or a previous injury to the same joint. The anterior cruciate ligament (ACL) was intact in 35 patients, partially disrupted in 28 and completely ruptured in 43. In the patients with an ACL lesion, associated injuries included meniscal tears (17 patients), cartilaginous loose bodies (6), and minimal osteochondral fractures of the patella (2), the tibial plateau (3) or the femoral condyle (9). We found no age-related trend in the pattern of ACL injuries. Isolated injuries included one small osteochondral fracture of the patella, and one partial and one total disruption of the posterior cruciate ligament. Three patients had cartilaginous loose bodies, and no injury was detected in five. Acute traumatic haemarthrosis indicates a serious ligament injury until proved otherwise, and arthroscopy is needed to complement careful history and clinical examination. All cases with a tense effusion developing within 12 hours of injury should have an aspiration. If haemarthrosis is confirmed, urgent admission and arthroscopy are indicated

Aims

Postoperative rehabilitation regimens following ankle arthrodesis vary considerably. A systematic review was conducted to determine the evidence for weightbearing recommendations following ankle arthrodesis, and to compare outcomes between different regimens.

Untreated 3- and 4-part fractures of the proximal humerus have a poor functional outcome. Open operation increases the risk of avascular necrosis and percutaneous reduction and fixation may be preferable. We report 27 patients, 9 with 3-part and 18 with 4-part fractures, treated by percutaneous reduction and screw fixation. Thirteen of the 4-part fractures were of the valgus type with no significant lateral displacement of the articular segment, and five showed significant shift. Instruments were introduced into the fracture through small incisions so that the fragments could be manoeuvred under the control of an image intensifier, taking advantage of ligamentotaxis as far as possible. A good reduction was achieved in most cases. The average follow-up was 24 months (18 to 47). All the 3-part fractures showed good to very good functional results, with an average Constant score of 91% (84% to 100%), and no signs of avascular necrosis. Good radiological results were achieved in 4-part fractures when impacted in valgus except for one patient with partial avascular necrosis of the head. In those with lateral displacement of the head, revision to a prosthesis was required in one patient because of avascular necrosis and in another because of secondary redisplacement of the fracture. Avascular necrosis was seen in 11% of 4-part fractures. The average Constant score in patients with 4-part fractures who did not need further operation was 87% (75% to 100%)

We report the radiological and clinical outcome of a press-fit (SLF) acetabular component at two to three years in two groups of patients having primary total hip replacement. In 69 the implant was coated with hydroxyapatite (HA) and in 40 it was uncoated. The stability of the cup was assessed by measurement of proximal migration and change in the angle of inclination. The clinical results in the two groups did not differ significantly, and the mean proximal linear wear was similar in both. Fewer radiolucent lines (RLLs) were seen on the radiographs of cups coated with HA. The mean proximal migration was studied by calculating regression lines for each patient using migration measurements: for the SLF+HA group the mean slope was 0.06 mm/year and for the SLF–HA group 0.20 mm/year (p = 0.22). The change in the angle of inclination during follow-up was also consistently smaller in HA–coated cups. Using regression methods the SLF+HA group had a mean slope of 0.08°/year and the SLF-HA group 0.44°/year (p = 0.023). Partial HA coating appeared to have no effect on the clinical outcome or on the rate of wear of polyethylene, but there was a trend towards a reduced rate of proximal migration, and a significant reduction in rotational migration and the number of radiolucent lines. This suggests that HA coating enhances the stability of this acetabular component

Aims

We investigated patient characteristics and outcomes of Vancouver type B periprosthetic fractures treated with femoral component revision and/or osteosynthesis.

Aims

There is little literature about total knee arthroplasty (TKA) after distal femoral osteotomy (DFO). Consequently, the purpose of this study was to analyze the outcomes of TKA after DFO, with particular emphasis on: survivorship free from aseptic loosening, revision, or any re-operation; complications; radiological results; and clinical outcome.

Low lumbar pain with radiation into the leg is a common symptom pattern caused by a number of pathological processes. Isolated disc resorption is one such entity which can be readily identified and is amenable to surgical treatment. This study consisted of two groups of patients. Group I were 50 patients suffering from isolated disc resorption at L5--S1 with ill-defined low backache extending into the buttocks and down one or both legs, but not into the feet. Clinical signs of nerve root dysfunction were found in 16 per cent of patients. Radiographic changes with loss of disc height, facet over-riding and intrusion into the nerve root canal and intervertebral foramen were common and frequently associated with sclerosis of the vertebral end-plate. Group II were a series of 45 patients with isolated disc resorption independently reviewed an average of 45 months after surgical decompression of the S1 (98 per cent) or lower lumbar nerve roots. Based on objective grading by the clinician and subjective assessment by the patient complete success was achieved in 62 per cent of the patients and partial success in 24 per cent. Provided there is full appreciation of the pathological anatomy, strict diagnostic criteria and meticulous surgery, decompression of the nerve root canal is a useful surgical procedure in severely disabled patients suffering from isolated disc resorption

1. When cortisone is administered to rabbits there is early rapid resorption of bone and a partial inhibition of new bone formation. After a few days the effect becomes less obvious, so that, if observations are made at later stages, the results may be ascribed then to simple inhibition of bone growth. 2. The effect of mechanical stress has been studied in the jaw. When tooth movement is induced mechanically there is, in ordinary circumstances, a resorption of bone on the side to which the tooth is moving (the "pressure" side) and bone formation on the opposite side (the "tension" side). After administration of cortisone there is increased resorption on the "pressure" side and there is greater resorption of connective tissues here. On the "tension" side there is resorption and inhibition of bone formation. 3. In the areas of stress, when cortisone is administered, collagen fibres are no longer in apposition, being separated by spaces presumably filled with altered ground substance; this kind of change may be responsible for many of the observed phenomena. 4. A.C.T.H. does not produce a demonstrable resorptive effect on bone or connective tissue until it has been administered for periods longer than is required for cortisone (three weeks); even then the change is not pronounced. 5. In the guinea pig there is slight delay in bone formation with large doses of both cortisone and A.C.T.H., but no significant bone resorption occurs

Aims

The aim of the Scaphoid Magnetic Resonance Imaging in Trauma (SMaRT) trial was to evaluate the clinical and cost implications of using immediate MRI in the acute management of patients with a suspected fracture of the scaphoid with negative radiographs.

We describe a method of partial limb salvage for the treatment of large primary malignant tumours of the arm. The tumour-bearing area is resected as a cylindrical segment and the distal arm is then replanted with the necessary shortening. The method is suitable for stage-IIB tumours with or without neurovascular involvement which, because of their extent, could otherwise be adequately treated only by amputation. From 1987 to 1992 we used this method in 12 patients with primary malignant bone or soft-tissue sarcomas. Wide resection margins were achieved in all, but six patients died from their disease at a mean of 21.5 months (6 to 48), none with any local recurrence. Five patients have no evidence of disease at a mean follow-up period of 52.2 months (22 to 78), and one was lost to follow-up at 48 months postoperatively when there was no evidence of disease. The results of the functional evaluation of ten patients with a follow-up of over ten months were excellent in one, good in six and fair in three, by the criteria of Enneking (1987). Recovery after nerve reconstruction was satisfactory in all cases with sensation S3 or higher and motor function M2+ or higher. Detailed evaluation of hand function on the Millesi score rated only 22% (9.6% to 33.7%) as compared with the contralateral side, but the patients were satisfied and refused further operations for the improvement of function. These oncological and functional results allow us to recommend resection-replantation as a valuable alternative to amputation for the treatment of primary malignant tumours of the arm

Aims

In the 1990s, a bioactive bone cement (BABC) containing apatite-wollastonite glass-ceramic (AW-GC) powder and bisphenol-a-glycidyl methacrylate resin was developed at our hospital. In 1996, we used BABC to fix the acetabular component in primary total hip arthroplasty (THA) in 20 patients as part of a clinical trial. The purpose of this study was to investigate the long-term results of primary THA using BABC.

1. In congenital absence of the fibula, the fibrous strip that replaces the bone, abnormal insertions of fibular muscles, and disturbances in the formation and growth of the tarsal bones all go to cause the valgus deformity of the foot and the complete or partial dislocation of the talo-tibial joint. 2. Conservative treatment is justified only for children less than a year old and then only as preparation for operation. 3. Between the second and seventh year of life operations upon the soft tissues are indicated, to eliminate the contractures occurring on the posterior and lateral sides, to restore the proper position of the foot in line with the axis of the tibia, and to restore the normal shape of the foot and muscular equilibrium. At the same time favourable conditions are created for operative reconstruction of the lateral malleolus. 4. Arthrodesis of the talo-tibial joint or reconstruction of the lateral malleolus by a bone graft with the aim of stabilising the foot in the axis of tibia is not advisable in the growing limb. 5. The results obtained in three cases described support the conclusion that the bifurcation operation recommended by Gruca produces a new lateral malleolus with an epiphysis that grows at the same rate as the remainder of the lower epiphysis of the tibia, does not affect the rate of growth of the tibial epiphysis, prevents the recurrence of the deformity, and preserves the mobility of the talo-tibial joint. 6. In early cases this reconstructive operation may be done at the same time as soft-tissue deformities are corrected and subluxation reduced. 7. It is probable that the bifurcation operation should be done on children aged between two and seven years in order to give the limb the best chance to develop normally

Aims

Plate and screw fixation has been the standard treatment for painful conditions of the wrist in non-rheumatoid patients in recent decades. We investigated the complications, re-operations, and final outcome in a consecutive series of patients who underwent wrist arthrodesis for non-inflammatory arthritis.