1. Nine cases of disturbance of the relationship between the scaphoid and the radius and between the scaphoid and the lunate bones are described. 2. Persistent dislocation of the scaphoid bone may follow reduction of perilunar dislocations or of other dislocations of the proximal row of the carpus. It may be obvious, as in waist-deep dislocation, or may be solely a rotational dislocation which may be difficult to diagnose. 3. Uncorrected rotational dislocation of the scaphoid bone caused significant disability in six of seven cases. 4. Aids to the diagnosis of this condition are described and a vigorous approach to the problem of correction is advocated. 5. The experience of other workers in this field is reviewed and discussed

Aims

Few risk factors for rotator cuff disease (RCD) and corresponding treatment have been firmly established. The aim of this study was to evaluate the relationship between numerous risk factors and the incidence of surgery for RCD in a large cohort.

Aims

Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees.

Aims

Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort.

Ten patients with 13 ankylosed elbows after burns are described. Six elbows, fixed in nearly full extension, had almost total functional disability; the other seven had varying amounts of deformity. In five of the 13 elbows there was a continuous bony mass with loss of the joint space; these were treated by a modified excision arthroplasty which restored good movement and useful function, though there was some lateral laxity. Six elbows had a posterior bony block; this was excised, which restored a useful arc of movement. The literature on bony ankylosis after burns is reviewed and the management of these cases in a developing country is described

1. A method has been described whereby the disability of hip disease, bilateral or unilateral, can be graded, and the quality of result following arthroplasty assessed, on a scale of numerical values. 2. The grade expresses the condition of the entire patient, rather than that of the hip joint alone. 3. Certain clinical criteria and physical tests have been adopted as the bases for scoring. The calculation of the patient's total score has been weighted to emphasise mobility, and to provide a more critical measure of the success of arthroplasty. Subjective tests (aside from the patient's estimate of his pain) are avoided, to provide as objective and accurate a method of assessment as possible

Twenty-one post-irradiation fractures of the femoral neck are reported in seventeen patients who had been treated by radiotherapy for carcinoma of the uterus. The clinical and radiological appearances are described and the diagnosis, prognosis and treatment of this type of fracture are discussed. Histological material has been studied in three cases. It is concluded:. 1. That there is a characteristic clinical picture in which premonitory pain is of paramount significance. 2. That when the diagnosis is considered, the likelihood of irradiation damage should take precedence over the remote possibility of metastatic invasion. 3. That the disability varies, but in general the prognosis is favourable. 4. That there is no specific line of treatment applicable to these fractures. 5. That avascularity is not the underlying cause of this lesion

1 . Attention is drawn to the not infrequent occurrence of downward subluxation of the shoulder joint accompanying fractures of the upper end of the humerus. 2. Such cases fall into early or late groups according to the time of onset of the subluxation. 3. The subluxation often disappears spontaneously, but it may persist and cause disability. It cannot safely be disregarded. 4. The etiology is discussed and experiments are described which lead to the conclusion that the subluxation is due chiefly to lack of tone in the scapulo-humeral muscles supporting the weight of the limb. 5. It is suggested that the use of a collar and cuff sling as a method of treatment for fractures of the shoulder is not without danger. A triangular sling usually prevents or cures the displacement

We retrospectively reviewed the operative treatment carried out between 1988 and 1994 of eight patients with habitual patellar dislocation. In four the condition was bilateral. All patients had recurrent dislocation with severe functional disability. The surgical technique involved distal advancement of the patella by complete mobilisation of the patellar tendon, lateral release and advancement of vastus medialis obliquus. The long-term results were assessed radiologically, clinically and functionally using the Lysholm knee score, by an independent observer. The mean age at operation was 10.3 years (7 to 14) with a mean follow-up of 13.5 years (11 to 16). One patient required revision. At the latest follow-up, all patellae were stable and knees functional with a mean Lysholm knee score of 98 points (95 to 100). In those aged younger than ten years at operation there was a statistically significant improvement in the sulcus angle at the latest follow-up (Student’s t-test, p = 0.001). Two patients developed asymptomatic patella infera as a late complication. This technique offers a satisfactory treatment for the immature patient presenting with habitual patellar dislocation associated with patella alta. If performed early, we believe that remodelling of the shallow trochlea may occur, adding intrinsic patellofemoral stability

We reviewed 16 patients with spina bifida and unilateral dislocation of the hip at an average age of 17 years. Nine had a high neurological level (thoracic to L3) and seven a low lesion (L4 to sacral). We assessed the influence of unilateral dislocation of the hip on leg-length discrepancy, hip pain, hip stiffness and pressure sores of the ischial tuberosity. In non-walking patients with high-level lesions, unilateral dislocation gave little functional disability and did not appear to require reduction. In walking patients with low-level lesions, leg-length discrepancy led to a poor gait and functional problems which could be prevented by reduction of the dislocation. In all patients with low lesions, surgery was successful in maintaining reduction; in two of five patients with high lesions it was unsuccessful

Malunion of fractures of the forearm in children can lead to permanent disability. The capacity of the radius and ulna to remodel spontaneously after malunion has been assessed in this study. Forty-nine children who had malunited fractures of the forearm were examined when the remodelling process was complete. It was noted that fractures of the distal third of the radius and ulna led to fewer problems than those of the diaphysis. It was concluded that malunion of the distal third of the radius and the ulna will remodel satisfactorily providing the child is less than 14 years of age. Gross malunion of the midshaft of the radius and ulna will spontaneously correct in an infant but little useful correction of deformity can be anticipated in diaphysial fractures when the child is aged eight years or more

1. Two patients are reported with progressive fibrosis of the vastus intermedius muscle causing limitation of flexion of the knee. The first patient, a girl of ten years who was one of binovular twins, noticed difficulty in walking at the age of five, the disability increasing with age. The other girl, aged three, was one of uniovular twins and displayed the abnormality as soon as she started walking. 2. The nature of the condition remains obscure. 3. Surgery is effective, and simple division of the affected muscle segment is recommended. A good range of passive flexion is obtained at once; the active range can be obtained thereafter by physiotherapy. Because this requires the patient's cooperation it is suggested that the best age for surgery is about five or six years

1. Tennis elbow is largely an affliction of middle age, and it is believed that degenerative changes in the orbicular ligament may underlie its pathology. 2. It has been shown that most patients may be relieved by either extra-articular or intra-articular injection of hydrocortisone, and operative intervention is required only in a minority of cases. 3. Contraction of the extensor carpi radialis brevis is considered to be the principal pain-producing factor, and Z-lengthening of the tendon of this muscle has been found to relieve the symptoms when conservative measures have failed. 4. The late results in fifty patients have shown that this operation causes diminution neither of the power of wrist dorsiflexion nor in the efficiency of the grip. The operation may therefore be undertaken with every prospect of relieving the discomfort of tennis elbow without inviting alternative disability

1. A report is made of 1000 consecutive cases of infection of the hand treated in the hand clinic of the Surgical Department of the Royal Victoria Infirmary, Newcastle-upon-Tyne. 2. Standard lesions are given a standard treatment. The methods of treatment are described and the results are expressed according to the time to healing from first attendance at the clinic. An attempt was made to review those cases in which a disability of any sort was anticipated, and an assessment made with regard to appearance and function. 3. Many patients came to hospital at a late stage when skin necrosis had already occurred, and particular attention is paid to the management of this complication. 4. It is concluded that the principles of conservative surgery applied to the treatment of infected hands give good results

There is a need for the accurate measurement of the outcome after knee surgery. The Oxford Knee Score is being increasingly used since it is reported to be short, simple, inexpensive and validated. We sent the questionnaire to 346 patients awaiting surgery to the hip or lumbar spine. Only 11% of 141 patients with proximal pathology who denied knee problems gave a maximum score. Their mean score was substantially lower than expected at 28.7 (maximum 48), and was significantly lower than the score of 36.5 obtained from patients after total knee replacement. We therefore suggest that the frequent coexistence of hip or spinal pathology will significantly alter both the absolute score and any improvement to be expected after knee surgery. Although sensitive to disability originating from the knee the Oxford Knee Score is not sufficiently specific since it is heavily influenced by more proximal pathology

We conducted a prospective, randomised, controlled trial of 45 patients (47 elbows), with tennis elbow, who underwent either a formal open release or a percutaneous tenotomy. All patients had pre- and post-operative assessment using the Disability of Arm, Shoulder and Hand (DASH) scoring system. Both groups were followed up for a minimum of 12 months. Statistical analyses using the Mann-Whitney U test and repeated measured ANOVA showed significant improvements for patient satisfaction (p = 0.012), time to return to work (p = 0.0001), improvements in DASH score (p = 0.001) and improvement in sporting activities (p = 0.046) in the percutaneous group. Those patients undergoing a percutaneous release returned to work on average three weeks earlier and improved significantly more quickly than those undergoing an open procedure. The percutaneous procedure is a quicker and simpler procedure to undertake and produces significantly better results

Aims

Distal radial fractures are the most common fracture sustained by the adult population. Most can be treated using cast immobilization without the need for surgery. The aim of this study was to assess the feasibility of a definitive trial comparing the commonly used fibreglass cast immobilization with an alternative product called Woodcast. Woodcast is a biodegradable casting material with theoretical benefits in terms of patient comfort as well as benefits to the environment.

1. Rusty staining of the synovial membrane is the gross manifestation of loading of phagocytic synovial-lining cells and of macrophages in the stratum synoviale with haemosiderin. 2. Absorption of blood effused into the joint cavities is the commonest cause of such synovial pigmentation. 3. Obvious discolouration of the synovial tissues usually follows only after repeated haemarthroses, in such conditions as haemophilia, synovial tumour and in some cases of chronic rheumatoid arthritis. 4. An identical naked-eye appearance is seen in multiple joints of patients with generalised haemochromatosis. 5. In haemochromatosis the iron-containing pigment tends to be confined to the surface layer of cells of the synovial membrane. 6. The presence of haemosiderin in synovial cells, per se, leads to no disability of the joint and is unaccompanied either by inflammatory reaction or fibrosis. Arthritis in a patient with haemochromatosis is fortuitous

Discogenic low back pain is a common cause of disability, but its pathogenesis is poorly understood. We collected 19 specimens of lumbar intervertebral discs from 17 patients with discogenic low back pain during posterior lumbar interbody fusion, 12 from physiologically ageing discs and ten from normal control discs. We investigated the histological features and assessed the immunoreactive activity of neurofilament (NF200) and neuropeptides such as substance P (SP) and vasoactive-intestinal peptide (VIP) in the nerve fibres. The distinct histological characteristic of the painful disc was the formation of a zone of vascularised granulation tissue from the nucleus pulposus to the outer part of the annulus fibrosus along the edges of the fissures. SP-, NF- and VIP-immunoreactive nerve fibres in the painful discs were more extensive than in the control discs. Growth of nerves deep into the annulus fibrosus and nucleus pulposus was observed mainly along the zone of granulation tissue in the painful discs. This suggests that the zone of granulation tissue with extensive innervation along the tears in the posterior part of the painful disc may be responsible for causing the pain of discography and of discogenic low back pain

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.