Aims

Stiffness is a common complication after total knee arthroplasty (TKA). Pathogenesis is not understood, treatment options are limited, and diagnosis is challenging. The aim of this study was to investigate if MRI can be used to visualize intra-articular scarring in patients with stiff, painful knee arthroplasties.

We investigated the function of biceps in 18 patients (19 shoulders) with lesions of the rotator cuff. Their mean age was 59 years. Another series of 18 patients (19 shoulders) with normal rotator cuffs as seen on MRI acted as a control group. Their mean age was 55 years. A brace was used to maintain contraction of biceps during elevation. Anteroposterior radiographs were obtained with the arm elevated at 0°, 45° and 90° with and without contraction of biceps. The distance between the centre of the head of the humerus and the glenoid was compared in the two groups. We found that in the group with tears there was significantly greater proximal migration of the head of the humerus at 0° and 45° of elevation without contraction of biceps but depression of the head of the humerus at 0°, 45° and 90° when biceps was functioning. We conclude that biceps is an active depressor of the head of the humerus in shoulders with lesions of the rotator cuff

A number of risk factors based upon mostly retrospective surgical data, have been formulated in order to identify impending pathological fractures of the femur from low-risk metastases. We have followed up patients taking part in a randomised trial of radiotherapy, prospectively, in order to determine if these factors were effective in predicting fractures. In 102 patients with 110 femoral lesions, 14 fractures occurred during follow-up. The risk factors studied were increasing pain, the size of the lesion, radiographic appearance, localisation, transverse/axial/circumferential involvement of the cortex and the scoring system of Mirels. Only axial cortical involvement > 30 mm (p = 0.01), and circumferential cortical involvement > 50% (p = 0.03) were predictive of fracture. Mirels’ scoring system was insufficiently specific to predict a fracture (p = 0.36). Our results indicate that most conventional risk factors overestimate the actual occurrence of pathological fractures of the femur. The risk factor of axial cortical involvement provides a simple, objective tool in order to decide which treatment is appropriate

1. Pain at the front of the radial side of the wrist may be caused by various lesions of the tendon and sheath of the flexor carpi radialis tendon. 2. The diagnosis may be established by testing resisted movement at the wrist and by the effect of injecting local anaesthetic into the tendon sheath. 3. In women over the age of fifty the lesion is associated with osteoarthritis of the joint between the scaphoid and the trapezium. 4. Osteoarthritis of the joint between the scaphoid and the trapezium is found in about 25 per cent of women over the age of fifty. 5. If the pain is not relieved by simple conservative measures it can usually be cured by incision of the tendon sheath. 6. The histological changes in the tendon sheath are similar to those found in tenovaginitis of the abductor pollicis longus and tibialis posterior tendons

We treated 13 children with histologically confirmed cystic tuberculosis of bone. Ten had solitary cystic lesions and three had the multicystic form. Signs and symptoms were related mainly to the joint adjacent to the cyst. Most lesions were in the metaphyses of long bones. They were radiolucent, round or oval, and resembled pyogenic infections, aneurysmal and simple bone cysts, cartilaginous tumours or osteoid osteoma. Only two of the children had pulmonary tuberculosis. The Mantoux skin test was negative in four children and the ESR was normal in five. Curettage followed by anti-tuberculosis therapy for one year resulted in good healing, but two children had residual joint contractures. Biopsy should be taken from the cystic area rather than from the synovium when a joint is involved

Between 1955 and 1989 we treated 24 patients (17 women and seven men) with giant-cell tumours of the spine at the Mayo Clinic. Their mean age was 30 years and the mean follow-up time was 12.4 years. Pain was the presenting symptom in all and half had a neurological deficit. The cervical, thoracic, and lumbar spines were equally involved. The tumours recurred in five of the 14 patients treated by one-stage surgery and in five of the ten treated by two-stage surgery. Seven patients received adjuvant radiotherapy, one for the primary lesion and six for recurrent lesions. Surgical management was by curettage or en bloc excision depending on the location and the extent of the tumour. Because of the risk of sarcomatous transformation, radiation therapy should be reserved for patients with incomplete excision or for those with local recurrence

Aims

Second-generation metal-on-metal (MoM) articulations in total hip arthroplasty (THA) were introduced in order to reduce wear-related complications. The current study reports on the serum cobalt levels and the clinical outcome at a minimum of 20 years following THA with a MoM (Metasul) or a ceramic-on-polyethylene (CoP) bearing.

In an attempt to explain the distribution of lesions of caisson disease of bone in the human femur, the regional distribution of circulating microspheres which had been labelled with scandium-46 was studies in the femur of the rabbit. Microspheres with a diameter of 15 microns were equally distributed between the two ends of the bone and between the upper and lower halves of the shaft. However, microspheres with a diameter of 50 microns congregated in the upper end of the femur and in the lower half of the shaft, the two sites most commonly affected by caisson disease. A large percentage of the microspheres in the shaft, especially the larger spheres, were retained in the marrow. It is suggested that the microcirculation of the marrow may act as a filter and that the nature and distribution of its vessels determine the site of impaction of circulating emboli. This would explain why lesions of the shaft mainly affect the medulla of the bone and not the cortex

Of 193 children with Perthes' disease at the Texas Scottish Rite Hospital for Cripppled Children, 24 were found to have only minimal changes. The cases were grouped relative to the area of the femoral head involved, with 10 involving the anterior portion, seven the posteromedial, three the lateral, and four the central portion. Almost all hips lost some height as measured by the epiphysial index but all had good results by the Mose criteria irrespective of treatment. The anterior lesion is the same as that described by Catterall as Group 1. The three additional groups have a similar benign natural history but distinct radiographic features. The need for early recognition of these patterns is emphasised if unnecessary treatment is to be avoided. Possible correlations of these lesions with the segmental blood supply of the femoral head are proposed and an hypothesis relating the Catterall classifications to the blood supply is put forward

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

1. The detailed findings are presented of a woman aged fifty who had widely distributed ossifying skeletal tumours, the structure and form of which have been shown to be low-grade osteoblastic osteogenic sarcoma. The patient was treated with heavy doses of P. 32. , to which is attributed some clinical improvement, but which induced a fatal aplastic anaemia. 2. The study of the several tumours, together with the history, the radiographs and the post-mortem findings, suggests that the lesions are multifocal skeletal primary tumours rather than numerous osseous metastases secondary to a solitary new growth in any one bone. 3. The focal neoplastic lesion is discussed in the light of personal experience of other osteogenic sarcomata of low grade but of solitary origin, and of the multifocal form of bone sarcoma which may complicate Paget's osteitis deformans

Visualisation of periacetabular osteolysis by standard anteroposterior (AP) radiographs underestimates the extent of bone loss around a metal-backed acetabular component. We have assessed the effectiveness of standard radiological views in depicting periacetabular osteolysis, and recommend additional projections which make these lesions more visible. This was accomplished using a computerised simulation of radiological views and a radiological analysis of simulated defects placed at regular intervals around the perimeter of a cadaver acetabulum. The AP view alone showed only 38% of the defects over all of the surface of the cup and failed to depict a 3 mm lesion over 83% of the cup. When combined with the AP view, additional 45° obturator-oblique and iliac-oblique projections increased the depiction, showing 81% of the defects. The addition of the 60° obturator-oblique view further improved the visualisation of posterior defects, increasing the rate of detection to 94%. Based on this analysis, we recommend using at least three radiographic views when assessing the presence and extent of acetabular osteolysis

Aims

Femoral revision component subsidence has been identified as predicting early failure in revision hip surgery. This comparative cohort study assessed the potential risk factors of subsidence in two commonly used femoral implant designs.

We investigated the factors related to the radiological outcome of a transtrochanteric curved varus osteotomy in patients with osteonecrosis of the hip. We reviewed 73 hips in 62 patients with a mean follow-up of 12.4 years (5 to 31.1). There were 28 men and 34 women, with a mean age of 33.3 years (15 to 68) at the time of surgery. The 73 hips were divided into two groups according to their radiological findings: group 1 showed progression of collapse and/or joint-space narrowing; group 2 had neither progressive collapse nor joint-space narrowing. Both of these factors and the radiological outcomes were analysed by a stepwise discriminant analysis. A total of 12 hips were categorised as group 1 and 61 as group 2. Both the post-operative intact ratio and the localisation of the necrotic lesion correlated with the radiological outcome. The cut-off point of the postoperative intact ratio to prevent the progression of collapse was 33.6%, and the cut-off point to prevent both the progression of collapse and joint-space narrowing was 41.9%. The results of this study indicate that a post-operative intact ratio of 33.0% is necessary if a satisfactory outcome is to be achieved after this varus osteotomy

Experimental injuries of cartilage and bone were produced by applying shear force to the articular surfaces of the lateral femoral condyles of six-month-old pigs under various loading conditions. The lesions were divided into two groups, 'open' or 'closed', depending on the presence of a crack on the articular surface. Each was further divided into four types according to the depth of penetrating injury: (1) splitting of uncalcified cartilage; (2) splitting at the subchondral plate; (3) subchondral fracture; and (4) intra-articular fracture. When shear force was applied at high speed but with low energy, the articular cartilage surface was the first to crack. At low speed and low energy, splits occurred in the deeper layers first. As the energy increased, both loading conditions eventually resulted in similar open lesions. Experimentally produced shear injuries are useful models for clinical osteochondral fracture, osteochondritis dissecans, and chondromalacia patellae

Forty-one cases of parosteal osteosarcoma were reviewed clinically, radiologically and pathologically. The fibrous and cartilaginous elements of each tumour were graded from I to IV for malignancy. Primary intramedullary involvement was found in one third of Grade I lesions, two-thirds of Grade II and nearly 90% of Grade III lesions. Thirty-five patients with adequate follow-up were also studied and evaluated as to the adequacy of surgical management in relation to the later development of local recurrence or metastasis or both. No metastases were seen from Grade I tumours despite a number of local recurrences. One third of patients with Grade II and half of those with Grade III tumours developed pulmonary metastases and died, all with involvement of the medullary cavity before distant spread. No patients with adequate surgical management developed local recurrence; in those with inadequate treatment there was an 88% local recurrence rate

In 15 patients who underwent open exploration of the brachial plexus, the somatosensory evoked potentials and nerve action potentials recorded at the time of operation were useful as guides to the most appropriate surgical procedure, and also in predicting the outcome in certain lesions. In three patients the apparent normality of the upper trunk of the plexus was concealing a more proximal lesion which was irrecoverable. The presence of a somatosensory evoked potential showed functional continuity in three patients in whom the C7 root was clinically involved and who recovered after operation. In five patients proximal stumps of ruptured C5 roots showed functional central continuity; this indicated their suitability for grafting. These patients recovered except one who suffered from co-existing disease. The electrophysiological studies also confirmed the clinical diagnosis of avulsion of the C8 and T1 roots and therefore prevented unnecessary dissection

The results of treatment of injuries of the thoracic and thoraco-lumbar spine with neurological involvement have been reviewed in a retrospective study of 115 patients, of whom eighty-nine received conservative and twenty-six surgical treatment. Operation was reserved, in general, for patients with irreducible dislocations and incomplete neurological lesions, open reduction and internal fixation being the commonest procedure. Only three patients required a delayed spinal fusion for suspected instability after a period of conservative treatment. On the other hand, ten patients, eight of whom had been treated surgically, were left with severe chronic spinal pain. Of the patients treated conservatively, 35% showed significant neurological improvement compared to 38% of those treated surgically, but the latter group contained a much higher proportion of incomplete lesions with a far better prognosis. It is concluded that the place for early operation might be still further restricted

In six patients with defective sensibility of the thumb the transfer of a neurovascular island flap was performed according to Littler's technique. This review one to eleven years later was mainly to determine if reorientation of the cortical representation of stimuli had developed and if tactile gnosis had persisted. The pick-up test was carried through by the three patients with a lesion of the dominant hand. All six patients referred pin-prick in the flap to the donor finger; all had absent two-point discrimination corresponding to the flap, although it had been present within normal limits a few months after operation; and all had better touch, pain and temperature sensibility in the flap than in the surrounding recipient area. All six reported functional improvement. For the best results an intelligent patient is required who has a lesion of the dominant hand and is prepared to use or exercise it regularly

1. A syndrome resulting from congenital lesions affecting the spinal cord and cauda equina, associated with spina bifida occulta, is described. 2. The syndrome consists of a progressive deformity of the lower limbs in children. One foot and the same leg grow less rapidly than the other. The foot develops a progressive deformity which begins as a cavo-varus and becomes a valgus one. Both lower limbs may be affected. There may be progression to sensory loss, trophic ulceration, disturbance of function of bowel and bladder and even paraplegia. 3. Methods of investigation including myelography are described. 4. Exploration of the spinal cord has been undertaken in twenty-four patients so affected. Extrinsic congenital lesions causing traction or pressure or a combination of traction and pressure on the spinal cord have been found in twenty-two of these. 5. In two-thirds of the patients some degree of improvement has followed operation