1. A patient wholly insensitive to painful stimuli as judged by psychical, physical, reflex and autonomic responses, showed multiple arthropathies. 2. Biopsy specimens of skin and periosteum from the region of the hip joint showed free nerve terminals similar in morphology to endings considered to subserve pain in normal subjects. The abnormality related to defective pain sensation therefore appears not to be due to a defect in the peripheral nerve endings for pain, but to be located more centrally in the nervous system. 3. In this patient, and in some patients with syringomyelia, arthropathy is associated with selective impairment of pain sensibility of the involved joints. It appears that tissue damage from the wear and tear of normal activity of a joint, if this damage is unheralded because of impairment of pain sense, can lead to arthropathy. 4. It is noted that further experimental evidence is still required to elucidate the role of various modalities of innervation in the maintenance of normal structure and function of joints

We have observed damage to the labrum as a result of repetitive acetabular impingement in non-dysplastic hips, in which the femoral neck appears to abut against the acetabular labrum and a non-spherical femoral head to press against the labrum and adjacent cartilage. In both mechanisms anatomical variations of the proximal femur may be a factor. We have measured the orientation of the femoral neck and the offset of the head at various circumferential positions, using MRI data from volunteers with no osteoarthritic changes on standard radiographs. Compared with the control subjects, paired for gender and age, patients showed a significant reduction in mean femoral anteversion and mean head-neck offset on the anterior aspect of the neck. This was consistent with the site of symptomatic impingement in flexion and internal rotation, and with lesions of the adjacent rim. Furthermore, when stratified for gender and age, and compared with the control group, the mean femoral head-neck offset was significantly reduced in the lateral-to-anterior aspect of the neck for young men, and in the anterolateral-to-anterior aspect of the neck for older women. For patients suspected of having impingement of the rim, anatomical variations in the proximal femur should be considered as a possible cause

Aims

Abnormal femoral torsion (FT) is increasingly recognized as an additional cause for femoroacetabular impingement (FAI). It is unknown if in-toeing of the foot is a specific diagnostic sign for increased FT in patients with symptomatic FAI. The aims of this study were to determine: 1) the prevalence and diagnostic accuracy of in-toeing to detect increased FT; 2) if foot progression angle (FPA) and tibial torsion (TT) are different among patients with abnormal FT; and 3) if FPA correlates with FT.

We undertook a prospective study of 61 children in Malawi with septic arthritis of the shoulder. They were randomised into two groups, treated by aspiration (group 1, 31 patients) or arthrotomy (group 2, 30 patients). Both received antibiotics for six weeks. We studied the results of blood tests, microbiology, and the clinical and radiological outcome one year after diagnosis. Only one patient was sickle-cell positive and three were HIV-positive. Non-typhoidal Salmonella species accounted for 86% (19/22) of the positive joint cultures in group 1 and 73% (16/22) in group 2. Of the 33 radiographs available for review at follow-up at six months, 23 (70%) showed evidence of glenohumeral damage. There was no statistical difference in radiological outcome for the two groups. We devised and validated a scoring system, the Blantyre Septic Joint Score, for the assessment of joints based upon swelling, tenderness, function and range of movement. Despite the radiological changes only one of the 24 joints examined at one year had any deficit in these parameters. There was no statistical difference in the clinical outcome for the two treatment groups at any stage during the period of follow-up

Injury to the dorsomedial cutaneous nerve in the foot may occur after operations for hallux valgus. Pressure neuropathy before operation is also described but remains largely unexplored. We have investigated the incidence of sensory deficit in the great toe before operating for hallux valgus and examined to what extent any deficit was related to the degree of angulation of the joint. Forty-three patients with a total of 61 great toes with hallux valgus presenting for consideration of surgical correction had their sensation tested in pre-designated zones using a five-filament set of Semmes-Weinstein monofilaments. These allowed good inter-observer reliability with an intra-class correlation coefficient of 0.84. Sensory symptoms were noted by only 21% of the patients, a measurable reduction in sensation by one monofilament grade or more was found in an additional 44%. No relationship was found between the degree of sensory loss and the degree of angulation. Patients with symptomatic hallux valgus may have sensory loss in the toe without being aware of it. Normal subjective sensation does not reliably predict normal sensory function. Given the potentially high rates of nerve damage following operations for hallux valgus, we recommend objective sensory testing as part of routine assessment before surgery

Ischaemia-reperfusion injury (IRI) is caused by endothelial and subendothelial damage by neutrophil-derived oxidants. Vitamin C is an antioxidant which attenuates endothelial injury after IRI. Our aim was to evaluate the effect of oral vitamin C in the prevention of IRI in skeletal muscle. We used a model of cross-clamping (3 hours) and reperfusion (1 hour) of the cremaster muscle in rats. Muscle function was assessed electrophysiologically by electrical field stimulation. Infiltration by neutrophils was determined by the activity of tissue myeloperoxidase (MPO) and tissue oedema by the wet-to-dry ratio. Neutrophil respiratory burst activity was measured in control animals and groups pretreated with vitamin C. IRI significantly decreased muscle function and increased muscle neutrophil MPO activity and muscle oedema. Pretreatment with vitamin C preserved muscle function and reduced tissue oedema and neutrophil infiltration. Neutrophil respiratory burst activity was reduced in the group treated with vitamin C compared with the control group. We conclude that pretreatment with oral vitamin C protects against acute muscle IRI, possibly by attenuating neutrophil respiratory burst activity

Bilateral venography was performed between 12 and 15 days after total hip replacement in 745 consecutive patients, all of whom had heparin prophylaxis. Of these, 81 patients (10.8%) showed evidence of recent deep vein thrombosis: 23 (3%) distal, 44 (5.9%) isolated proximal, five (0.7%) both proximal and distal, and nine (1.2%) extensive thrombosis from calf to thigh. Compared with previous reports heparin appeared to have reduced the number of distal and contralateral thromboses, but was far less effective in reducing proximal femoral thrombosis. In a cadaver study, the femoral veins were inspected during simulated total hip replacement by either an anterior or a posterior approach. In every case the femoral vein became kinked or folded in the thigh position imposed during the preparation of the femur. Local damage appears to be an important factor in proximal thrombosis; care at operation could help to minimise trauma to the femoral veins and reduce the number of such cases

The results of three different types of meniscectomy have been compared in 219 knees, 71 treated by arthroscopic partial meniscectomy, 45 treated by open partial meniscectomy, and 103 treated by open total meniscectomy, with a mean follow-up of 4.3 years. Knees which had undergone previous operations or had other simultaneous operative procedures or ligamentous damage were excluded. Knees with chondromalacia were included provided that this did not amount to frank osteoarthritis. Simple indicators were used for the rate of early recovery from the operation, and the Tapper and Hoover scale was used to record the symptomatic results in the longer term. It was found that knees treated by arthroscopic partial meniscectomy did considerably better than the others by all the criteria used. In most parts of the study there was a clear gradation between the results of the three types of treatment: arthroscopic techniques did better than open operations, and partial meniscectomy did better than total meniscectomy

We present a study of ten consecutive patients who underwent excision of thoracic or thoracolumbar hemivertebrae for either angular deformity in the coronal plane, or both coronal and sagittal deformity. Vertebral excision was carried out anteriorly alone in two patients. Seven patients had undergone previous posterior spinal fusion. Their mean age at surgery was 13.4 years (6 to 19). The mean follow-up was 78.5 months (20 to 180). The results were evaluated by radiological review of the preoperative, postoperative and most recent follow-up films. The mean preoperative coronal curve was 78.2° (30 to 115) and was corrected to 33.9° (7 to 58) postoperatively, a mean correction of 59%. Preoperative coronal decompensation of 35 mm was improved to 11 mm postoperatively. Seven patients had significant coronal decompensation preoperatively, which was corrected to a physiological range postoperatively. There were no major complications and no neurological damage. We have shown that resection of thoracic and thoracolumbar hemivertebrae can be performed safely, without undue risk of neurological compromise, in experienced hands

Coxa valga may sometimes occur as a complication of varus osteotomy for congenital dislocation of the hip. Six such cases are described with a minimum follow-up of nine years. In three cases the varus osteotomy had been performed on only one side; in one case it was done on both sides and coxa valga developed bilaterally; and in two further bilateral cases coxa valga developed on one side only. In each case the coxa valga was sub-capital. Detailed radiographic analysis included measurements of neck-shaft angle, acetabular angle and C.E. angle. The epiphysis-shaft angle is described; it is an index of the constant tendency of the capital epiphysis to assume a horizontal position. The cause remains unknown, but damage to the trochanteric growth plate or to the lateral part of the capital growth plate could not be identified as aetiological factors. Poor acetabular cover was considered a possible factor. All the patients in this series had functionally excellent hips, but the long-term prognosis of the hips with partly uncovered femoral heads is doubtful

1. Prosthetic acetabular cups of the Charnley and McKee-Farrar designs were cemented into cadaveric pelves using different procedures for preparing the acetabulum. 2. The torsional moments needed to loosen these cups were measured. 3. The torsional moments so measured were found to be from about four to more than twenty times higher than the frictional moments measured in independent tests on the two designs of prosthesis. 4. It is argued that late looseness of the acetabular component after total hip replacement, in the absence of infection, seems most likely to be due to thermal damage to the bone occurring at the time of polymerisation of the cement, and to subsequent bone resorption. 5. Surgical preparation of the acetabulum should include removal of all the articular cartilage and cleaning of the acetabular fossa, but the drilling of additional holes in the floor of the acetabulum seems unimportant. 6. The possibility of fatigue fracture in bone as a factor contributing to late loosening is an argument in favour of metal-on-polyethylene prostheses with their lower frictional moments, although the importance of this factor cannot be estimated

1. The pathology and pathogenesis of dislocations and fracture-dislocations of the cervical spine has been reviewed. 2. A method of treatment using skeletal traction and manipulation under relaxant general anaesthesia is described. Results of treatment are given for all patients admitted to the Centre with flexion-rotation dislocations of the cervical spine complicated by neurological lesions, between November 1961 and December 1968. 3. After reviewing the literature and considering the results obtained in seventy-six cases, we advocate a policy of conservative management with gentle manipulation of the cervical spine in selected cases, reduction being maintained thereafter by skeletal traction. We reserve operation for the few cases that demonstrate late instability or for those rarer cases in which manipulation fails and the patient has either an incomplete neurological lesion or a double skeletal injury. 4. The low incidence of late instability after adequate conservative treatment is stressed, and the danger of overdistraction of the cervical spine by heavy traction in patients with severe ligamentous damage is emphasised

1. A study has been made of the blood supply of the human patella. There are two main systems, one penetrating the middle third of the anterior surface and the other entering the lower pole of the bone behind the patellar ligament. 2. The relationship between these findings and the complication of avascular necrosis of the upper fragment of the patella after fracture is discussed. Forty-one cases of necrosis after operation have been studied and notes made on the pathological, clinical and radiological evolution of the condition. Whatever the severity of the ischaemic necrosis the prognosis was not substantially affected and good function was observed in all knees six months after injury. 3. The surgical implications of the vascular anatomy are discussed. It is pointed out that surgical intervention may damage the blood vessels entering the anterior surface of the bone and that circumferential repair of patellar fractures may strangle the vessels in their peripatellar course. 4. If removal of one-half of the patella after a transverse fracture is indicated, vascular studies indicate that the upper fragment should be removed

1. Radiographs of both shoulders were performed on 106 unselected necropsy subjects and those found to be abnormal were examined pathologically. 2. Radiological abnormalities were found in sixty-eight shoulders of thirty-eight subjects. Pathological examination showed rotator cuff tears and associated abnormalities in thirty-five of these, rheumatoid arthritis in one, a previous fracture in one, and one was not examined. 3. The criteria for radiological diagnosis of rotator cuff tears are examined and discussed. 4. The radiological changes give little indication of the severity of the tears or associated abnormalities except in the case of complete rupture of the cuff when acromio-humeral articulation occurs. 5. The lesions are all explicable on a traumatic basis. There is no correlation with the presence or absence of osteoarthritic disease of the joint. 6. The biceps tendon may become damaged or even ruptured in this condition. 7. Villous synovial proliferation was found in fourteen cases, in five of which it was pigmented with histological appearances resembling pigmented villonodular synovitis. The significance of this finding is briefly discussed

1. The semilunar cartilages are part of the rotator mechanism of the knee joint. 2. Movement of the weight-bearing knee comprises synchronous lateral rotation of the tibia with extension and medial rotation of the tibia with flexion. 3. When this synchrony is disturbed, injuries to the semilunar cartilages result. 4. Damage to the anterior two-thirds of the medial cartilage blocks lateral rotation of the tibia, with consequent physical signs that are pathognomonic of the retracted and the bowstring cartilage, which are the most common types of injury. 5. Each type of cartilage injury produces its own pattern of erosion of articular cartilage and its own sequence of symptoms as so-called arthritis develops. 6. The sequence of symptoms may be halted and often reversed by removal of the torn cartilage. Operation is warranted in most cases however long the history and whatever the age of the patient. 7. The development of medial retropatellar arthritis is explained. The symptoms are often relieved by removal of the medial semilunar cartilage and adequate post-operative rehabilitation

Amputation or post-mortem specimens from eight cases of joint tuberculosis, with immobilisation changes in bone, have been studied by fine-detail slab radiographs and subsequent histological examination. The findings in three of these cases are presented in detail. The immobilisation changes take the form of a true osteoporosis, which is strikingly focal in nature. In the adult the sites of most marked involvement include the subcortical bone adjacent to articular surfaces and the bone in the neighbourhood of the obliterated epiphysial plates. Areas of permanent change in bone structure may result, although commencing "repair" is seen in the form of newly developed bone trabeculae in the osteoporotic areas. In one case, where immobilisation occurred at an early age, changes in the growing epiphysial plates were produced in addition to osteoporosis. This is correlated with the known susceptibility of growing epiphysial cartilage to a wide variety of damaging agents. Radiologically, it is important to discriminate between these immobilisation changes and the bone destruction which might be produced by extension of the tuberculous lesion itself

Fractures of the scaphoid are most common in young men; immobilisation in a cast usually means a long period away from work and athletic activities. Early rigid fixation has been shown to promote a rapid functional recovery, but open reduction and internal fixation is technically demanding with the dangers of damage to the radiocarpal ligaments, the scaphotrapezial joint, and the blood supply of the scaphoid. For minimally displaced or undisplaced B1 or B2 fractures, these problems can be overcome by percutaneous fixation. We report our technique and the results of a pilot study in 15 patients. There was no immobilisation; patients were allowed movement soon after operation, but union was obtained in all at a mean of 57 days (38 to 71). The range of movement after union was equal to that of the contralateral limb and grip strength was 98% of the contralateral side at three months. Patients were able to return to sedentary work within four days and to manual work within five weeks. Our initial results show that percutaneous scaphoid fixation for acute fractures is satisfactory and gives rapid functional recovery

After a severe ankle sprain the incidence of residual complaints, particularly on the medial side of the joint, is high. We studied a consecutive series of 30 patients who had operative repair of acute ruptures of lateral ligaments. During operation, arthroscopy revealed a fresh injury to the articular cartilage in 20 ankles, in 19 at the tip and/or anterior distal part of the medial malleolus as well as on the opposite medial facet of the talus. In six patients, a loose piece of articular cartilage was found. We conclude that in patients with a rupture of one or more of the lateral ankle ligaments after an inversion injury, an impingement occurs between the medial malleolus and the medial facet of the talus. Patients with a lesion of the lateral ankle ligament caused by a high-velocity injury (a faulty landing during jumping or running) had a higher incidence of macroscopic cartilage damage (p < 0.01), medially-located pressure pain (p = 0.06) and medially-located complaints at one-year follow-up (p = 0.02) than those with a low-velocity injury (a stumble)

Damage to articular cartilage is a common injury, for which there is no effective treatment. Our aims were to investigate the temporal sequence of the repair of articular cartilage and to define a critical-size defect. Full-thickness defects were made in adult male New Zealand white rabbits. The diameter (1 to 4 mm) of the defects was varied in order to determine the effect that the size and depth of the defect had on its healing. The defects were made in the femoral groove of the knee with one defect per knee and eight knees per group. The tissues were fixed in formalin at days 3, 7, 14, 21, 28, 42, 84 and 126 after operation and the sections stained with Toluidine Blue. These were then examined and evaluated for several parameters including the degree of metachromasia and the amount of subchondral bone which had reformed in the defect. The defects had a characteristic pattern of healing which differed at different days and for different sizes of defect. Specifically, the defects of 1 mm first peaked in terms of metachromasia at day 21, those of 2 mm at day 28, followed by defects of 3 mm and 4 mm. The healing of the subchondral bone was slowest in defects of 1 mm

We report complications from the use of modular components in 20 hip replacements in 18 patients. Fifteen complications (in 13 patients) were related to failure of a modular interface after operation. Femoral head detachment from its trunnion was seen in 6 hips from trauma (3), reduction of a dislocation (2), and normal activity (1). In one case the base of the trunnion fractured below an extra-long modular head. In seven other hips the modular polyethylene liner dislodged from its shell, causing severe damage to the shell in four cases with extensive metallosis. In one other hip an asymmetrical polyethylene liner rotated, resulting in impingement of the femoral component and recurrent dislocation. Operative errors were seen in five cases: implantation of a trial acetabular component in one; and mismatching between the size of the femoral head and the acetabular component in the others. Surgeons who use hip replacements with modular components should be aware of the potential for operative error and of the importance of early treatment for postoperative mechanical failure