The parameters of cellular proliferation and growth in the growth plates of immature rats were measured after unilateral tibial osteotomy and used to calculate growth rates. Distal osteotomy of one tibia was followed by a bilateral increase in the calculated growth rate of the distal growth plates. However, the ipsilateral distal growth plate grew faster than the contralateral between 12 and 18 days after operation, which appeared to be related to increased cell proliferation and height. Proximal osteotomy led to an increase in growth rates proximally which was more marked on the contralateral side. The lesser response of the ipsilateral growth plate may have been due to local impairment of blood supply, or to greater local release of metabolites after bony damage. Distal tibial osteotomy gave similar results to circumferential release of the distal tibial periosteum. Proximal osteotomy, however, produced a relative impairment of growth on the operated side. This may be of importance in the correction of childhood deformities associated with inequality of leg length

Many knee replacement prostheses, embodying various principles of design, are now available and there is need for a method by which valid comparisons of results can be made. An important criterion of success is durability, so the length of time the prostheses have been in situ must be taken into account. Such a method is proposed here and is applied to the results of 673 knee replacements, of nine different types, implanted at the same hospital between 1970 and 1983. A prosthesis was considered to have failed if it had been removed or persistently caused severe pain. Two types of prosthesis were found to be significantly less successful than the other seven, between which none consistently showed significant superiority. Results for the seven types were similar despite the facts that they had been used for knees with different degrees of damage, some as secondary implants, and that they were of different design and at different stages of technical development. The more recently introduced types of prosthesis, designed to have theoretical advantages, were found in practice to be no more successful than the models they superseded

We report two cases of aneurysm of the external iliac artery after arthroplasty of the hip. In each case the patients suffered from severe, seropositive, rheumatoid arthritis, had been treated with oral corticosteroids and had defects in the acetabular floor which were complicated by sepsis. In these circumstances bleeding from the wound in the hip should be investigated by immediate arteriography with anteroposterior and lateral views. Though vascular injury during operations on the hip is rare, recognition is important as safe and satisfactory treatment can be achieved. In the surgical management of these cases the following points should be noted: an alternative blood supply to the limb must be established using separate surgical incisions; to reduce the risk of sepsis these incisions should be closed and dressed before exploring the aneurysm; the aneurysmal vessel must be isolated and ligated, no attempt being made at primary repair; the aneurysm should be opened longitudinally to avoid damaging the femoral nerve which overlies it; and all foreign material should be removed from the hip

To investigate the effect of instability on the remodelling of a minor articular surface offset, we created a 0.5 mm coronal step-off of the medial femoral condyle in 12 New Zealand white rabbits and transected the anterior cruciate ligament (ACL). A control group of 12 rabbits had only ACL resection and the opposite knee was used as the non-operated control. The osteoarthritic changes at 6, 12 and 24 weeks after surgery were evaluated histologically. In addition, changes in the immunological detection of 3-B-3(-) and 7-D-4 chondroitin-6-sulphate epitopes were determined because of the previous association of such changes with repair of cartilage and early osteoarthritis. In the instability/step-off group there was rapidly progressing focal degeneration of cartilage on the high side of the defect, not seen in previous step-off studies in stable knees. The rest of the femoral condyles and the tibial plateaux of the instability/step-off group had moderate osteoarthritis similar to that of the instability group. 3-B-3(-) was detectable in the early and the intermediate stages of osteoarthritis but no staining was seen in the severely damaged cartilage zones. Immunoreactivity with 7-D-4 increased as degeneration progressed. Our findings have shown that even a minor surface offset may induce rapid degeneration of cartilage when the stability of the knee is compromised

This is a study of children who first attended as infants with either progressive infantile idiopathic scoliosis or congenital scoliosis. All had a pattern of scoliosis in which early and damaging deterioration is inevitable. The infants were treated from before the age of three, initially by plaster casts and then a Milwaukee brace, followed at about the age of ten by correction and fusion. The cases were then observed to the end of growth or near that point. In the main study there were twelve cases, six of progressive infantile idiopathic scoliosis and six of congenital scoliosis, which were followed through this long period. Only one of the twelve had a curve worse at the end of growth compared with the initial radiograph as an infant; this one curve had increased only 16 degrees in almost as many years. Although small, the series does show that it is nearly always possible to control even the most serious scoliosis in an infant, if it is tackled early and unremittingly. There are supportive studies of children who have partially completed this regime, and interim results in a newer group of children with spina bifida and scoliosis

1. Ten consecutive fractures of the dome of the talus are reported. Six were lateral, three medial and one anterior. 2. The injury is most commonly seen in the second and third decades of life, and with the exception of the rare anterior dome fracture, results from an inversion injury of the ankle. The possibility of a dome fracture associated with strain of the lateral ligament of the ankle joint should therefore always be borne in mind. 3. Antero-posterior views in neutral and in plantar fiexion are helpful in diagnosing medial dome fractures. Lateral fractures are best seen in an antero-posterior view taken in neutral flexion with 10 degrees inward rotation of the limb. 4. A large dome fracture with displacement should be accurately reduced by open operation in order to preserve congruity of the joint surface. 5. A small fracture with no displacement may be treated conservatively until radiographically it appears united. 6. A small fracture with marked displacement is best treated by early excision of the fragment to prevent further damage to the ankle joint

From the experimental evidence above, it is clear that in the upper four centimetres of the forearm the posterior interosseous nerve moves up to one centimetre or more medially relative to the radius on pronation of the forearm. This movement becomes of importance when considered in relation to methods of operative approach for excision of the radial head. Operative approaches have been described in which emphasis has been placed on the position of incision, but in none of these is there any mention of the position of the forearm. We suggest that the following precautions should be taken. 1) During excision of the radial head the forearm should be kept in full pronation. 2) The incision should be as posterior as possible to ensure that it is well clear of the nerve. 3) With the forearm pronated the incision extends from a little above the lateral epicondyle along the postero-lateral aspect of the forearm for not more than 5 centimetres; proportionately less in a child. 4) The surgical assistant's attention should be brought to the damage that the posterior interosseous nerve might sustain from undue pressure–for instance by retraction, especially by bone levers–in the anterior part of the wound

1. An investigation was made of the tolerance of the cells in the femoral head in rabbits for ischaemia brought about by transecting the ligament of the femoral head and applying a ligature around the femoral neck. The animals were killed two, six, twelve, twenty-four and seventy-two hours after operation. 2. In the cells of the bone marrow and in the osteoblasts distinct histological signs of disintegration were present six hours after operation. Pyknosis of the osteocyte nuclei was found after twenty-four hours' ischaemia; sometimes vacuolar clarifications could be observed in these pyknotic nuclei. After three days of ischaemia the staining affinity for Feulgen and haematoxylin of a number of osteocyte nuclei had visibly decreased. 3. The Feulgen-DNA content of the osteocyte nuclei-as measured in individual nuclei by means of an integrated microdensitometer-was significantly reduced as compared with similar nuclei from the control side as early as after six hours of ischaemia. This DNA loss was progressive with the period of ischaemia. From these facts, the conclusion was reached that in the femoral head of the rabbit the period of reversible damage for osteocytes must have ended within six hours

1. A study of fifty patients with dislocations of the lunate bone or perilunar dislocations has been made. The period of observation was adequate in thirty-eight. 2. The injuries generally occur in young or middle-aged men after unusually severe trauma. 3. Associated injuries are frequent, and the most common of these is damage to the median nerve. 4. In one-third of the cases the nature of the lesion was not initially diagnosed or the initial treatment was inadequate. 5. A dislocated lunate bone may be replaced even at a late stage and even if the displacement is severe so long as there is some soft-tissue attachment. The anterior approach may safely be used for the replacement. 6. The lunate bone may be removed without involving the necessity for arthrodesis of the wrist. 7. Open reduction should be employed for trans-scaphoid dislocations whenever exact realignment and good fixation cannot be achieved by closed methods. 8. Excision of the proximal row of the carpus gives the possibility of salvage of a reasonable degree of function, and may be preferable to arthrodesis or removal of only part of the proximal row

The present investigation has shown that crude papain can be used to produce rapid changes in the epiphysial cartilage of various young laboratory animals (rabbits, mice, rats, guinea pigs and cats). 1. Single injections of crude papain produce profound changes in the epiphysial cartilage. These changes disappear within a few days. They are radiographically visible as a narrowing of the epiphysial plates. Histologically, the formation of bony trabeculae in the primary spongiosa is found to be arrested. 2. Repeated injections of crude papain cause permanent damage to the epiphysial cartilage, often with bony closure. Consequently, the longitudinal growth of the injected animals, when compared to the controls, is found to be retarded or permanently arrested, and there may be severe bony deformity. 3. Using inactivated crystalline papain, we have been able to produce changes in the epiphysial cartilage identical with those caused by the injection of crude papain. 4. The injection of crude papain is dispelled by the addition of cysteine, but retains its full strength if hydrogen peroxide is added

1. In five out of eleven cases of osteoclastoma it was found that osteoclasts were present inside clearly defined blood vessels either within the tumours or in the tissues immediately surrounding the tumours. In two further cases it was found that osteoclasts protruded into the vessels although they were not lying free within the vessels. 2. The possible modes of entry of these cells into the blood stream are discussed. Although accidental dissemination of osteoclasts into damaged blood vessels could not be excluded, it was felt that the process was equally likely to be related to some inherent property of the osteoclasts. From further observations it is suggested that osteoclasts are capable of local destruction of the connective tissues of the vessel walls, probably by enzyme action. Such an action might be analogous to the processes by which, in the opinion of many, osteoclasts bring about the resorption of bone. 3. There did not seem to be any relationship between the finding of intravascular osteoclasts and the malignancy of the tumour, assessing the latter either on histological or clinical grounds. The finding of intravascular osteoclasts does not therefore appear to be of any prognostic significance

Aims

The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening. This study compares outcomes following antegrade and retrograde femoral lengthening in both adolescent and adult patients.

Aims

There has been a recent resurgence in interest in combined partial knee arthroplasty (PKA) as an alternative to total knee arthroplasty (TKA). The varied terminology used to describe these procedures leads to confusion and ambiguity in communication between surgeons, allied health professionals, and patients. A standardized classification system is required for patient safety, accurate clinical record-keeping, clear communication, correct coding for appropriate remuneration, and joint registry data collection.

High-pressure lavage produces greater visible damage to bone at a macroscopic and microscopic level when compared with low-pressure lavage and can result in delay in the healing of fractures. Osteoblasts and adipocytes are derived from mesenchymal stem cells. Conditions which lead to bone loss often involve a switch from the osteoblast to adipocyte lineage. We have therefore examined the effect of high- and low-pressure irrigation on the differentiation of adipocytes. Calvaria-derived bone cells were exposed to either low-pressure or high-pressure irrigation with normal saline. After 14 days the cells were fixed and the osteoblasts and adipocytes quantified using Oil Red O to stain cytoplasmic lipid droplets (triglycerides) in the cells. Osteoblasts were quantified using a commercially available alkaline-phosphatase staining assay. A standard quantitative reverse transcription-polymerase chain reaction (RT-PCR) was performed. Messenger RNA levels for osteocalcin, a marker of osteoblasts, and PPARγ2, a marker of adipocytes, were measured. High-pressure lavage resulted in an increase in adipogenesis of 50% when compared with low-pressure lavage. Our findings suggest that high-pressure lavage may promote differentiation of mesenchymal stem cells towards the adipoctye lineage. This may have clinical significance in the development of delayed and nonunion after treatment of fractures of long bones

We analysed the incidence of avascular necrosis in 101 hips of 90 infants with congenital dislocation treated with the Pavlik harness and followed up for more than one year. Using ultrasonography in the flexed-abducted position the hips were classified as type A when the femoral head was displaced posteriorly, but within the socket and making contact with the posterior inner wall of the acetabulum; type B when it was in contact with the posterior margin of the acetabulum, with its centre at this level or anterior to it; and type C when it was displaced out of the socket, with its centre posterior to the posterior rim of the acetabulum. Eighty-seven hips were reduced by the harness (86%), and seven of these developed avascular necrosis (8%). All 69 hips with type-A dislocation were reduced, and only one (1.4%) showed slight avascular necrosis. Eighteen (78.3%) of 23 hips with type-B dislocation were reduced, and six developed avascular necrosis (33.3%). In one hip, the femoral head was severely damaged. None of the nine hips with type-C dislocation was reduced in the harness. We conclude that the Pavlik harness is indicated for type-A, but not for type-B or type-C dislocations

Porous blocks of calcium hydroxyapatite ceramic were evaluated as delivery systems for the sustained release of antibiotics. We tested gentamicin sulphate, cefoperazone sodium, and flomoxef sodium in powder form placed in a cylindrical cavity in calcium hydroxyapatite blocks, using in vitro studies of elution and in vivo studies in rats. Gentamicin sulphate gave a maximum concentration within the first week, which gradually decreased but was still effective at 12 weeks, when 70% of the antibiotic had been released. Even at this stage the antibiotic concentration from a 75 mg dose was five times the minimum inhibitory concentration for staphylococci. In the in vivo studies the release of gentamicin sulphate into the normal bone of rats was at similar rates and levels. The bacteriocidal activity of the drugs was not affected by packing into calcium hydroxyapatite ceramic and the blocks were completely biocompatible on histology. This new system overcomes the disadvantages of other drug delivery systems, avoiding thermal damage to the antibiotics and a second operation for the removal of the carrier. Some mechanical strength is provided by the ceramic and healing may be accelerated by bone ingrowth into its micropores

Aims

Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures.

The results and complications of the use of Bailey-Dubow extensible rods in 28 lower limb bones of 10 patients suffering from osteogenesis imperfecta are reviewed. Twenty-eight operations were for the primary insertion of the rods into the femur or tibia; a further nine operations were needed for the treatment of complications. These complications included 10 instances of proximal migration of the distal end of the rod, one of incorrect placement in the proximal femur, four instances of loosening of a T-piece and three of infection about a rod, two of these being in one child. Most complications arose from technical faults at insertion. The details of technique which have evolved from experience are described. Only one fracture has occurred in a bone after correct placement of a rod. Of the 10 patients, seven of whom had never walked before, seven were able to walk and two others had achieved walking, but were under treatment for complications at the time of review. There was no evidence of damage to growth epiphyses. The greater technical complexity of insertion of Bailey-Dubow rods is well justified by the results obtained when they are correctly applied