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

Polyethylene liners of modular acetabular components wear sometimes need to be replaced, despite the metal shell being well fixed. Replacing the liner is a relatively simple procedure, but very little is known of the outcome of revision. We prospectively followed up 1126 Harris-Galante I metal-backed, uncemented components for between nine and 19 years. We found 38 (3.4%) liners of 1126 acetabular components wore and required revision. These revisions were then followed up for a mean of 4.8 years. The rate of dislocation was 28.9%. Nine of the dislocations occurred once and two were recurrent. The overall secondary revision rate was three of 38 total hip replacements (7.9%) at a mean follow-up of 4.8 years. This gives a 92.1% survivorship (35 of 38) at under five years. In isolated revision of a liner, we had a complication rate of 23% (three of 13). In revision of a liner combined with revision of the femoral stem, there was a complication rate of 48% (12 of 25). We discuss possible reasons for the high dislocation rates. Leaving the well-fixed acetabular shell in situ leads to an increased risk of instability. However, this needs to be balanced against the otherwise low complication rate for revision of the liner. Patients should be consented accordingly

Simultaneous dislocation of the elbow and the proximal radio-ulnar joint is rare. Two children with this uncommon injury are reported. One child had a transverse divergent dislocation that was treated successfully by closed reduction. The other had a convergent dislocation (or translocation of the radius and ulna) which needed open reduction. Convergent dislocation is even rarer than transverse divergent dislocation, and this is believed to be the first time it has been reported

A review of the pathology, mechanism, and operative treatment of recurrent dislocation of the shoulder, based on an analysis of 180 cases, with 159 operations, is presented. From this analysis the following conclusions have been made and appear to be substantiated:. 1. The pathology comprises two important elements: (a) anterior detachment of the glenoid labrum from the bone margin of the glenoid, associated with some degree of stripping of the anterior part of the capsule from the front of the neck of the scapula, found in 87 per cent. of cases examined adequately at operation; (b) defect or flattening of the posterolateral aspect of the articular surface of the head of the humerus which engages with the glenoid cavity when the arm is in external rotation and abduction; this defect is demonstrated most readily in antero-posterior radiographs taken with the humerus in 60 to 70 degrees of internal rotation and was shown to be present in 82 per cent. of cases which had been subjected to adequate radiographic examination. 2. The frequency of the humeral head defect has been under-estimated in the past, because of the difficulty of demonstrating it, particularly when the defect is small. 3. Either type of lesion alone may predispose to recurrence of the dislocation. 4. Both types of lesion are often present in the same shoulder. When this is the case the tendency to redislocation is great. 5. The initial dislocation, which results in the development of one or both these persistent structural abnormalities, may be due to very different types of injury, the commonest of which is a fall on the outstretched hand. The factor common to all these injuries is a resultant force acting on the humeral head in the direction of the anterior glenoid margin. 6. In the treatment of recurrent dislocation of the shoulder joint the Nicola operation is unreliable, and it may be associated with a recurrence rate as high as 36 per cent. It is believed that continued instability after this operation is usually due to the presence of a defect of the humeral head. 7. Operative treatment should aim at repairing, or nullifying, the effects of both types of lesion. For anterior detachment of the labrum this involves either suturing the labrum back to the glenoid margin, or constructing some form of anterior buttress, fibrous or bony: for humeral head defects it necessitates some procedure designed to limit external rotation, thus preventing the defect from coming into engagement with the glenoid cavity. Such limitation of external rotation does not constitute a significant disability

Based on the constancy with which the limbus is inverted into the joint in a typical congenital dislocation of the hip, a hypothesis is presented which suggests that the sequence of events leading to established dislocation is: 1) lateral rotation aided and abetted by anteversion; 2) extension of the hips causing subluxation; 3) dislocation and inversion of the limbus; 4) secondary changes in the upper end of the femur, pelvis and acetabulum which will also develop if the deformity does not progress beyond a subluxation. A pen picture is drawn showing how anteversion is either moulded away during growth to produce a normal hip, or persists with or without dislocation. The fate of the persistently inverted limbus is discussed and a line of treatment based on these findings is briefly considered

Surgical dislocation of the hip is rarely undertaken. The potential danger to the vascularity of the femoral head has been emphasised, but there is little information as to how this danger can be avoided. We describe a technique for operative dislocation of the hip, based on detailed anatomical studies of the blood supply. It combines aspects of approaches which have been reported previously and consists of an anterior dislocation through a posterior approach with a ‘trochanteric flip’ osteotomy. The external rotator muscles are not divided and the medial femoral circumflex artery is protected by the intact obturator externus. We report our experience using this approach in 213 hips over a period of seven years and include 19 patients who underwent simultaneous intertrochanteric osteotomy. The perfusion of the femoral head was verified intraoperatively and, to date, none has subsequently developed avascular necrosis. There is little morbidity associated with the technique and it allows the treatment of a variety of conditions, which may not respond well to other methods including arthroscopy. Surgical dislocation gives new insight into the pathogenesis of some hip disorders and the possibility of preserving the hip with techniques such as transplantation of cartilage

1. The operative findings in seventeen cases of recurrent dislocation of the shoulder are presented and discussed. Detachment of the glenoid labrum (thirteen cases) and the formation of a posterior humeral groove (eleven cases) were the most consistent findings. 2. In one case recurrent dislocation of the shoulder was due to avulsion of the subscapularis muscle. 3. The surgical treatment of these cases is described, usually consisting of a modification of Bankart's operation. 4. The results of follow-up are given as an intermediate report. No post-operative dislocation has so far been reported

1. Two cases of recurrent post-traumatic dislocation of the hip are reported. 2. The literature is reviewed and the rarity of the condition is emphasised. Only twenty-two cases have been previously reported, eleven in adults and eleven in children. 3. The sequence of events leading to recurrent dislocation is not understood but the following important facts emerge. The initial incident could not be distinguished from that causing uncomplicated dislocations. There was a significant delay in reduction in a number of cases. Subsequent dislocations followed minor injury. A large defect in the posterior capsule with a large synovial-lined pouch or false joint was found at operation in both our cases. The ligamentum teres was not seen at operation. The surgeon was unable to redislocate the hips during the operation. 4. In both cases reported here treatment was by excision of the posterior pouch and repair of the capsular defect. 5. Based on the above facts some tentative deductions are made

The brachial artery is rarely injured after closed dislocation of the elbow. We describe an unusual variation of this injury, namely, a delayed thrombosis of the brachial artery after a closed dislocation sustained during a low-energy fall. This has not previously been described in the English literature, but may be more common than this suggests. We stress the importance of a thorough neurovascular examination and vigilance in regard to this potentially disastrous complication

1. Twenty-two dislocations of the hip occurring in patients paralysed from an early age have been studied. All showed abnormal coxa valga. The coxa valga, which may gradually reach 180 degrees, precedes dislocation and makes it inevitable. The presence of unbalanced adductor power may hasten dislocation, but the latter can occur in complete flaccid paralysis. 2. The combination of structural instability of the hip joint and muscular weakness may make independent walking impossible, but restoration of stability gives considerable improvement in any remaining muscular power and may alter the patient's whole future. 3. A method of correcting the basic deformity of coxa valga by osteotomy is described and the results of nine operations are reviewed

1. At an operation for recurrent posterior dislocation of the shoulder observations were made on the mechanism, head defect, method of reduction, and the position of greatest stability. 2. Experimentally, avulsion of the glenoid labrum in a monkey was shown to be capable of sound repair without operation. 3. In the treatment of primary posterior dislocation it is suggested that the position of abduction, lateral rotation and extension is favourable for the approximation of the stripped labrum and capsule to the glenoid rim, and for an effective buttress after cicatrisation. 4. If the risk of recurrence is to be reduced to a minimum the shoulder should be retained in the position of greatest stability for at least four weeks, to allow firm union of the avulsed soft tissues. 5. This position for an optimum buttress would also apply after surgical repair for recurrent posterior dislocation

Of 545 consecutive patients with anterior shoulder dislocations, 108 (20%) were aged 60 years or more at the time of injury. We reviewed and radiographed 95 of these elderly patients after a mean follow-up of 7.1 years. Axillary nerve injuries were seen in 9.3% of the 108 patients, but all recovered completely in 3 to 12 months. There were single or multiple recurrences of dislocation in 21 patients (22.1%), but within this group age had no influence on the tendency to redislocate. Tears of the rotator-cuff were diagnosed by imaging studies or clinically in 58 patients (61%), including all who had redislocations. Sixteen patients required surgery. Eight with a single dislocation and a cuff tear had only repair of the torn cuff. Of the eight patients with multiple dislocations requiring operation, five also had a torn cuff and needed either a stabilising procedure and a cuff repair or repair of the cuff only. All patients who were operated on had a satisfactory result, with the exception of those with multiple redislocations and a cuff tear who had repair of the cuff only. Anterior shoulder dislocation in elderly subjects is more common than is generally believed; 20% suffer redislocation and 60% have a cuff tear. Operation may be needed to repair a torn cuff or to stabilise the shoulder. Patients with multiple redislocations will probably require both procedures

1. Fifty dislocations and fracture-dislocations of the pelvis have been reviewed. 2. Complications were unusual. Two patients with rupture of the bladder died; two with rupture of the urethra survived. Of eight patients with retroperitoneal haemorrhage four died; the treatment advised is controlled blood transfusion maintaining a blood-pressure of not more than 100 mm. 3. Two types of pelvic disruption should be distinguished: 1) pubic injury with sacro-iliac dislocation; 2) pubic injury with fracture near the sacro-iliac joint. The first is twice as common as the second. 4. In each type, displacement is maintained by extension of the hip and outward roll of the limb. This may be controlled by the Watson-Jones plaster method but the pelvic sling technique is preferred and was used in all cases in this series. 5. The prognosis in fracture-dislocations is very good; nearly all patients went back to heavy work. 6. The prognosis in sacro-iliac dislocations is not so good; only half the patients went back to heavy work and there was often persistent sacro-iliac pain. Sacro-iliac arthrodesis is advised in those cases

Seven children with chronic post-traumatic dislocation of the radial head were treated by open reduction and ligament reconstruction by a triceps tendon slip. In the four patients with anterior dislocation, good results were achieved; in the two with anterolateral dislocations bowing of the ulna persisted and subluxation recurred. One patient with an anterior dislocation developed a radio-ulnar synostosis. For anterolateral dislocations, we advise the combining of open reduction and ligament reconstruction with osteotomy of the ulna

1. Coracoid transplantation for recurring dislocation of the shoulder is described. 2. In my experience of over thirty cases only once has true dislocation recurred after this operation. Recurrence was due to avulsion of the bone block. 3. Failure to repair the original detachment of the glenoid labrum is a frequent cause of recurrence of dislocation of the shoulder. An explanation is offered for this failure; namely that the injured labrum adheres to the deep surface of the subscapularis muscle instead of reattaching itself to bone. This reinforces Watson-Jones's advice that the original dislocation should be treated by complete immobilisation in full medial rotation for three weeks

During open reduction of an irreducible anterior dislocation of a total hip replacement with an Oxinium femoral head, it was observed that the head had been significantly damaged. Gross and scanning electron microscopic examination revealed cracking, gouging, and delamination of the surface. Because of the risk which this poses for damaging the polyethylene acetabular liner, it is strongly recommended that patients with this type of prosthetic head be carefully monitored after a dislocation

1 . Dislocation of the upper end of the fibula is probably less unusual than the paucity of the published reports suggests. 2. Dislocation may be anterior or posterior, anterior dislocation occurring about twice as often as posterior. Rarely the fibula moves proximally. 3. In most cases a closed manipulation suffices for reduction, and a full and rapid return of normal function follows. 4. Five cases are described. In one case operative reduction was required

1. The literature of dislocation of the hip in childhood from 1922 to 1954 is reviewed. A total of eighty-eight cases have been recorded. 2. A further case, in a child of one year and eleven months, is described. 3. Nine of the children whose cases have been recorded developed Perthes' disease of the hip after the dislocation, an incidence of 10 per cent. A similar incidence of avascular necrosis of the femoral head has been reported after dislocation of the hip in adults

Twenty-three patients, aged from 10 to 60 years, underwent open reduction for untreated posterior dislocations of the elbow. The dislocations had been unreduced for periods varying from one month to two years. All patients underwent a standard procedure based on the Speed technique. Complications after operation included one case of gross sepsis and five cases of ulnar neuritis. Most patients gained a useful range of flexion-extension of the elbow. Neither the age of the patient nor the duration of the unreduced dislocation influenced the result

Entire human cadaveric cervical spines with the basiocciput were subjected to load in a compression apparatus to simulate the clinical situation of forward dislocation. The movements were recorded by lateral cineradiography. Vertical load was measured by a potentiometric transmitter synchronised with each frame of the cineradiograph. The lower part of the spine was flexed and fixed, and the upper extended and free to move forward. Vertical compression then produced bilateral dislocation of the facets without fracture. If lateral tilt or axial rotation occurred as well, a unilateral dislocation was produced. The maximum vertical load was only 145 kilograms, and coincided with the rupture of the posterior ligament and capsule and the stripping of the anterior longitudinal ligament, but this occurred before dislocation. The low vertical load indicates a peculiar vulnerabiity of the cervical spine in this position and correlates well with the minor trauma often seen in association with forward dislocation