This series, albeit consecutive and unselected, is very small; conclusions must therefore be tentative. The results do however suggest that the dangers of late manipulative reduction properly performed may have been exaggerated. Attempted without undue force it proved a harmless procedure, often successful even in cases of long duration. When it succeeds, the results in slips of unacceptable degree are at least as good as those following the more major surgical procedures, which can thus be avoided. Even when the displacement is minor its correction should on theoretical grounds at least decrease the prospects of later osteoarthritis. The only absolute contra-indication is a fused epiphysial plate. The degree of slip and above all the duration of symptoms should not preclude an attempt at manipulative reduction.

1. A brief description is given of normal epiphysial growth of the human femur.

2. Some ways in which abnormality of the growth plates may affect the shape and length of the human femur are described.

3. The influence of the blood supply on growth is discussed with particular reference to the etiology and treatment of congenital coxa vara.

I have attempted to call attention briefly to an operation that has proved to be of use in many patients with non-union of the neck of the femur and have tried to point out not only the indications but also the contra-indications, and to stress some of the precautions in the technique and after-care of the operation. This trochanteric reconstruction operation may help to solve some of the problems related to the ununited hip fracture.

Transepiphyseal separation of the neck of the femur following grand mal seizures is described in two children with cerebral palsy. Closed reduction and percutaneous fixation was followed by a period in a hip spica. Although the incidence of avascular necrosis of the femoral head is high following such injury, this has not occurred in these patients at a follow-up of 18 months.

1. Degenerative lesions of the shoulder joint can often be demonstrated radiographically before there is actual rupture of the musculo-tendinous cuff.

2. The characteristic pathological, clinical and radiographic features of degenerative lesionsare described.

3. All injuries of the shoulder joint, however trivial, occurring in patients over middle age, should be studied carefully by radiographic examination.

4. In injuries of the shoulder joint the presence of a degenerative lesion prolongs the duration of symptoms, and the prognosis is less satisfactory than when there is no radiographic evidence of abnormality.

1. A case of giant-cell tumour of the proximal end of the humerus treated by resection and fibular grafting twenty-nine years ago is reported. An excellent functional result has been maintained.

2. The literature is reviewed and the results claimed by earlier workers are noted.

3. The present field of application of the operation is probably in cases of advanced or recurrent giant-cell tumour of bone.

Techniques are described by which metal implants can be designed and produced to fit precisely a bony site at a subsequent operation. CT scans and solid modelling were used to produce an accurate three-dimensional representation of the surface of the bone. These techniques were applied to the production of an internal fixation device for shoulder arthrodesis after the resection of a neoplasm of the proximal humerus. The reconstruction utilised a free vascularised fibular graft between the scapula and the distal humeral remnant, fixation being secured with the custom-made implant.

Aims. The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD). Methods. Patients with adult spinal deformity who had undergone T9-to-pelvis fusion were stratified using the ASD-Modified Frailty Index into not frail, frail, and severely frail categories. ASD was defined as at least one of: scoliosis ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, or pelvic tilt ≥ 25°. Means comparisons tests were used to assess differences between both groups. Logistic regression analyses were used to analyze associations between frailty categories, UIV, and outcomes. Results. A total of 477 patients were included (mean age 60.3 years (SD 14.9), mean BMI 27.5 kg/m. 2. (SD 5.8), mean Charlson Comorbidity Index (CCI) 1.67 (SD 1.66)). Overall, 74% of patients were female (n = 353), and 49.6% of patients were not frail (237), 35.4% frail (n = 169), and 15% severely frail (n = 71). At baseline, differences in age, BMI, CCI, and deformity were significant (all p = 0.001). Overall, 15.5% of patients (n = 74) had experienced mechanical complications by two years (8.1% not frail (n = 36), 15.1% frail (n = 26), and 16.3% severely frail (n = 12); p = 0.013). Reoperations also differed between groups (20.2% (n = 48) vs 23.3% (n = 39) vs 32.6% (n = 23); p = 0.011). Controlling for osteoporosis, baseline deformity, and degree of correction (by sagittal age-adjusted score (SAAS) matching), frail and severely frail patients were more likely to experience mechanical complications if they had heart failure (odds ratio (OR) 6.6 (95% CI 1.6 to 26.7); p = 0.008), depression (OR 5.1 (95% CI 1.1 to 25.7); p = 0.048), or cancer (OR 1.5 (95% CI 1.1 to 1.4); p = 0.004). Frail and severely frail patients experienced higher rates of mechanical complication than ‘not frail’ patients at two years (19% (n = 45) vs 11.9% (n = 29); p = 0.003). When controlling for baseline deformity and degree of correction in severely frail and frail patients, severely frail patients were less likely to experience clinically relevant proximal junctional kyphosis or failure or mechanical complications by two years, if they had a more proximal UIV. Conclusion. Frail patients are at risk of a poor outcome after surgery for adult spinal deformity due to their comorbidities. Although a definitively prescriptive upper instrumented vertebra remains elusive, these patients appear to be at greater risk for a poor outcome if the upper instrumented vertebra is sited more distally. Cite this article: Bone Joint J 2024;106-B(11):1342–1347

Aims. To determine whether side-bending films in scoliosis are assessed for adequacy in clinical practice; and to introduce a novel method for doing so. Methods. Six surgeons and eight radiographers were invited to participate in four online surveys. The generic survey comprised erect and left and right bending radiographs of eight individuals with scoliosis, with an average age of 14.6 years. Respondents were asked to indicate whether each bending film was optimal (adequate) or suboptimal. In the first survey, they were also asked if they currently assessed the adequacy of bending films. A similar second survey was sent out two weeks later, using the same eight cases but in a different order. In the third survey, a guide for assessing bending film adequacy was attached along with the radiographs to introduce the novel T1-45B method, in which the upper endplate of T1 must tilt ≥ 45° from baseline for the study to be considered optimal. A fourth and final survey was subsequently conducted for confirmation. Results. Overall, 12 (86%) of 14 respondents did not use any criteria to assess the bending film adequacy; the remaining two each described a different invalidated method. In total, 12 (86%) of the respondents felt T1-45B was easy to learn and apply. There was fair to substantial intra-rater reliability (k = 0.25 to 0.88) which improved to fair to almost perfect (k = 0.38 to 0.88) post-introduction of the guide. Inter-rater reliability varied considerably among the rater groups but similarly increased following introduction of the guide (k. S1. = 0.19 to 0.34, k. S2. = 0.33 to 0.43 vs k. S3. = 0.49 to 0.5, k. S4. = 0.35 to 0.43). Conclusion. Many surgeons and radiographers do not assess spinal bending films for adequacy. We propose that the change in the plane of the upper endplate of T1 on side-bending can be used in this evaluation. In the T1-45B method, a change of ≥ 45° on side bending qualifies as an adequate bend effort. Cite this article: Bone Jt Open 2023;4(9):689–695