1. A collected series of forty-seven traumatic dislocations of the hip in children is reported and reviewed in detail. 2. All were simple hip dislocations, and no child was included in whom there was any other injury to the affected joint. 3. All were posterior dislocations. 4. No anatomical predisposition was observed. 5. Significant complications occurred in fourteen children: avascular necrosis of the head of the femur in four, degenerative joint changes in three, premature epiphysial fusion in one and overgrowth of the femoral head in six. Study of the children with these complications revealed no common cause except the dislocation itself. 6. The injury responsible was often trivial. 7. The results suggest that it is harmless to bear weight four weeks after reduction

1. A series of eighty-one hips with slipped upper femoral epiphysis in sixty-three patients is reviewed. 2. The importance of early diagnosis is emphasised. 3. Conservative treatment is condemned. 4. In attempting reduction violent manipulation and strong traction must be avoided. 5. In cases of slight displacement pinning in the position of displacement gives the best results. 6. Three or four small pins are recommended for fixation. 7. When the amount of slip is 50 per cent or more of the diameter of the head gentle manipulation should be tried and, if successful, followed by fixation with three or four pins. 8. The hip with an irreducible slip of 50 per cent or more should be treated by pertrochanteric or subtrochanteric osteotomy

1. The structure and blood supply of the femoral head and neck, the mechanics of weight bearing, and the known effects of an inert foreign body are considered in relation to arthroplasty. 2. Some artificial hips are reviewed from the biomechanical standpoint. 3. From the information now available it is inferred that mechanical soundness and clinical success are not only co-related but interdependent; and that the mechanical problem of design offers most scope for further development at the present stage of our knowledge. 4. To this end six propositions are submitted. 5. A theoretical replacement arthroplasty, confined to the head and neck, in which breakdown of the component forces suggests that reciprocal use of both tensional and compressive loads might occur as in the natural femur, is described

In children with obstetric brachial plexus palsy (OBPP) who develop an internal rotation deformity of the shoulder, release of subscapularis improves the range of external rotation of the shoulder and the strength of supination of the forearm. We studied the strength of supination in 35 healthy adult volunteers at 45° of both internal and external rotation. The mean and maximum torques were greater in external than internal rotation by 8.7% and 7.5%, respectively. This was highly significant (p < 0.0001). The increased strength of supination in external rotation is probably because the maximum power of biceps, particularly the long head, may be exerted in this position. In children the difference may be even greater due to anatomical differences causing the dramatic increases in the strength of supination after surgery for OBPP. In adults our findings suggest that the supination exercises which are undertaken after injury or surgery to the forearm or wrist should be performed in external rotation

We studied five cadaver shoulders to determine the strength relationship of the four rotator cuff muscles. The mean fibre length and volume of each muscle were measured, from which the physiological cross-sectional area was calculated. This value was used to estimate the force which each muscle was capable of generating. The lever arm of each muscle about the humeral head was then measured and the moment exerted was calculated. The strength ratios between the muscles were more or less constant in the five specimens. Subscapularis was the most powerful muscle and contributed 53% of the cuff moment; supraspinatus contributed 14%, infraspinatus 22% and teres minor 10%. The force-generating capacity of the subscapularis was equal to that of the other three muscles combined

We describe 11 cases of posterior fracture-dislocation of the shoulder that required open reduction and fixation. Difficulties with access through anterior approaches led us to use the superior subacromial approach. This is an extension of the approach often used to expose the rotator cuff; the joint is opened by splitting the supraspinatus tendon 5 mm behind the cuff interval. The glenoid, proximal humerus and any fracture fragments can be seen from above, allowing reduction of the dislocation and osteosynthesis to be performed with minimal risk of damage to the humeral head and its blood supply. The proximity of the axillary nerve limits the exposure of the proximal humeral shaft. The superior subacromial approach is ideal for posterior dislocation with fracture of the articular segment, but is not suitable when there is a fracture of the proximal humeral shaft

A leading problem with cementless hip replacement is thigh pain, probably due to some degree of loosening. This is most pronounced during activities such as stair climbing or getting up from a chair. Our study compares the immediate fixation of three stems in widespread clinical use, using a cadaver test simulation in which the femur was horizontal, and cyclic forces acted vertically downward on the prosthetic head with gradual increments of load. We implanted and tested 18 pairs of femurs, making analyses between stem types by right to left comparisons. We found no statistically significant differences in loosening between cementless AML and PCA prostheses, but cemented stems withstood greater loads than uncemented stems by a factor of five or more

We reviewed eight children (ten shoulders) who had suffered neonatal sepsis, after a mean follow-up of 14 years (11 to 15). The delay between the onset of symptoms and diagnosis was one day in five patients, two days in three and seven days in one. All ten shoulders were treated by aspiration, followed by arthrotomy in two. At follow-up, five of the ten shoulders had a full range of movement and the others had minimal restriction of external rotation. Shortening of 10 cm was present in one patient, while two with bilateral involvement had disproportionally short humeri. Early diagnosis and treatment favour the outcome in septic arthritis of the shoulder. With late diagnosis, deformation of the humeral head and shortening of the humerus cause marked cosmetic abnormality but negligible functional loss

A prospective trial is reported which compares distal osteotomy of the first metatarsal with Keller's arthroplasty in the treatment of adult hallux valgus. A total of 33 patients attended for review at least three years after operation. Symptomatic improvement, as assessed by patient satisfaction, pain relief, cosmetic improvement and restoration of function, was similar in the two groups. Objective measurement showed that the range of movement of the metatarsophalangeal joint was better maintained after osteotomy, as was the relationship of the sesamoid bones to the head of the first metatarsal. Correction of the valgus deformity also was significantly better in the patients who underwent osteotomy and in these patients the first intermetatarsal angle was reduced to within normal limits. There was no evidence that initial degenerative changes or subluxation at the metatarsophalangeal joint compromised a successful result from osteotomy

1. The epiphyses of the metatarsal heads of 250-gramme rabbits were separated at the zone of cell columns, stripped of perichondrium, labelled with tritiated thymidine and transplanted into the back muscles of the same animals. 2. Endochondral ossification started in the grafts at four days, was well established by seven days and progressed until fourteen days, the end of the study. 3. Progressive passage of the label down the zone of cell columns and into the hypertrophic zone was observed. 4. The tritiated-. 3. H thymidine label had disappeared from the cartilage cells by ten days. No labelling was observed in the bone cells at any stage. 5. It was not possible to demonstrate from the experiment that growth plate chondrocytes are precursors of osteoblasts in the process of endochondral ossification in rabbits

1. Correction of hallux valgus by spike osteotomy of the neck of the first metatarsal is described, and the results in eighty-two feet are presented. 2. A high proportion of satisfactory results can be obtained, but great care is needed in both selection and technique. 3. The ideal case is one of moderate deformity, without degenerative arthritis, and with symptoms referable to increased width of the forefoot; the operation should not be performed in cases with obvious degenerative change, nor when metatarsalgia is a prominent symptom. 4. It is important to displace the metatarsal head as far laterally as possible, and vital to avoid dorsal angulation or displacement. 5. It is suggested that enough is now known about the natural evolution of hallux valgus and the results of some operations for prophylactic surgery to be undertaken in carefully selected cases

We treated 31 hips in 30 patients with advanced osteoarthritis of the hip secondary to acetabular dysplasia, by valgus-extension femoral osteotomy. The mean follow-up was 12.7 years (10 to 17). Acetabuloplasty was added in ten severely dysplastic hips. In 28 hips, radiological widening of the joint space was seen three years after operation, but in 12 had narrowed again by ten years. Survivorship analysis showed that the rate of survival was 82% using the pain score as the index of failure, and 72% based on radiological findings at ten years. Better long-term results were obtained in hips which had an acetabular head index greater than 70% or a roof osteophyte more than 5 mm in length three years after operation. Acetabuloplasty should be added for the hip which is severely dysplastic and with a poorly developed roof osteophyte

We treated 12 shoulders in ten patients with irreparable rotator-cuff tears by transfer of the latissimus dorsi. There were nine men and one woman. Their average age was 64.0 years and the average follow-up was 35.6 months (26 to 42). The results were excellent in four shoulders, good in four, fair in one, and poor in three. Active forward flexion improved from a preoperative average of 99° to a postoperative average of 135°. Osteoarthritic changes appeared in five shoulders and proximal migration of the humeral head progressed in six. EMG revealed that nine of the 12 transferred muscles showed activity which was synergistic with the supraspinatus on external rotation with abduction. We conclude that latissimus dorsi transfer can be effective in restoring shoulder function after massive irreparable tears of the rotator cuff

Open reduction and internal fixation was employed in the treatment of 25 severely displaced fractures and fracture-dislocations of the proximal humerus. Our aims were accurate reduction and stable fixation to allow early mobilisation and to achieve full functional recovery. In 15 fractures an AO T-plate was used and in 10 a bent semitubular plate was employed as a blade plate. Excellent or satisfactory results were obtained in all six patients with two-part fractures involving the surgical neck; in four of the five patients with three-part fractures involving the surgical neck and tuberosities; in nine of the 11 patients with fracture-dislocation; and in two of the three patients with split fractures of the humeral head. Overall results were good or satisfactory in 21 of the 25 cases. Unsatisfactory results were associated with rotator cuff damage

Objectives

Intra-articular injections of local anaesthetics (LA), glucocorticoids (GC), or hyaluronic acid (HA) are used to treat osteoarthritis (OA). Contrast agents (CA) are needed to prove successful intra-articular injection or aspiration, or to visualize articular structures dynamically during fluoroscopy. Tranexamic acid (TA) is used to control haemostasis and prevent excessive intra-articular bleeding. Despite their common usage, little is known about the cytotoxicity of common drugs injected into joints. Thus, the aim of our study was to investigate the effects of LA, GC, HA, CA, and TA on the viability of primary human chondrocytes and tenocytes in vitro.

Patients suffering from generalised convulsions may dislocate their shoulders either anteriorly or posteriorly. Those with anterior dislocation are likely to have recurrent episodes because of secondary bony damage to the anterior rim of the glenoid and head of the humerus. In such patients there is high rate of failure of the standard soft-tissue stabilisation procedures. We have therefore devised a bone buttress operation in which autograft or allograft is secured to the deficient anterior glenoid and shaped to form an extension of its articular surface. We report our experience in 14 patients with grandmal epilepsy and recurrent anterior dislocation of the shoulder. After the bone buttress operation there were no further dislocations and all patients were satisfied despite a small restriction in their range of movement. We believe this to be the operation of choice for patients with this difficult problem

During the 11-year-period from 1970 to 1980, 799 total hip arthroplasties with metal-on-plastic prostheses were performed for primary osteoarthritis. In all cases high viscosity cement was used, but not under pressure; acetabular cartilage was removed, but the femoral canal was not plugged. The rate of revision and risk factors were evaluated by survivorship analysis. The overall cumulative revision rates were 11%, 14% and 19% after 8, 10, and 14 years respectively. When prophylactic antibiotics were not used, there was a significant risk of revision for infection. The risk of revision for mechanical loosening of both the acetabular and femoral components was significantly increased for men, younger patients, and if a snap-fit prosthesis with a 35 mm head and short wedged stem was used. The survivorship findings were validated by multivariate statistical analysis

We studied the morphological changes in the proximal femur in 42 patients (42 hips) who had had varus derotation osteotomy of the upper femur for residual acetabular dysplasia and congenital subluxation of the hip and who did not show deformity of the head of the femur. In 19 patients the alignment of the whole leg was examined. The femoral neck-shaft angle (FNSA) at the final examination was unrelated to that immediately after operation or to the state of the acetabulum at that time. The postoperative FNSA was not related to the final result but the CE angle obtained at surgery influenced the outcome. The femoral length did not differ significantly between the unaffected and affected sides. Significant differences were found in the femorotibial angle (176.6 degrees v 174.5 degrees) and in the point of intersection between the mechanical axis and knee (65.0% v 57.2%)

1. Resolving infantile scoliosis is transient and unimportant; progressive infantile idiopathic scoliosis can be catastrophic. 2. To be able to differentiate the two at an early stage is a considerable advance. This is important for many reasons, but particularly for parents who are anxious for the future of an infant with a small curve which looks so innocent but which can be so malignant. 3. With the new observations reported by Mehta on the difference of the angles between the apical vertebra and its two ribs, and on the radiological relationship of these rib heads to the vertebral body, the prognosis is now almost wholly reliable. 4. Our former clinical impression that all cases with compensatory curves are progressive has now been verified. 5. At last an early distinction between progressive and resolving scoliosis can be made with confidence

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