We have divided Severin group-V severely dysplastic hips with a false into three subtypes, based on the height and shape of the socket. We performed rotational acetabular osteotomy (RAO) in 19 hips in 17 young adults with a type-1 ‘low’ false acetabulum which had direct contact with the true acetabulum. This is a periacetabular osteotomy which gives acetabular coverage with articular cartilage and produces a nearly normal position of the head. Concomitant osteotomies of the proximal femur were carried out in 11 hips. We reviewed the patients clinically and radiologically at a mean of ten years (6 to 18) after operation. Of the 19 hips, 15 showed very good or good results. This operation is indicated in young adults with a dysplastic hip and a type-1 low false acetabulum. Subclassification of Severin group V is a convenient way of defining those patients who would benefit from the procedure

We investigated several factors which affect the stability of cortical screws in osteoporotic bone using 18 femora from cadavers of women aged between 45 and 96 years (mean 76). We performed bone densitometry to measure the bone mineral density of the cortical and cancellous bone of the shaft and head of the femur, respectively. The thickness and overall bone mass of the cortical layer of the shaft of the femur were measured using a microCT scanner. The force required to pull-out a 3.5 mm titanium cortical bone screw was determined after standardised insertion into specimens of the cortex of the femoral shaft. A significant correlation was found between the pull-out strength and the overall bone mass of the cortical layer (r. 2. = 0.867, p < 0.01) and also between its thickness (r. 2. = 0.826, p < 0.01) and bone mineral density (r. 2. = 0.861, p < 0.01). There was no statistically significant correlation between the age of the donor and the pull-out force (p = 0.246), the cortical thickness (p = 0.199), the bone mineral density (p = 0.697) or the level of osteoporosis (p = 0.378). We conclude that the overall bone mass, the thickness and the bone mineral density of the cortical layer, are the main factors which affect the stability of a screw in human female osteoporotic cortical bone

We examined 108 uncemented femoral stems with modular femoral heads which had been retrieved for reasons other than loosening. There were detectable amounts of wear and corrosion in 10 of 29 (34.5%) mixed-alloy components and 7 of 79 (9%) single-alloy components after a mean implantation time of 25 months. We found no correlation between the presence or extent of corrosion or surface damage and any of time in situ, initial diagnosis, reason for removal, age, or weight. Stems with wear and corrosion were less likely to show histological bony ingrowth. The interface between the head and stem of modular total hip components is a possible source of ion release and wear debris, but wear and corrosion were totally absent in most specimens. This suggests that this problem could be avoided, and that further research is required to develop manufacturing methods which would minimise such changes

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

Ten uncemented total hip replacements were performed in 1975 using an implant in which the cobalt-chrome femoral stem was coated to give a porous surface. In all but one case a high-density polyethylene head was used. The radiological changes in the upper femoral shafts were assessed between three and nine years later. Seven showed extensive stress-relieving changes, loss of calcar, stress fractures at the root of the lesser trochanter with subsequent detachment, and osteoporosis followed by avulsion of the greater trochanter. In these seven patients the lower part of the stem appeared to be soundly embedded, although in only one was there evidence of bony incorporation. It is suggested that if the fixation of a fully coated implant of this sort remains sound, gross atrophy of the upper femoral shaft develops after five years. This atrophy, associated with an implant which can be removed only at the expense of further bone destruction, presents substantial problems if revision is needed

1. One hundred and twenty-three patients with rheumatoid arthritis who had synovectomy and excision of the head of the radius performed on 154 elbows have been reviewed one to six years after operation. 2. The severity of the disease process at the time of operation was graded radiologically and an attempt made to relate this to the results. 3. Overall, the clinical results were most satisfactory; more than 70 per cent of the patients were pleased with the outcome. When radiographic deterioration of the joint was taken into account, however, only 54 per cent achieved a "satisfactory" result. 4. Clearance of the synovium through combined medial and lateral incisions gave better results than a lateral approach alone. 5. When the disease was far advanced by the time of operation any good results were likely to be short-lived. 6. The indications for synovectomy of the rheumatoid elbow are discussed in the light of these findings

1. The results of 243 thoracoplasty operations are discussed. It was found that scoliosis developed in over 99 per cent of cases and that the curve was convex towards the side of operation. The angle of curvature correlated closely with the number of ribs removed. 2. If the head, neck and tubercle of the rib and the transverse process of the corresponding vertebra were all removed the degree of scoliosis was increased, whereas if a thoracoplasty was performed with apicolysis and embedding of the scapula the spinal deformity was less. Possible explanations for these phenomena are discussed. 3. No evidence was found to support the theory of causation by imbalance between the paired "pneumatic cylinders" (lungs and thoracic cage) supporting the thoracic spine. 4. The scoliosis was found to progress for many years; some factors influencing this course are discussed. 5. No correlation was found between the age of the patient at the time of thoracoplasty and the degree of subsequent scoliosis, but severe spinal deformity can arise even in older adults

We compared the results of the surgical treatment of trochanteric hip fractures before and after surgeons had been introduced to the tip-apex distance (TAD) as a method of evaluating screw position. There were 198 fractures evaluated retrospectively and 118 after instruction. The TAD is the sum of the distance from the tip of the screw to the apex of the femoral head on antero-posterior and lateral views. This decreased from a mean of 25 mm in the control group to 20 mm in the study group (p = 0.0001). The number of mechanical failures by cut-out of the screw from the head decreased from 16 (8%) in the control group at a mean of 13 months to none in the study group at a mean of eight months (p = 0.0015). There were significantly fewer poor reductions in the study group. Our study confirms the importance of good surgical technique in the treatment of trochanteric fractures and supports the concept of the TAD as a clinically useful way of describing the position of the screw

1. Fifty-eight major injuries in the region of the talus were reviewed regarding treatment, incidence of complications and long-term results. 2. The prognosis for simple fractures of the head, neck or body was good, as was that for dislocations of the midtarsal and peritalar joints. 3. The prognosis for fracture-dislocations of the neck and body was better than has been frequently reported. It was related to the degree of initial trauma. A good result occurs only if accurate reduction is effected and maintained. Fixation with a Kirschner wire is a useful method of maintaining the reduction after unstable fracture-dislocations. 4. Avascular necrosis occurred only in the more severe injuries and its incidence was related to the degree of initial displacement. The late results were better than have been previously described. The condition is best treated conservatively by protection from weight-bearing until revascularisation is well advanced. 5. A case with an unusual pattern of fracture of the neck of the talus is described following a plantar-flexion inversion injury

1. Pathological hallux valgus may be differentiated from an increase in the normal valgus alignment of the great toe by the relationship to each other of the articular surfaces of the first metatarso-phalangeal joint; these are congruous in the normal joint, but displaced on each other in the pathological. 2. The earliest change is lateral deviation of the proximal phalanx on the metatarsal head, which may progress rapidly to subluxation. 3. Subluxation is an early change in a high proportion of cases, and is frequently present when the patient is first seen in adolescence. 4. Once subluxation has occurred progression of the deformity is likely. 5. Metatarsus primus varus and hallux valgus increase pari passu. There is not enough evidence to be certain which of these is the primary change, but such as there is suggests that lateral deviation of the great toe occurs first, and increase in the intermetatarsal angle is secondary to this. 6. It is suggested that hallux valgus should be regarded primarily and fundamentally as a subluxation, or tendency to subluxation, of the first metatarso-phalangeal joint

1. The arterial supply of the upper end of the femur has been studied in twenty-four children and twenty adults. 2. The arterial system was demonstrated by injection of radio-opaque material, with Spalteholz' method of clarification, and histological section of the neck and ligamentum teres. 3. The upper end of the femur is supplied by the nutrient artery of the shaft, the retinacular vessels of the capsule, and the foveolar artery of the ligamentum teres. 4. The retinacular vessels consist of three separate groups: postero-superior, posteroinferior, and anterior. These vessels are the chief supply to the epiphysis and femoral head at all ages. 5. The foveolar artery constitutes a small and subsidiary blood supply to the femoral epiphysis. In this series, it penetrated the cartilaginous or osseous head in 33 per cent. of young specimens and 70 per cent. of adult specimens. The foveolar vessels increase in size with age. 6. The site of the vascular pathology in various lesions of the femoral head is considered

Lack of full extension of the elbow is a common abnormality in patients with achondroplasia. We studied 23 patients (41 elbows) clinically and radiologically. Extension of the elbow was assessed clinically and the angle of posterior bowing of the distal humerus was measured from lateral radiographs. There was limited extension of the elbow in 28 (68.3%) and the mean loss of extension was 13.1°. Posterior bowing of the humerus was seen in all elbows with a mean angle of 17.0°. There was a positive correlation between these two measurements. Posterior bowing greater than 20° caused a loss of full elbow extension. Posterior dislocation of the radial head was seen in nine elbows (22.0%). The mean loss of extension of the elbows was 28.7° which was significantly greater than that of these elbows in which the head was not dislocated (8.7°), although posterior bowing was not significantly different between these two groups (19.3° and 16.3°). Posterior bowing of the distal humerus is a principal cause of loss of extension of the elbow. Posterior dislocation of the radial head causes further limitation of movement in the more severely affected joints

Survivorship analysis of 215 medial displacement pelvic osteotomies undertaken for symptomatic, incongruent dysplasia of the hip since 1966 showed that four of every five hips had not required conversion to a total hip arthroplasty. The radiological characteristics of 86 osteotomies were evaluated at a mean of 18 years (5 to 30) after surgery which was performed at the age of 15.9 ± 9.5 years. Revision was significantly (p < 0.05) more likely in those patients operated on after the age of 25 years. The centre-edge (CE) angle increased from 2.5 ± 13.9° before to 41.8 ± 15.0° immediately after operation. The increase in CE angle was maintained at later review (38.5 ± 16.5°). Even with severe dysplasia with a CE angle less than zero a substantial improvement in the cover of the femoral head was achieved, usually by medial shift of the lower pelvic fragment. However, the head was not invariably medialised by the osteotomy and lateral movement of the ilium was noted when the position of the joint was relatively medial before operation or when the hip was arthritic. In the longer term pelvic remodelling did not reverse the medialisation produced by the osteotomy, and the cover of the femoral head was maintained

We used a rat model in vivo to study the effects of the concentration of polyethylene particles on the bone-implant interface around stable implants in the proximal tibia. Intra-articular injections of 10. 4. , 10. 6. or 10. 8. high-density polyethylene (HDPE) particles per joint were given 8, 10 and 12 weeks after surgery. The animals were killed after 14 and 26 weeks and the response at the interface determined. Fibrous tissue was seen at the bone-implant interface when the head of the implant was flush with the top of the tibia but not when it was sunk below the tibial plateau. In the latter case the implant was completely surrounded by a shell of bone. The area of fibrous tissue and that of the gap between the implant and bone was related to the concentration of particles in the 14-week group (p < 0.05). Foreign-body granulomas containing HDPE particles were seen at the bone-implant interface in animals given 10. 8. particles. The pathology resembles that seen around prostheses with aseptic loosening and we suggest that this is a useful model by which to study this process

We treated 35 brachymetatarsal rays of 18 feet in 12 patients by one-stage lengthening with interpositional bone grafts or by gradual lengthening with callotasis combined with shortening of the adjacent metatarsals and phalanges. Definition of the two parabolas which connect the metatarsal heads and the tips of the toes, and recognition of three patterns of metatarsal length, were helpful guides in treatment. In total, 36 excisions of the phalanges and/or the metatarsals were undertaken. The mean shortening was 8 mm. The radiological results were satisfactory. The mean values were as follows: one-stage lengthening, length gain, 1.3 cm; healing index, 1.3 months/cm; percentage increase, 30%; gradual lengthening, length gain, 2.0 cm; healing index, 2.0 months/cm; percentage increase, 50%. Associated shortening of an adjacent bone can avoid the disadvantages of one-stage lengthening which may not achieve target length and can result in neurovascular complications. Reduction of the target length enables the surgeon to carry out one-stage instead of gradual lengthening. It also shortens the length of treatment in the group undergoing callotasis and improves cosmesis

We reviewed retrospectively 236 consecutive patients seen in our soft-tissue sarcoma clinic. Of these, 95 had had a primary soft-tissue sarcoma excised elsewhere, but with histologically inadequate resection margins. All these patients had a secondary and wider re-excision. The tissues removed at the secondary re-excision were examined histologically for the presence of residual tumour. Definite tumour tissue was found in 29 of 55 lower-limb specimens, 16 of 25 upper-limb, 7 of 10 trunk and 4 of 5 head and neck specimens. In 31 cases some residual tumour was visible macroscopically, and in 56 of the 95 patients (59%) the primary tumour had been incompletely excised. Our results indicate that surgical assessment of the adequacy of excision is very inaccurate and that most local recurrences are the consequence of inadequate primary surgery. The large number of patients who had inadequate initial treatment emphasises the need for a co-ordinated multidisciplinary approach to the management of patients with soft-tissue sarcoma

We have studied the long-term results of core decompression as the sole treatment for Ficat stages I, II and III ischaemic necrosis of 128 femoral heads in 90 patients. The 5-, 10- and 15-year survival rates for the three stages were respectively: stage I 100%, 96% and 90%; stage II 85%, 74% and 66%; and stage III 58%, 35% and 23%. At a mean follow-up of 11 years (4.5 to 19), 55 hips had failed (43%). No further surgery had been needed for 88% of stage-I, 72% of stage-II and 26% of stage-III hips; but despite the generally satisfactory clinical results, 56% of the hips had progressed radiographically by at least one Ficat stage. Complications of the core procedure included four fractures, all from postoperative falls, and one head perforation due to technical error. We conclude that core decompression delays the need for total hip replacement in young patients with ischaemic necrosis

We studied prospectively 30 patients who had a Mitchell’s osteotomy secured by either a suture followed by immobilisation in a plaster boot for six weeks, or by a cortical screw with early mobilisation. The mean time for return to social activities after fixation by a screw was 2.9 weeks and to work 4.9 weeks, which was significantly earlier than those who had stabilisation by a suture (5.7 and 8.7 weeks, respectively; p < 0.001). Use of a screw also produced a higher degree of patient satisfaction at six weeks, and an earlier return to wearing normal footwear. The improvement in forefoot scores was significantly greater after fixation by a screw at six weeks (p = 0.036) and three months (p = 0.024). At one year, two screws had been removed because of pain at the site of the screw head. Internal fixation of Mitchell’s osteotomy by a screw allows the safe early mobilisation of patients and reduces the time required for convalescence

Of 44 patients (55 hips) with slipped upper femoral epiphysis treated from 1963 to 1989, 13 (14 hips) developed chondrolysis. Eight hips had chondrolysis at the time of presentation, all in female patients who were either coloured or black and who had moderate or severe slips. The other six hips had persistent pin penetration of the joint; in five of these the pin penetrated the anterosuperior quadrant of the head. Removal of penetrating pins resulted in improvement in pain in all six hips and in the range of movement in four. Chondrolysis did not develop in any of 11 hips with transient intraoperative pin penetration. In hips with chondrolysis maximum joint-space narrowing developed within the first year; improvement in joint space and range of movement continued for up to three years after maximal involvement. At an average follow-up of 13.3 years no patient had pain but five hips were stiff

From 1981 to 1986 we treated 413 patients for acute spinal-cord injuries. We reviewed 356 patients followed for a minimum of two years of whom 71 (20%) developed heterotopic ossification around one or more joints. Heterotopic ossification occurred more often in male patients (23%) than in female (10%), and was most frequent in the 20- to 30-year age group. It was also more common after injuries of the lower cervical or thoracic spine than after those of the lumbar spine. Patients with severe neurological deficits (Frankel grades A and B) showed significantly more heterotopic ossification but there was no correlation with the number or severity of associated head and limb injuries. Serum calcium levels did not change significantly in either group for 30 weeks after injury, but the erythrocyte sedimentation rate and the alkaline phosphatase level were significantly increased at six weeks in patients with heterotopic ossification