We have reviewed the literature on the anatomy of the posteromedial peripheral ligamentous structures of the knee and found differing descriptions. Our aim was to clarify the differing descriptions with a simplified interpretation of the anatomy and its contribution to the stability of the knee. We dissected 20 fresh-frozen cadaver knees and the anatomy was recorded using video and still digital photography. The anatomy was described by dividing the medial collateral ligament (MCL) complex into thirds, from anterior to posterior and into superficial and deep layers. The main passive restraining structures of the posteromedial aspect of the knee were found to be superficial MCL (parallel, longitudinal fibres), the deep MCL and the posteromedial capsule (PMC). In the posterior third, the superficial and deep layers blend. Although there are oblique fibres (capsular condensations) running posterodistally from femur to tibia, no discrete ligament was seen. In extension, the PMC appears to be an important functional unit in restraining tibial internal rotation and valgus. Our aim was to clarify and possibly simplify the anatomy of the posteromedial structures. The information would serve as the basis for future biomechanical studies to investigate the contribution of the posteromedial structures to joint stability

A new technique of shoulder fusion is presented using a posterior approach. After removal of the articular cartilage, a Rush pin is introduced from the spine of the scapula, through the glenoid into the medullary canal of the humerus. This is supplemented by tension-band wiring from the acromion to the neck of the humerus and a muscle pedicle graft attached to the acromion. A shoulder spica is applied for four to six weeks. Four patients with injuries to the upper brachial plexus and 14 with paralysis of the upper arm due to anterior poliomyelitis have been followed for three years. One of the 18 patients developed nonunion; she had removed her own cast prematurely. This method of fixation provides high shear resistance and low axial stiffness without deforming plastically. It does not affect bone growth in young patients, is effective in patients with osteoporosis, and gives a high rate of union

Chronic rotator-cuff syndrome with impingement is satisfactorily treated by acromioplasty by both open and arthroscopic techniques, but the Neer operation with deltoid detachment requires a prolonged rehabilitation. Arthroscopic acromioplasty reduces recovery time but is a difficult procedure. McShane, Leinberry and Fenlin (1987) described a conservative open anterior technique with good results and shortened rehabilitation. A similar technique has been used in 25 patients with an average age of 46 years. After a mean follow-up of 24 months, 80% were very satisfied and none was dissatisfied. The average recovery times were 2.7 weeks for activities of daily living, 1.9 months for return to work and 3.7 months for all activities including overhead manual labour

We treated 110 fractures of the middle third of the clavicle in 108 patients aged between 14 and 66 years, by fixation with 2 mm Kirschner wires. The wire was introduced, using an air drill and a telescoping guide, from the medial into the lateral fragment. The medial end of the wire which perforated the anterior cortex of the medial fragment was bent backwards to prevent migration into the lung or mediastinum. In cases of nonunion and acute fracture in which a bone gap was present, bone graft was laid around the fracture site after internal fixation. All the fractures united. No wires broke but in three patients one migrated before union was achieved. Twenty-one patients failed to return for removal of the wire; nine of them had radiological evidence of union before they were lost to follow-up

The design and use of a prong plate for the treatment of displaced fractures of the femoral neck is described. The prongs hold the femoral head, and the plate is screwed to the anterior cortex of the femoral neck and trochanteric region. The new plate has been used in 32 patients with Garden stage III or IV fractures and 29 had a good result. Bony union was seen within 11 weeks in all patients in whom bleeding of the femoral head was noted at operation, but was much delayed in patients without bleeding. Late segmental aseptic necrosis was seen in four patients after follow-up of at least two years, and successfully treated. The prong plate allows accurate reduction, impaction and strong rigid fixation with less disturbance of the intramedullary blood flow than other fixation methods

Using roentgen stereophotogrammetry we have recorded the three-dimensional movements of the knee during an anteroposterior laxity test in 36 patients with torn anterior cruciate ligaments and in three cadaver knees. At 30 degrees of knee flexion and before loads were applied the tibia occupied a more laterally rotated position if the anterior cruciate ligament had been injured. When the tibia was pulled anteriorly knees with cruciate deficiency rotated more laterally and were more abducted than normal knees. Posterior traction induced lateral rotation in the injured knee and medial rotation in the intact one. Precise knowledge of the three-dimensional instability of the anterior cruciate deficient knee may be important when the laxity is evaluated only in relation to one of the three cardinal axes

In the Trillat procedure for recurrent anterior instability of the shoulder the coracoid process is osteotomised and tilted downward to act as a bone block, and a screw is used to fix it and the Bankart lesion to the anterior scapular neck. We reviewed 52 cases after a mean follow-up of 69 months. Results in 73% of shoulders were excellent, 10% were good, 7% fair and 10% poor. Dislocation recurred in 4%, but a positive apprehension sign was present in 10 other shoulders. Some degenerative changes were seen in 62% of shoulders, a complication known to be associated with bone-block procedures. The most important reason for loss of lateral rotation was iatrogenic impingement of the coracoid. This frequent and potentially serious complication can also cause posterior subluxation of the humeral head and osteoarthritis

We evaluated scapular dysplasia and malposition in 15 patients with the Sprengel deformity using three-dimensional CT (3D-CT). The shape, height-to-width ratio, the areas of both scapulae, the anterior curvature of the supraspinous portion and glenoid version were assessed on scapular posterior, medial and inferior views. The degree of rotation and superior displacement were measured on the trunk posterior view. The omovertebral connection was also assessed and correlated with the operative findings. Most of the affected scapulae had a characteristic shape with a decrease in the height-to-width ratio and were larger than the contralateral scapulae. There was an inverse relationship between scapular rotation and superior displacement. The typical curve of the supraspinous portion of the scapula was seen in only three cases. There was no significant difference in glenoid version. The point of tethering of the omovertebral connection may determine the shape, rotation and superior displacement of the scapula. 3D-CT was helpful in delineating the deformity in detail, and in planning scapuloplasty

Late-onset idiopathic scoliosis is associated with a rib hump in the thoracic region, and surgery is indicated when this deformity becomes unacceptable. Fifty patients with this deformity were treated by the Leeds procedure, which consists of segmental wiring to a kyphotically-contoured square-ended Harrington rod; this procedure not only derotates the spine but restores the natural thoracic kyphosis, thus avoiding subsequent buckling. All patients were followed up for a minimum of two years. Forty-two of these, who had a pre-operative Cobb angle of less than 60 degrees, were treated by one-stage instrumentation and fusion, while the remaining eight with greater curves underwent preliminary anterior multiple discectomy to provide flexibility with shortening. Postoperative loss of correction was not observed and there were no neurological complications

Atlanto-axial rotatory fixation is one of a spectrum of rotatory abnormalities of the atlanto-axial joint. Rotatory fixation without anterior displacement of the atlas (Type I) has been reported in only a few cases in which there has been a prolonged interval between injury and diagnosis. The majority of these cases eventually required cervical fusion for persistent deformity or instability. Two cases are presented in which this diagnosis was made early with the aid of rotated odontoid radiographs, tomography and computerised axial tomography. Treatment by a short period of halter traction achieved reduction and early return of function. The authors conclude that early recognition and treatment of this rare condition may prevent the subsequent deformity and instability for which cervical fusion has been required

We studied the kinetics of the knee in 20 patients (22 knees) 12 months after total knee arthroplasty (TKA), by using three-dimensional radiostereometry and film-exchanger techniques. Eleven knees had a concave (constrained) tibial implant and 11 a posterior-stabilised prosthesis. Eleven normal knees served as a control group. In the posterior-stabilised knees there was less proximal and posterior displacement of the centre of the tibial plateau during extension from 45° to 15°, with a decrease in the anterior translation of the femoral condyles of 4 mm at 45°. There was less internal tibial rotation and increased distal positioning of the centre of the tibial plateau with both designs when compared with the normal knees, and in both the centre of the plateau was displaced posteriorly by more than 1 cm. Increased AP translation has been recorded in all prosthetic designs so far studied by radiostereometry. The use of a posterior-stabilised design of tibial insert could reduce this translation but not to that of the normal knee

Two cases of unusual snapping at the elbow are described. In both, the medial head of the triceps was found to be separated from the main muscle belly. During flexion of the elbow, the medial head dislocated over the medial epicondyle, producing a characteristic snapping phenomenon. Both cases were of long standing and had been asymptomatic for years. The first clinical symptoms were those of an ulnar neuropathy. In order to restore the normal position of the medial head of the triceps, its tendon was detached from the olecranon, passed under the central tendon and interlaced to it. The ulnar nerve was left in the epicondylar groove in one case and transposed anteriorly in the other. At the end of the procedure flexion of the elbow was unobstructed and the snapping phenomenon had disappeared

We describe six patients aged from 10 to 15 years who, after injury to the distal tibial physis, presented with the following clinical findings: 1) severe pain and swelling of the ankle; 2) hypoaesthesia or anaesthesia in the web space of the great toe; 3) weakness of extensor hallucis longus and extensor digitorum communis; and 4) pain on passive flexion of the toes, especially the great toe. In four patients, the fractures were not reduced for more than 24 hours. The intramuscular pressure beneath the superior extensor retinaculum of the ankle was greater than 40 mmHg in all cases (40 to 130 mmHg), and less than 20 mmHg in the anterior compartment. Treatment consisted of release of the superior extensor retinaculum and stabilisation of the fracture. All patients had prompt relief of pain and improved strength and sensation within 24 hours, although two had some residual numbness in the web space of the great toe

In order to investigate the functional anatomy of gluteus minimus we dissected 16 hips in fresh cadavers. The muscle originates from the external aspect of the ilium, between the anterior and inferior gluteal lines, and also at the sciatic notch from the inside of the pelvis where it protects the superior gluteal nerve and artery. It inserts anterosuperiorly into the capsule of the hip and continues to its main insertion on the greater trochanter. Based on these anatomical findings, a model was developed using plastic bones. A study of its mechanics showed that gluteus minimus acts as a flexor, an abductor and an internal or external rotator, depending on the position of the femur and which part of the muscle is active. It follows that one of its functions is to stabilise the head of the femur in the acetabulum by tightening the capsule and applying pressure on the head. Careful preservation or reattachment of the tendon of gluteus minimus during surgery on the hip is strongly recommended

We report a review of 54 patients with chronic anterior cruciate ligament rupture treated by patellar-quadriceps tendon graft augmented with polypropylene braid (Kennedy-LAD). The femoral placement of the graft was randomised to either a modified over-the-top (OTT) or a tunnel position obtained by an isometric drill guide (ISO). At the two-year follow-up both procedures had resulted in improvement of subjective knee function and activity level. Stereoradiographic measurements showed reduction of anteroposterior laxity to near normal in about one-third of the patients, but muscle strength and objective functional performance showed little or no changes. The OTT group had better subjective knee function. We were unable to confirm the theoretical advantages of the use of the drill guide, partly because it provided a tibial tunnel which was too anterior

Objectives

Legg–Calvé–Perthes’ disease (LCP) is an idiopathic osteonecrosis of the femoral head that is most common in children between four and eight years old. The factors that lead to the onset of LCP are still unclear; however, it is believed that interruption of the blood supply to the developing epiphysis is an important factor in the development of the condition.

We present the mid- to long-term results of the Chiari pelvic osteotomy for dysplastic hips. We followed 135 hips in 129 patients, with a mean age at the time of surgery of 24 years, for a mean of 16.2 years. We used the anterior iliofemoral approach without trochanteric osteotomy in the initial 31 hips. Thereafter, we used transtrochanteric approaches in an attempt to ensure that the osteotomy was at the most appropriate level, and to advance the high-riding greater trochanter distally. The next 79 hips therefore underwent a posterolateral approach and the most recent 25 hips an Ollier lateral U approach. The clinical result was excellent or good in 103 hips (77%). The outcome in 104 hips in which we used a transtrochanteric approach was superior, the osteotomy level was more appropriate and a Trendelenburg gait less common than in 31 hips in which we used an anterior approach. We therefore recommend the use of a transtrochanteric approach in order to ensure that the osteotomy is at an appropriate level and in order to achieve effective distal advancement of the high-riding greater trochanter

Posterior fixation of intervertebral discs is used to treat, and occasionally diagnose, discogenic pain since it is thought that it will reduce the internal loading of the discs in vitro. We measured the internal loading of ten intervertebral discs using stress profilometry under simulated physiological loads and then after posterior fixation. Partial discectomies were performed to simulate advanced disc degeneration and the sequence repeated. Posterior fixation had very little effect on the magnitude of the loads acting on the disc and none when disc degeneration was simulated. It did, however, reduce bulging of the anterior annulus under combined bending and compression (p < 0.03). Recent experiments in vivo have shown that discogenic pain is associated with abnormal bulging of the annulus which suggests that the clinical benefit of fixation may be due to this

Aims

Accurate placement of the acetabular component is essential in total hip arthroplasty (THA). The purpose of this study was to determine if the ability to achieve inclination of the acetabular component within the ‘safe-zone’ of 30° to 50° could be improved with the use of an inclinometer.

The management of traumatic dislocation of the knee in 40 patients (41 knees) with a mean age of 26.3 years is described. They were treated by primary repair and reconstruction with autologous grafting of the anterior (ACL) and posterior cruciate ligaments (PCL) and repair injuries to the collateral ligament and soft-tissue. The ACL and PCL were reconstructed using the patellar tendon and the gracilis and semitendinosus tendons, respectively. Early mobilisation using a continuous-passive-movement machine and active exercises was started on the second day after operation. At a mean follow-up of 39 months no patient reported ‘giving way’ and all except one had good range of movement. Of the 41 knees, 21 were rated as excellent, 15 good, four fair and one poor. Early reconstruction of the cruciate ligaments and primary repair of the collateral ligaments followed by an aggressive rehabilitation programme are recommended for these young, active patients