Spinal accessory nerve palsy leads to painful disability of the shoulder, carrying an uncertain prognosis. We reviewed the long-term outcome in 16 patients who were treated for pain, weakness of active elevation and asymmetry of the shoulder and the neck due to chronic paralysis of the trapezius muscle, as a result of nerve palsy. Of four patients who were treated conservatively, none regained satisfactory function, although two became pain-free. The other 12 patients were treated operatively with transfer of the levator scapulae to the acromion and the rhomboid muscles to the infraspinatus fossa (the Eden-Lange procedure). At a mean follow-up of 32 years, the clinical outcome of the operatively treated patients was excellent in nine, fair in two, and poor in one patient, as determined by the Constant score. Pain was adequately relieved in 11 and overhead function was restored in nine patients. Pre-operative electromyography had been carried out in four patients. In two, who eventually had a poor outcome, a concomitant long thoracic and dorsal scapular nerve lesion had been present. The Eden-Lange procedure gives very satisfactory long-term results for the treatment of isolated paralysis of trapezius. In the presence of an additional serratus anterior palsy or weak rhomboid muscles, the procedure is less successful in restoring shoulder function

We have used the Ilizarov technique for severe flexion deformity of the knee in 11 patients (13 knees) between 1986 and 1994 and have followed them up for an average of 4.1 years. The age of the patients at operation ranged from 1.7 to 18.8 years. The femoral and tibial components were connected by two anterior hinges, medial and lateral, and two posterior distraction rods. The deformity was corrected to a femorotibial lateral shaft angle of less than 20°. A permanent orthosis was applied after removal of the fixator. Fractures occurred in four patients and paralysis of the common peroneal nerve in another. There was a recurrence of the deformity in four patients. At the last review all patients were able to walk on their operated leg with or without an orthosis. We have found the Ilizarov method to be helpful in correcting severe fixed flexion deformity of the knee, with relatively few complications, but the basic principles of the method must be carefully followed

We present a study of ten consecutive patients who underwent excision of thoracic or thoracolumbar hemivertebrae for either angular deformity in the coronal plane, or both coronal and sagittal deformity. Vertebral excision was carried out anteriorly alone in two patients. Seven patients had undergone previous posterior spinal fusion. Their mean age at surgery was 13.4 years (6 to 19). The mean follow-up was 78.5 months (20 to 180). The results were evaluated by radiological review of the preoperative, postoperative and most recent follow-up films. The mean preoperative coronal curve was 78.2° (30 to 115) and was corrected to 33.9° (7 to 58) postoperatively, a mean correction of 59%. Preoperative coronal decompensation of 35 mm was improved to 11 mm postoperatively. Seven patients had significant coronal decompensation preoperatively, which was corrected to a physiological range postoperatively. There were no major complications and no neurological damage. We have shown that resection of thoracic and thoracolumbar hemivertebrae can be performed safely, without undue risk of neurological compromise, in experienced hands

Primary osteoarthritis of the ankle with no history of trauma is rare. We report the use of a low tibial osteotomy on 18 ankles in 18 patients, two men and 16 women. The osteotomy is designed to correct the varus tilt and anterior opening of the distal tibial joint surface where it has been shown by weight-bearing radiographs and arthroscopy that there is healthy articular cartilage on the lateral side of the ankle. An opening-wedge osteotomy was used to achieve slight overcorrection. Follow-up of the 18 ankles at an average of 6 years 11 months (2.7 to 12.10) showed the results by our own scoring system to be excellent in six ankles, good in nine, and fair in three with no poor results. Of the three patients with fair results, two had been undercorrected and the third had little residual articular cartilage. Arthroscopic examination of ten ankles showed repair by fibrocartilage in seven. We conclude that slight overcorrection of deformity by low tibial osteotomy is effective in treating intermediate-stage primary osteoarthritis of the ankle

Congenital convex pes valgus (congenital vertical talus) is a rare condition. We reviewed ten feet in seven patients who had had surgical correction. All had been operated on by the senior author (JF) and the same surgical technique was used throughout, incorporating transfer of the tibialis anterior to the neck of the talus. The mean age at surgery was 31 months and the mean follow-up was nine years (6 to 14). All patients completed a questionnaire and had clinical, radiological and photographic evaluation performed by an independent examiner. None had required further surgery. All but one were satisfied with the result, and had no functional limitations. They all wore normal shoes. The mean ankle dorsiflexion was 17° and plantar flexion 21°. The mean arc of subtalar motion was 27°. All radiological parameters measured were within the normal range, although irregularity of the talonavicular joint was common. No avascular necrosis of the body of the talus was seen. We conclude that the medium-term results of this procedure are very satisfactory

Patellofemoral problems are a common cause of morbidity and reoperation after total knee arthroplasty. We made a prospective study of 52 patients who had bilateral arthroplasty (104 knees) and in whom the patella was resurfaced on one side and not on the other. A movable-bearing prosthesis with an anatomical femoral groove was implanted on both sides by the same surgeon using an otherwise identical technique. The mean follow-up was 5.24 years (2 to 10). In the 30 available patients (60 knees) there was no difference between the two sides in subjective preference, performance on ascending and descending stairs or the incidence of anterior knee pain. Radiographs showed no differences in prosthetic alignment, femoral condylar height, patellar congruency or joint line position. The use of an appropriate prosthetic design and careful surgical technique can provide equivalent results after knee arthroplasty with or without patellar resurfacing. Given the indications and criteria, which we discuss, retention of the patellar surface is an acceptable option

Objectives

In this study, we compared the pain behaviour and osteoarthritis (OA) progression between anterior cruciate ligament transection (ACLT) and osteochondral injury in surgically-induced OA rat models.

The rate of success of transtrochanteric rotational osteotomy for osteonecrosis of the femoral head may be improved if patients are preselected using MRI. We have used three criteria for selection for osteotomy (i) minor collapse of the infarcted area, loss of congruity or the crescent sign, without narrowing of the joint space or acetabular involvement (ii) patients younger than 55 years and with a painful hip (iii) patients with an intact area constituting an arc of more than 120° between the central vertical line of the femoral head and the posterior or anterior margin of the necrotic portion as seen on a midsagittal MRI. Seventeen patients were selected, with a follow-up of more than 42 months. A bone scan four weeks after operation showed adequate perfusion of the proximal segment in all hips. The hip score of Merle d’Aubigné et al improved from 13.5 points before operation to 17.2 points at the latest follow-up. Further collapse of the femoral head did not occur. The use of MRI instead of plain radiographs for the selection of patients has improved the success rate of transtrochanteric rotational osteotomy

We treated 39 knees with chronic deficiency of the anterior cruciate ligament by reconstruction using the ABC carbon and polyester prosthetic ligament; 31 (79.5%) were reviewed at an average follow-up of 34 months. There had been four complete failures requiring revision. The remaining 27 were studied in detail. On the Lysholm rating, only 11 knees (41%) had good results with a score of over 76. The mean anterior drawer movement was reduced from 7.6 mm before operation to 5.8 mm at review. The mean difference from the opposite uninjured knee was 3.9 mm before operation, 1 mm (in 21 patients) at mean follow-up of 7.4 months and 2.5 mm (in 27 patients) at 34 months, indicating progressive loss of effect. In our opinion the results are unsatisfactory: we do not recommend the use of this prosthetic ligament

In six unloaded cadaver knees we used MRI to determine the shapes of the articular surfaces and their relative movements. These were confirmed by dissection. Medially, the femoral condyle in sagittal section is composed of the arcs of two circles and that of the tibia of two angled flats. The anterior facets articulate in extension. At about 20° the femur ‘rocks’ to articulate through the posterior facets. The medial femoral condyle does not move anteroposteriorly with flexion to 110°. Laterally, the femoral condyle is composed entirely, or almost entirely, of a single circular facet similar in radius and arc to the posterior medial facet. The tibia is roughly flat. The femur tends to roll backwards with flexion. The combination during flexion of no antero-posterior movement medially (i.e., sliding) and backward rolling (combined with sliding) laterally equates to internal rotation of the tibia around a medial axis with flexion. About 5° of this rotation may be obligatory from 0° to 10° flexion; thereafter little rotation occurs to at least 45°. Total rotation at 110° is about 20°, most if not all of which can be suppressed by applying external rotation to the tibia at 90°

Consecutive patients with a confirmed rupture of at least one of the lateral ligaments of the ankle were randomly assigned to receive either operative or functional treatment. They were evaluated at a median of 8 years (6 to 11). In total, 370 patients were included. Follow-up was available for 317 (86%). Fewer patients allocated to operative treatment reported residual pain compared with those who had been allocated to functional treatment (16% versus 25%, RR 0.64, CI 041 to 1.0). Fewer surgically-treated patients reported symptoms of giving way (20% versus 32%, RR 0.62, CI 0.42 to 0.92) and recurrent sprains (22% versus 34%, RR 0.66, CI 0.45 to 0.94). The anterior drawer test was less frequently positive in surgically-treated patients (30% versus 54%, RR 0.54, CI 0.41 to 0.72). The median Povacz score was significantly higher in the operative group (26 versus 22, p < 0.001). Compared with functional treatment, operative treatment gives a better long-term outcome in terms of residual pain, recurrent sprains and stability

We report the management of two children and 11 adults with paraplegia secondary to vertebral hydatidosis. Destruction of pedicles, posterior vertebral elements and discs as well as the vertebral bodies was common and all six patients with thoracic disease had involvement of adjacent ribs. The 13 patients had a total of 42 major surgical procedures; two patients died from postoperative complications and four from complications of the disease and paraplegia. All eight patients initially treated by laminectomy or anterior decompression alone relapsed within two years and seven required further surgery. Circumferential decompression and grafting gave the best results, six of nine patients being in remission an average of three years and six months later. The prognosis for such patients is poor; remission is the aim, rather than cure. Anthelminthic drugs may improve the prognosis, but radical surgery is likely to remain the keystone of treatment in the foreseeable future

Bilateral venography was performed between 12 and 15 days after total hip replacement in 745 consecutive patients, all of whom had heparin prophylaxis. Of these, 81 patients (10.8%) showed evidence of recent deep vein thrombosis: 23 (3%) distal, 44 (5.9%) isolated proximal, five (0.7%) both proximal and distal, and nine (1.2%) extensive thrombosis from calf to thigh. Compared with previous reports heparin appeared to have reduced the number of distal and contralateral thromboses, but was far less effective in reducing proximal femoral thrombosis. In a cadaver study, the femoral veins were inspected during simulated total hip replacement by either an anterior or a posterior approach. In every case the femoral vein became kinked or folded in the thigh position imposed during the preparation of the femur. Local damage appears to be an important factor in proximal thrombosis; care at operation could help to minimise trauma to the femoral veins and reduce the number of such cases

We have studied the kinematics of the knee in the sagittal plane, using a four-bar linkage as model, and assuming that a "neutral fibre" in each ligament remains isometric throughout flexion. We devised a computer program to calculate the distance separating any pair of points, one on each bone, for various cruciate attachments at various angles of flexion. The parameters for the linkage in four cadaveric knees were obtained by marking the centre of attachment of the cruciate ligaments with tacks and taking lateral radiographs. The movements of the bones were then calculated, in the computer model, for various attachments of "replacement" ligament fibres, the distance between the attachment sites being plotted against the angle of flexion. It was then possible to define zones around the isometric attachment points within which changes in length would be predictable. Our results show that the position of the femoral sites of attachment of both anterior and posterior cruciate replacement was more critical than that of the tibial attachments

Eleven articulated scoliotic spines were examined radiographically and morphometrically. Measurement of the curve on anteroposterior radiographs of the specimens gave a mean Cobb angle of 70 degrees, though true anteroposterior radiographs of the deformity revealed a mean Cobb angle of 99 degrees (41% greater). Lateral radiographs gave the erroneous impression that there was a mean kyphosis of 41 degrees while true lateral projections revealed a mean apical lordosis of 14 degrees. Morphometric measurements confirmed the presence of a lordosis at bony level, the apical vertebral bodies being significantly taller anteriorly (P less than 0.02). There were significant correlations (P less than 0.01) between the true size of the lateral scoliosis, the amount of axial rotation and the size of the apical lordosis. This study illustrates the three-dimensional nature of the deformity in scoliosis and its property of changing in character and magnitude according to the plane of radiographic projection

This paper examines the fate of decalcified allografts (homografts) of iliac cancellous bone impregnated with autologous red marrow and implanted intermuscularly into the anterior abdominal wall of rabbits. In contrast to the findings of Urist and other workers that cortical bone decalcified with hydrochloric acid (HCl) and then freeze-dried is inductive to new bone formation in various heterotopic sites, evidence is presented that iliac bone decalcified by HCl and grafted alone to a muscular site is itself very weakly inductive to bone formation. However, when combined with autologous bone marrow the HCl-decalcified bone provides a better substrate for bone formation by marrow cells than does either undecalcified iliac bone, or iliac bone decalcified with ethylene-diamine-tetra-acetic acid. The freezing or freeze-drying of decalcified bone does not affect new bone formation when implanted alone or with autologous marrow. The differences between the cortical and cancellous bone as inductive substrates for osteogenesis are discussed and the interrelationship of bone and marrow in combined bone grafts are re-evaluated

Little is known of the effects of synovectomy on articular cartilage. In order to investigate this matter, anterior synovectomy of the knee was performed in thirty-five normal adult rabbits and in thirty-five which were given 25 milligrams of hydrocortisone intramuscularly each week afterwards. The animals were killed at intervals from four to 110 days after synovectomy. Histological examination of the regenerating synovium in both groups showed complete structural and functional regeneration by eighty days in the first group and a delay in regeneration in the steroid group. . 35. Sulphur autoradiographs of the articular cartilage of femoral and tibial condyles revealed surface fibrillation and chondrocyte death in 23 per cent of normal knees after eighty days but only 1·8 per cent of knees of animals receiving hydrocortisone. Thus synovectomy in a healthy joint may have an unfavourable effect on the physiology of cartilage by alteration of synovial composition and hyaluronate content in normal joints. Systemically-administered hydrocortisone may reduce this harmful effect in normal cartilage

The records of 243 patients with Thompson prostheses for displaced femoral neck fractures have been studied. One hundred and seven prostheses were inserted through an anterior approach and 136 by a posterior approach. The short-term results and complications in these otherwise comparable groups are discussed. The infection rate of 18·5 per cent in the group operated upon by the posterior approach was thrice that after operations by the anterior route (6·5 per cent infected). Drained wounds had significantly less infection (6·3 per cent) compared with the undrained group (28 per cent infected). Other factors influencing the infection rate are discussed. The anterior approach offered greater stability. Of the twenty dislocations in the series, nineteen followed operations by the posterior approach. The mortality rate six weeks after operation was 6·5 per cent after the anterior approach and 20·6 per cent after the posterior approach. Statistical analysis significantly favours the anterior approach