We have reviewed 40 patients after replacement of a ruptured anterior cruciate ligament with a free graft of the medial third of the patellar tendon, combining this in 17 of the cases with a MacIntosh extra-articular tenodesis. The average age of the patients at operation was 25.4 years; instability of the knee had been present for 1.5 to 9 years, and the mean follow-up was 2.9 years. The results, assessed on subjective stability, were good in 29 patients, over half being able to return to their original sport, and fair in eight. The technique of operation for free patellar tendon grafting is described in detail and the indications for this and for an additional MacIntosh tenodesis are discussed

In 45 patients we assessed the functional results and complications for three different reconstructive procedures after resection of primary tumors of the proximal humerus. An osteoarticular allograft was used in 11, a clavicula pro humero operation in 15 and a tumour prosthesis in 19. The glenoid was resected with the proximal humerus in 25 patients. The axillary nerve was resected in 42 patients. The complication rate was lowest after reconstruction with a tumour prosthesis. The clavicula pro humero operation resulted in the most revisions. Cumulative survival rates for all the reconstructive procedures were similar. At follow-up at two years the functional results for the three reconstructive procedures were the same with a mean functional rating of 79% (Musculoskeletal Tumor Society). Excision of the glenoid had no influence on the functional result. Our findings indicate that the use of a tumour prosthesis is the most reliable limb-salvage procedure for the proximal humerus. The clavicula pro humero is an appropriate procedure if a prosthesis cannot be used

We made a prospective study of the incidence of fatal pulmonary embolism in patients after total knee replacement with no prophylactic anticoagulation. There were 499 consecutive patients having 527 knee replacements. They all wore anti-thromboembolic stockings and were mobilised 48 hours after surgery. No patient was lost to follow-up. One patient died of pulmonary embolism 22 days after operation. There were no other deaths within three months of operation. The incidence of fatal pulmonary embolism was 0.19% (95% confidence interval: 0 to 0.6%). Fatal pulmonary embolism is rare after total knee replacement without prophylactic anticoagulation and the routine anticoagulation of these patients is of doubtful value

Aims

The modified Dunn procedure has the potential to restore the anatomy in hips with severe slipped capital femoral epiphyses (SCFE). However, there is a risk of developing avascular necrosis of the femoral head (AVN). In this paper, we report on clinical outcome, radiological outcome, AVN rate and complications, and the cumulative survivorship at long-term follow-up in patients undergoing the modified Dunn procedure for severe SCFE.

Twenty knees, in which a total of 32 previous operations had been performed, were arthrodesed by the Charnley compression technique combined with intramedullary nailing. Patients with previous infection were excluded from the series, but three neuropathic knees were included. Bony union was evident after an average of six months in all but one patient who died three months after operation. One patient developed deep infection that resolved after removing the nail. The combined technique is simple and only limited bone resection is needed; it gives immediate stability and relief of pain with minimal morbidity

Homologous blood transfusions are not without risks, especially in young women and girls. In patients undergoing certain elective surgical procedures autologous blood transfusion is a good alternative. Normovolaemic haemodilution in association with autotransfusion offers the additional advantages of reduced loss of red cell mass during the operation and an increase in tissue blood flow. In this study twenty-seven adolescent patients undergoing Harrington instrumentation for idiopathic scoliosis had haemodilutional autotransfusions during their operations, none requiring homologous blood. Eighteen were given an average of 750 millilitres of homologous blood in the postoperative period which compared favourably with controls who required 1280 millilitres

The results of excision arthroplasty on forty hips in thirty-two patients have been studied by personal review. The mean follow-up was ten years and the results were graded in the Lazansky system. The outcome was fairly predictable, most patients achieving a fair to good result. The patients were satisfied with the operation in unilateral cases as a secondary operation, but it was generally unsatisfactory as a primary procedure or when performed bilaterally. Pain relief was satisfactory, and previously infected hips achieved sound wound and bone healing. Half could walk with no aid or one stick. No correlation could be found between the radiological appearances and the quality of the result

1. Trigger thumbs present at birth can be safely watched for twelve months because there is an expected spontaneous recovery rate of at least 30 per cent. 2. Trigger thumbs in children first noticed between the age of six to thirty months can be safely watched for six months because there is an expected spontaneous recovery rate of about 12 per cent. 3. Delayed operation left no residual contracture of the interphalangeal joint provided the release was done before the age of four years. 4. Operation is recommended if the child is over the age of three years when first seen

1. The record is presented of an attempt to treat osteochondritis dissecans on idealistic lines. 2. The operative technique to be adopted in the various circumstances likely to be encountered in the knee joint is described. Two cases affecting the talus are recorded. 3. The radiological appearance has become virtually normal in twenty-seven cases (the remaining four are recent); healing has been observed directly in seven cases in which a second operation to remove the means of internal fixation was necessary; and the patients' complaints have been eliminated, but the long term results of treatment are unknown. 4. Suggestions are made for possible developments in the technique of operation

1. It is suggested that replacement of the costo-clavicular ligament is mechanically an essential part of the operative treatment of recurrent sterno-clavicular dislocation. 2. Tenodesis of the subclavius appears to be the simplest and safest way of achieving such replacement. 3. Two cases are described of recurrent sterno-clavicular dislocation treated by this procedure and capsulorrhaphy. 4. Full function was restored in both cases; and there had been no recurrence at the times of follow-up—three years and six months after operation in the first case, and twelve months after operation in the second. In this case the joint had withstood violence that had shattered the clavicle. 5. Further trial in judiciously selected cases, with report, is suggested

Fresh frozen allogeneic tendon was used to reconstruct the lateral ligaments in 17 ankles. Two or more years later, 13 returned for follow-up examination. The mean age at operation was 23 years (range 15 to 39); the interval between injury and operation varied from six months to 20 years. There were no infections and no immunological rejections, and according to Sefton's criteria, nine patients were excellent and four good. No patient complained of instability of the ankle and stress radiography confirmed this improvement. Allograft reconstruction of the lateral ligaments of the ankle is a new method of treatment which restores stability without sacrificing normal tendons

Two prospective studies of ingrowing toenail management were conducted. In the first, 163 patients (204 ingrowing nail edges) who had not had previous surgery were randomised and treated by total nail avulsion, nail edge excision, or nail edge excision with phenolisation of the germinal matrix; recurrence rates one year postoperatively were 73%, 73% and 9% respectively. In the second study, 63 ingrowing nail edges which had recurred after previous operations underwent nail edge excision and phenolisation. There was a 5% recurrence rate and 5% incidence of dystrophy of the nail one year after operation

We studied 55 patients who had undergone elective removal of forearm plates between 1980 and 1986; 44 plates were removed from the radius and 37 from the ulna. Before removal only 20 patients (36%) had definite symptoms attributable to the plates, but 44 patients (80%) were advised by the surgeon to have the plates removed. In 22 cases (40%) the operation was followed by a significant complication. The complication rate was higher with junior surgeons and was permanent in 50% of cases. It is recommended that forearm plates should be removed only if they are causing significant symptoms, and that the operation should not be delegated to the most junior surgeon

We compared the long-term outcome in 61 patients (62 fractures) treated operatively or conservatively for an acute fracture of the carpal scaphoid. A total of 30 fractures was randomised to conservative treatment using a cast and 32 to operative treatment using a Herbert bone screw. The duration of sick leave was shorter for patients treated by operation, but this was only significant in patients with blue-collar occupations. There were no differences between the groups in respect of function, radiological healing of the fracture, or carpal arthritis after follow-up at 12 years. Those managed by operation showed radiological signs of arthritis of the scaphotrapezial joint more often, but this finding did not correlate with subjective symptoms. Operative treatment of an acute fracture of the scaphoid allows early return of function and should be regarded as an alternative to conservative treatment in patients in whom immobilisation in a cast for three months is not acceptable for reasons related to sports, social life or work

Over a five-year period, adult patients with marginal impaction of acetabular fractures were identified from a registry of patients who underwent acetabular reconstruction in two tertiary referral centres. Fractures were classified according to the system of Judet and Letournel. A topographic classification to describe the extent of articular impaction was used, dividing the joint surface into superior, middle and inferior thirds. Demographic information, hospitalisation and surgery-related complications, functional (EuroQol 5-D) and radiological outcome according to Matta’s criteria were recorded and analysed. In all, 60 patients (57 men, three women) with a mean age of 41 years (18 to 72) were available at a mean follow-up of 48 months (24 to 206). The quality of the reduction was ‘anatomical’ in 44 hips (73.3%) and ‘imperfect’ in 16 (26.7%). The originally achieved anatomical reduction was lost in12 patients (25.8%). Radiologically, 33 hips (55%) were graded as ‘excellent’, 11 (18.3%) as ‘good’, one (1.7%) as ‘fair’ and 15 (25%) as ‘poor’. A total of 11 further operations were required in 11 cases, of which six were total hip replacements. Univariate linear regression analysis of the functional outcome showed that factors associated with worse pain were increasing age and an inferior location of the impaction. Elevation of the articular impaction leads to joint preservation with satisfactory overall medium-term functional results, but secondary collapse is likely to occur in some patients. Cite this article: Bone Joint J 2013;95-B:230–8

We have reviewed 50 patients at a mean period of 2.7 years after operations to restore elbow flexion lost as a result of traction injuries of the brachial plexus. A variety of operations were used and, in general, patient satisfaction was high. Objectively, however, the power in the transferred muscles was poor; less than half of the patients had a significant improvement in function. Poor control of the shoulder often compromised the result. Latissimus dorsi and triceps transfers proved most reliable, and some Steindler flexorplasties also gave satisfactory results. Pectoralis major transfers were disappointing and we do not recommend their use in women

The serum liver enzyme levels of 40 consecutive patients before and after cemented hip replacement were compared with a control group having operation without use of cement. Serum gammaglutamyl transferase (SGGT) was abnormally raised, for more than four days, in 12 of the 40 patients (32%) in whom bone cement was used, compared with one of the 36 control patients. The changes in SGGT levels after operation correlated with the weight of cement used (r = 0.66, p less than 0.001), but there was return to normal levels in all patients. A temporary dose-related effect of bone cement on liver function is demonstrated

Ten patients with humeral shaft fractures and no clinical or radiographic signs of healing after at least six weeks' immobilisation were treated by flexible intramedullary nailing using a closed retrograde technique. Bone grafting was not performed, and active movement was encouraged after operation. Nine fractures healed; the mean time to union was 10.5 weeks (range 6 to 22 weeks). One patient needed compression plating and bone grafting at 22 weeks, and another required re-operation for distal migration of the rods. There were no infections, nerve palsies or other complications. Stiffness of the shoulder which had developed during early treatment improved after operation

A series of 100 patients with pain in the leg was studied and the accuracy of electrical studies in the diagnosis of nerve root lesions was investigated before operation. The electrical studies which were performed on all the patients, included recordings of fibrillation potentials, H-reflex and ankle reflex latencies. This diagnosis technique was found to be more accurate than radiculography or clinical examination and did not give false evidence. Seventy patients were classed as having a lesion of the nerve root. Fifty of these patients were treated surgically. The operation revealed compression of the nerve root by osteophytes arising from degenerative and incompletely dislocated posterior facet joints in 43 patients

Traumatic posterior dislocation of the hip associated with a fracture of the posterior acetabular wall and of the neck of the femur is a rare injury. A 29-year-old man presented at a level 1 trauma centre with a locked posterior dislocation of the right hip, with fractures of the femoral neck and the posterior wall of the acetabulum after a bicycle accident. An attempted closed reduction had failed. This case report describes in detail the surgical management and the clinical and radiological outcome. Open reduction and fixation with preservation of the intact retinaculum was undertaken within five hours of injury with surgical dislocation of the hip and a trochanteric osteotomy. Two years after operation the function of the injured hip was good. Plain radiographs and MR scans showed early signs of osteoarthritis with some loss of joint space but no evidence of avascular necrosis. The patient had begun skiing and hiking again. The combination of fractures of the neck of the femur and of the posterior wall of the acetabulum hampers closed reduction of a posterior dislocation of the hip. Surgical dislocation of the hip with trochanteric flip osteotomy allows controlled open reduction of the fractures, with inspection of the hip joint and preservation of the vascular supply