Between 1980 and 1984 nine adult patients in the renal unit of Guy's Hospital developed bone and joint infection. The commonest site of infection was the spine. In this series two patients died, a mortality of 22%. The purpose of this paper is to illustrate the pitfalls in the diagnosis and management of bone and joint infection in patients with renal failure and renal transplants

We have considered the indications for and results of transplanting pronator teres to extensor carpi radialis brevis in cerebral palsy. The operation has some virtue but a very limited application. We achieved satisfactory functional results in six of nine patients and some improvement in one. Two operations failed because of poor selection. In all patients the appearance of the limb was improved

1. A method of correcting poliomyelitic lateral rotation deformity of the thigh by transplant of one or more of the hamstring muscles to the femur is described. 2. The results in seven cases are recorded. 3. Though it is emphasised that this is no more than a preliminary communication and the number of patients so treated is small, the satisfactory results suggest that the procedure is mechanically and physiologically sound

1 . Twenty-two cases of transplantation of the tibialis anterior for relapsed club-foot have been reviewed. Results were good in sixteen cases, fair in two and bad in four. 2. The operation and routine treatment are described. 3. The reasons for the four failures are discussed. 4. It is concluded that the operation is well worth while, and will often avoid the need for bony stabilisation at a later date

Two patients with osteochondritis dissecans of the hip were operated on and their case histories are presented. The relatively large foci were situated on the weight-bearing surface of the joint and the fragments were fixed using transplants of cortical bone. In both cases the focus healed, and the symptoms were relieved. At follow-up six and nine years later respectively, the clinical results were good and no signs of osteoarthritis had as yet developed

1. Sixteen cases of thenar paralysis are reviewed in which a bone graft was inserted between the first and second metacarpals to maintain fixed abduction and opposition of the thumb. 2. The technique of the operation is described and the causes of failure are discussed. 3. The operation is intended for those cases in which tendon transplantation to restore active opposition of the thumb is unsuitable. Rotation of the first metacarpal into full opposition is the most important feature of the operation

In cases of established calcaneus after anterior poliomyelitis the deformity can be greatly reduced by combining an extensive plantar release with an oblique transverse osteotomy of the calcaneus that permits displacement upwards and backwards of the posterior weight-bearing part of the bone. The procedure greatly improves the mechanical advantage of subsequent tendon transplantations to the heel. Between 1956 and 1969 fifteen such osteotomies were carried out and the long-term results have been reviewed

1. The indications for and technique of posterior iliopsoas transplantation are described with particular reference to paralytic dislocation and subluxation of the hip in children. 2. Experience of 150 operations in ninety-five patients and of the long-term results of forty-one operations are given. 3. Reduction of the dislocation has been maintained in every case even when there was complete paralysis of all gluteal muscles. 4. All the children are able to walk without the aid of hip splintage

1. Fifteen cases of bone transplantation for fibrous union of fractures of long bones are described, using boiled minced cancellous bone from cadavers. One transplant became infected but the infection responded to treatment. 2. In one patient with non-union of the shaft of the humerus, bony union was not obtained, but a good functional result obviated further treatment. 3. It is suggested that this relatively simple method of bone transplantation could be used more widely if its potentialities were appreciated more fully

We report the transfer of the sternal part of the pectoralis major to the lower pole of the scapula in 15 patients with winged scapula. At follow-up after 1 to 16 years nine had a satisfactory result and were gainfully employed, though in four of these re-operation had been necessary. Two patients had fair results; the transplant functioned, but they had limited voluntary control. Four were failures: two had had paralysis of other shoulder girdle muscles in addition to the serratus anterior. The indications for the operation are discussed

The effect of early fusion on growth of the spine has been studied in rabbits. Free periosteal grafts from the tibia were transplanted either posteriorly between the spinous and articular processes or postero-laterally between the articular and transverse processes. Sound bony fusion was achieved in both the thoracic and the lumbar spine. Spinal fusion caused local narrowing and wedging of the intervertebral spaces, followed by retardation of growth and wedging of the vertebrae. A progressive structural scoliosis developed after unilateral postero-lateral fusion and a lordosis developed after posterior fusion

1. A small series of fourteen pollicisations has been studied. 2. The keyword, so far as the operation is concerned, has been simplicity. 3. It has been appreciated that a transposed finger can never become a thumb, and it may not be wise to strive too har1d by means of transplants to emulate the perfection of the normal thumb, especially if this is done at the expense of one of the fundamental priorities. 4. Nevertheless, if sensibility, good position and proximal stability are achieved, pollicisation can provide a useful addition to hand function and a reasonably satisfactory appearance

We examined solvent-dried, gamma-irradiated (SD-R) allografts and fresh-frozen (FF) allografts mechanically and morphologically. Before transplantation, FF grafts were more than six times stronger than SD-R grafts. After four weeks, the tensile strength was about the same in both groups. At 24 weeks only collagen fibrils of small diameter were observed in the SD-R grafts while in FF grafts fibrils of small and intermediate diameter were seen. Clinically, we suggest that SD-R grafts could be used as a favourable alternative to FF grafts if care was taken regarding their initial mechanical weakness

In paralytic lesions in which the triceps surae is the only active muscle in the leg, elongation or division of the tendo calcaneus alone may not be enough to prevent recurrence of equinus deformity. In 10 patients (13 limbs) with this pattern of muscle activity, equinus deformity was treated by hemitransplantation of the tendo calcaneus. At follow-up, which was beyond the end of growth in seven limbs, there was no recurrence of deformity in nine. In three of the four failures, a technical fault may have caused loss of activity in the transplanted part of the tendon. The two-stage operation described is recommended in the management of this pattern of paralytic deformity

1 . Sloughing of homogenous skin grafts and clouding of corneal transplants have been shown to be due to antigen-antibody reaction; antigens A and B have been demonstrated in human epidermis and corneal tissue; and anti-red-cell agglutination has been observed in dogs after homogenous bone transplantation. Human bone was therefore examined in thirty-three experiments to determine the presence or absence of A and B antigens. 2. The bone was separated into hard cortical bone, hard washed cancellous bone and soft-tissue washings of bone. 3. Adsorption experiments showed that A and B antigens are absent from cortical bone. A and B antigens are present in cancellous bone

1. Coracoid transplantation for recurring dislocation of the shoulder is described. 2. In my experience of over thirty cases only once has true dislocation recurred after this operation. Recurrence was due to avulsion of the bone block. 3. Failure to repair the original detachment of the glenoid labrum is a frequent cause of recurrence of dislocation of the shoulder. An explanation is offered for this failure; namely that the injured labrum adheres to the deep surface of the subscapularis muscle instead of reattaching itself to bone. This reinforces Watson-Jones's advice that the original dislocation should be treated by complete immobilisation in full medial rotation for three weeks

Cryopreserved patellar tendon allografts are often recommended for reconstruction of anterior cruciate ligaments (ACLs) because living donor fibroblasts are thought to promote repair. Animal studies, however, indicate that ligaments regenerate from recipient rather than donor cells. If applicable to man, these observations suggest that allograft cell viability is unimportant. We therefore used short tandem repeat analysis with polymerase chain reaction (PCR) amplification to determine the source of cells in nine human ACLs reconstructed with cryopreserved patellar tendon allografts. PCR amplification of donor and recipient DNA obtained before operation and DNA from the graft obtained two to ten months after transplantation revealed the genotype of cells and showed only recipient cells in the graft area. Rather than preserve the viability of donor cells, a technique is required which will facilitate the introduction of recipient cells into patellar tendon allografts

A vascularised bone-graft procedure from the base of the second metacarpal was performed in 14 patients with nonunion of the scaphoid. There were 11 men and three women with a mean age of 22 years. In eight patients, who had dorsiflexed intercalated segment instability (DISI), an open wedge was formed at the site of nonunion, and the vascular pedicle was grafted from the volar side. In the six patients without DISI, transplantation was carried out through the same dorsal skin incision. Complete bony union was obtained in all patients after a mean post-operative period of 10.2 weeks, and DISI was corrected in all affected patients. According to Cooney’s clinical scoring system, the results were excellent in five, good in six, and fair in three patients. Because of its technical simplicity and the limited dissection needed, the procedure should be considered for the primary surgical treatment of patients with nonunion of the scaphoid

As our understanding of hip function and disease improves, it is evident that the acetabular fossa has received little attention, despite it comprising over half of the acetabulum’s surface area and showing the first signs of degeneration. The fossa’s function is expected to be more than augmenting static stability with the ligamentum teres and being a templating landmark in arthroplasty. Indeed, the fossa, which is almost mature at 16 weeks of intrauterine development, plays a key role in hip development, enabling its nutrition through vascularization and synovial fluid, as well as the influx of chondrogenic stem/progenitor cells that build articular cartilage. The pulvinar, a fibrofatty tissue in the fossa, has the same developmental origin as the synovium and articular cartilage and is a biologically active area. Its unique anatomy allows for homogeneous distribution of the axial loads into the joint. It is composed of intra-articular adipose tissue (IAAT), which has adipocytes, fibroblasts, leucocytes, and abundant mast cells, which participate in the inflammatory cascade after an insult to the joint. Hence, the fossa and pulvinar should be considered in decision-making and surgical outcomes in hip preservation surgery, not only for their size, shape, and extent, but also for their biological capacity as a source of cytokines, immune cells, and chondrogenic stem cells.

Cite this article: Bone Joint Res 2020;9(12):857–869.

Avascular necrosis of bone is a well-recognised phenomenon in patients on long-term steroid therapy, especially after renal transplantation. There are only four cases reported in the literature of multifocal avascular necrosis after short-term high-dose steroid therapy, and three additional cases are reported in this paper. All the hips have needed reconstructive surgery within two and a half years of the onset of symptoms; in one patient, however, this has been prevented by other medical problems. In two of the three patients reported in this paper the shoulders also were affected; eventually they became pain-free but movement was restricted. Short-term high-dose steroid therapy has only recently been recognised as a cause of avascular necrosis and attempts should be made to prevent the incidence increasing