Aims. Slipped upper femoral epiphysis (SUFE) has well documented biochemical and mechanical risk factors. Femoral and acetabular morphologies seem to be equally important. Acetabular retroversion has a low prevalence in asymptomatic adults. Hips with dysplasia, osteoarthritis, and Perthes’ disease, however, have higher rates, ranging from 18% to 48%. The aim of our study was to assess the prevalence of acetabular retroversion in patients presenting with SUFE using both validated radiological signs and tomographical measurements. Methods. A retrospective review of all SUFE surgical cases presenting to the Royal Children’s Hospital, Melbourne, Australia, from 2012 to 2019 were evaluated. Preoperative plain radiographs were assessed for slip angle, validated radiological signs of retroversion, and standardized postoperative CT scans were used to assess cranial and mid-acetabular version. Results. In all, 116 SUFEs presented in 107 patients who underwent surgical intervention; 47 (52%) were male, with a mean age of 12.7 years (7.5 to 16.6). Complete radiological data was available for 91 patients (99 hips) with adequate axial CT imaging of both hips. Overall, 82 patients (82%) underwent pinning in situ (PIS), with subcapital realignment surgery (SRS) performed in 17 patients (18%) (slip angles > 75°). Contralateral prophylactic PIS was performed in 72 patients (87%). On the slip side, 62 patients (68%) had one or more radiological sign of retroversion. Tomographical acetabular retroversion was more pronounced cranially than caudally of the acetabulum on both the affected side and the contralateral side (p < 0.001) as expected in the normal population. Increasing severity of the slip was found to be directly proportional to the degree of reduction in cranial and central acetabular version (p < 0.05) in the SUFE hips. Conclusion. Acetabular retroversion is more prevalent in patients with SUFE than previously reported, and have been shown be correlated to the severity of the slip presentation. The presence of radiological signs of acetabular retroversion could be used to justify prophylactic contralateral pinning. Cite this article: Bone Jt Open 2022;3(2):158–164

We have reviewed our experience in managing 11 patients who sustained an indirect sternal fracture in combination with an upper thoracic spinal injury between 2003 and 2006. These fractures have previously been described as ‘associated’ fractures, but since the upper thorax is an anatomical entity composed of the upper thoracic spine, ribs and sternum joined together, we feel that the term ‘fractures of the upper transthoracic cage’ is a better description. These injuries are a challenge because they are unusual and easily overlooked. They require a systematic clinical and radiological examination to identify both lesions. This high-energy trauma gives severe devastating concomitant injuries and CT with contrast and reconstruction is essential after resuscitation to confirm the presence of all the lesions. The injury level occurs principally at T4–T5 and at the manubriosternal joint. These unstable fractures need early posterior stabilisation and fusion or, if treated conservatively, a very close follow-up

Aims . To analyse the influence of upper extremity trauma on the long-term outcome of polytraumatised patients. . Patients and Methods. A total of 629 multiply injured patients were included in a follow-up study at least ten years after injury (mean age 26.5 years, standard deviation 12.4). The extent of the patients’ injury was classified using the Injury Severity Score. Outcome was measured using the Hannover Score for Polytrauma Outcome (HASPOC), Short Form (SF)-12, rehabilitation duration, and employment status. Outcomes for patients with and without a fracture of the upper extremity were compared and analysed with regard to specific fracture regions and any additional brachial plexus lesion. Results. In all, 307 multiply-injured patients with and 322 without upper extremity injuries were included in the study. The groups with and without upper limb injuries were similar with respect to demographic data and injury pattern, except for midface trauma. There were no significant differences in the long-term outcome. In patients with brachial plexus lesions there were significantly more who were unemployed, required greater retraining and a worse HASPOC. Conclusion. Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus. Cite this article: Bone Joint J 2017;99-B:255–60

Although much has been published on the causes of slipped upper femoral epiphysis and the results of treatment, little attention has been given to the mechanism of the slip. This study presents the results of the analysis of 13 adolescent femora, and the attempts to reproduce the radiological appearances of a typical slip. The mean age of the skeletons was 13 years (11 to 15). It was found that the internal bony architecture in the zone of the growth plate was such that a slip of the epiphysis on the metaphysis (in the normal meaning of the word slip) could not take place, largely relating to the presence of a tubercle of bone projecting down from the epiphysis. The only way that the appearance of a typical slipped upper femoral epiphysis could be reproduced was by rotating the epiphysis posteromedially on the metaphysis. The presence and size of this peg-like tubercle was shown radiologically by CT scanning in one pair of intact adolescent femurs

Aims

This study analysed the clinical and radiological outcome of anatomical reduction of a moderate or severe stable slipped capital femoral epiphysis (SCFE) treated by subcapital osteotomy (a modified Dunn osteotomy) through the surgical approach described by Ganz.

One hundred and nine children with myelodysplasia were evaluated and classified according to the level and type of paralysis and its effect on functional ability. Thirty-one per cent of the patients were paralysed at the thoracic level, 26% at the upper lumbar level, 30% at the lower lumbar level and 13% at the sacral level. Fifty-four per cent of these patients demonstrated the classic flaccid paralysis in the lower limbs with normal upper limbs; 9% were flaccid in the lower limbs, but were spastic in the upper; 24% were spastic in the lower limbs; 13% were spastic in the upper and lower limbs. Patients with spastic lower limbs required more orthopaedic procedures, more days in hospital and in casts, and were less likely to walk than those with flaccid paralysis. Patients with spastic upper limbs were less likely to be independent in activities of daily living and were more likely to require special schools than patients with normal upper limbs. In addition to the spinal cord level of the lesion, the degree of spasticity is important in the evaluation, treatment and prognosis of myelodysplastic patients

1. Epiphysial tilt commonly precedes slipping. 2. This tilt is due to a diminished or arrested growth from compression of the back of the epiphysial plate. 3. The stresses on the upper end of the femur are such that the upper femoral epiphysial plate is peculiarly liable to compression. 4. A primary abnormality of the cartilage of the epiphysial plate renders it susceptible to the effect of compression. 5. Because this abnormality is diffuse, deformities due to a similar pathology may be found elsewhere, notably in the spine

1. During the past twenty-five years there have been admitted to this orthopaedic service twelve children or adolescents having a close relative who previously or subsequently developed slipped upper femoral epiphysis. This represents an incidence of approximately 7 per cent. 2. There is some evidence that the incidence is considerably higher. 3. In addition to those with close relations also with slipped epiphysis, two patients had parents with osteoarthritis of the hip. 4. I believe, therefore, that in slipped upper femoral epiphysis there is evidence of a genetic defect. This is probably due to a recessive gene of low penetrance. The frequency in this region is high because the north-east of Scotland has very definite geographical boundaries and the rural, agricultural population, from which the majority of these cases were drawn, has formed until recently a stable community likely to show a greater than average incidence

1. An apparatus was designed to determine the shearing strength of the upper tibial epiphysis in the rat. Observations were made with this instrumenton normal animals, on animals receiving growth-hormone, and on animals receiving oestrogen. 2. When the epiphysis separates from the diaphysis, the plane of cleavage is constant, passing through the third layer of the epiphysial plate. 3. Growth-hormone decreases and sex-hormone increases the shearing strength of the epiphysial plate. These changes are due to alterations produced by these two hormones in the thickness of the third layer of the epiphysial plate. 4. It is suggested that these findings may be of significance in providing an anatomical basis for slipping of the upper femoral epiphysis in man, especially when it is associated with the adiposo-genital syndrome or with rapid adolescent growth

The pathogenesis of slipped upper femoral epiphysis is unknown but the condition has been linked with various endocrine disorders. Nine patients with slipped epiphyses in association with primary juvenile hypothyroidism are presented. In all patients, slipping occurred or symptoms developed in the affected hip before the hypothyroidism was diagnosed. A generalised pathology was suggested by the absence of trauma (8 patients), by bilateral slipping (6 patients), and by obesity and short stature in all patients. All cases had delayed skeletal maturation and characteristic metaphysial changes were seen on their radiographs. The clinical diagnosis of juvenile hypothyroidism can be difficult but it merits consideration in patients who have a slipped upper femoral epiphysis in association with short stature, obesity, delay in skeletal maturity, or any one of these

Slipped upper femoral epiphysis remains a disease of unknown aetiology. Recent evidence has bolstered speculation that the immune system may play a role in the aetiology or pathogenesis of slipped epiphysis or of one of its complications, chondrolysis. This study reports the finding of immune complexes in the synovial fluid of all but one hip affected with slipped epiphysis in a consecutive series. In seven patients, immune complexes were detected by both the Raji cell assay and C1q-binding assay; in two, by the C1q-assay only; and in one, by the Raji cell assay only. No patients had immune complexes in the serum. Twenty-one patients with synovitis of the knee or hip caused by a variety of disorders served as the control group. Two of these patients had immune complexes in their synovial fluid. It appears that the immune complexes characterise the synovitis found with slipped upper femoral epiphysis as distinct from most other synovitides

Slipped upper femoral epiphysis (SUFE) is the most common hip disorder to affect adolescents. Controversy exists over the optimal treatment of severe slips, with a continuing debate between in situ fixation versus corrective surgery. We present our experience in a series of 57 patients presenting with severe unilateral SUFE (defined > 50°) managed with a subcapital cuneiform osteotomy. Between 2001 and 2011, 57 patients (35 male, 22 female) with a mean age of 13.1 years (9.6 to 20.3, SD 2.3) were referred to our tertiary referral institution with a severe slip. The affected limb was rested in slings and springs before corrective surgery which was performed via an anterior Smith-Petersen approach. Radiographic analysis confirmed an improvement in mean head–shaft slip angle from 53.8. o. (standard deviation (. sd) 3.2). pre-operatively to 9.1. o. (. sd. 3.1) post-operatively, with minimal associated femoral neck shortening. In total 50 (88%) patients were complication free at a mean follow-up of seven years (2.8 to 13.9 years, . sd. 3). Their mean Oxford hip score was 44 (37 to 48) and median visual analogue pain score was 0 out of 10 (interquartile range 0 to 4). A total of six patients (10.5%) developed avascular necrosis requiring further surgery and one (1.8%) patient developed chondrolysis but declined further intervention. . This is a technically demanding operation with variable outcomes reported in the literature. We have demonstrated good results in our tertiary centre. Cite this article: Bone Joint J 2015;97-B:1718–25

We report 16 cases in which the upper cervical spine was approached through the mouth for operative decompression and stabilisation, with or without removal of diseased tissues. The indications are discussed and the technique is described. Results are compared with those of other reported series. We believe that this operation has a place in the treatment of certain conditions affecting the upper part of the cervical spine and the foramen magnum, with or without involvement of the medulla and spinal cord

1. Thirteen cases of traumatic separation of the upper femoral epiphysis have been studied. Four were previously reported and nine new cases are analysed. 2. This is a rare injury occurring in young children and is due to severe violence. 3. Separation occurred at the epiphysial plate, and severe posterior displacement was frequent. The fracture line does not penetrate the epiphysis. 4. Premature fusion, avascular necrosis or non-union (individually or together) occurred in eleven of the thirteen patients. 5. Separation of the upper femoral epiphysis is a serious injury which is likely to lead to permanent deformity

Reports of spondylolysis in vertebrae other than those of the lower lumbar spine are rare. We report 32 patients with upper lumbar spondylolysis who have been studied clinically, radiologically and scintigraphically. Twenty patients had bilateral lesions, and seven of those with unilateral lesions had structural changes or anomalies in the opposite posterior arch. Positive scans were found to be associated with a short clinical history, and indicated stress-related lesions. Our findings suggest that mechanical factors may play a role in the aetiology of spondylolysis in the upper lumbar spine similar to that which they play in the lower lumbar spine, and that local structural anomalies may contribute to abnormal loading of these vertebrae

Six patients, aged between 3 and 51 years, with tuberculosis of the upper cervical spine were studied. Prominent features of the disease included pain and stiffness, paralysis, swelling of the retropharyngeal soft tissue, osteolytic erosions, and atlanto-axial subluxation. Cure was obtained with antibiotics, transoral decompression and C1-2 fusion

We reviewed the management of 100 cases of slipped upper femoral epiphysis treated over a period of 26 years. A total of 14 slips was identified as unstable on admission. These underwent reduction and stabilisation within 24 hours of the onset of severe symptoms. Of the 86 stable slips four progressed to avascular necrosis (AVN), which was not seen in the unstable slips. The literature on slipped upper femoral epiphysis suggests that the acute unstable slip is at higher risk of developing AVN. We recommend reduction and stabilisation of unstable slips within 24 hours of the onset of symptoms in order to reduce the risk of AVN

Slipped upper femoral epiphysis (SUFE) with an open physis is rare in an adult and the condition may present without prior diagnosis of an underlying medical condition. We have treated a 29-year-old man with bilateral SUFE associated with autoimmune hypothyroidism. The management was delayed and complicated by co-existing autoimmune chronic active hepatitis. He underwent thyroxine therapy and bilateral pinning in situ with a single ASNIS screw. Closure of the physis occurred after five months on the right side. The left side required a further corrective intertrochanteric osteotomy, and it was only after 13 months that complete fusion of this physis was seen. The case highlights the need to consider endocrine and metabolic conditions in atypical presentation of SUFE

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

We describe a surgical approach to the upper thoracic spine which allows an adequate exposure of the vertebral bodies from T1 to T3. The approach causes little functional disturbance and is especially useful in older patients with spinal tumours causing spinal cord compression

1. The surgical management of two children with congenital hypoplasia of the upper end of the femur is described. 2. Early exploration is advocated to establish the nature and extent of the anomaly and to attempt its correction. 3. The preliminary results are sufficiently encouraging for us to recommend that further attempts at surgical treatment be considered in patients with this disorder

The anterior exposure of the upper thoracic spine using standard methods is often difficult and limited. We report our experience using a technique described by Sundaresan et al. (1984) in which the medial portion of one clavicle and part of the manubrium sterni are excised. In 10 cases we found this to be a useful and safe procedure

1 . Dislocation of the upper end of the fibula is probably less unusual than the paucity of the published reports suggests. 2. Dislocation may be anterior or posterior, anterior dislocation occurring about twice as often as posterior. Rarely the fibula moves proximally. 3. In most cases a closed manipulation suffices for reduction, and a full and rapid return of normal function follows. 4. Five cases are described. In one case operative reduction was required

1. Ninety-eight cases of fracture of the upper end of the tibia treated by operative reduction have been reviewed. 2. The true split fractures and the mildly comminuted compression fractures showed the best results. The "mosaic" cases showed the least satisfactory results. 3. Age has scarcely any effect on the end-results and is consequently no contra-indication to operation. 4. Nearly half the patients regained normal or almost normal mobility in the knee joint. 5. In no case did a meniscus left in place cause symptoms indicating internal derangement

The frequency of slipping and osteoarthritis of the contralateral hip was recorded in 260 patients with slipped upper femoral epiphysis between 1910 and 1960. Twenty-three of these patients (9%) had primary bilateral slipping, 32 (12%) had a contralateral slip diagnosed later during adolescence and a further 104 (40%) had signs of contralateral slipping at follow-up 16 to 66 years later, giving a total of 159 cases (61%) with bilateral slips. Of the 104 slippings diagnosed at follow-up, 25% showed osteoarthritis. It is concluded that, with a slipped epiphysis, prophylactic contralateral pinning should be performed to avoid slipping and to reduce the risk of osteoarthritis

We describe three cases of infantile tibia vara resulting from an atraumatic slip of the proximal tibial epiphysis upon the metaphysis. There appears to be an association between this condition and severe obesity. Radiologically, the condition is characterised by a dome-shaped metaphysis, an open growth plate and disruption of the continuity between the lateral borders of the epiphysis and metaphysis, with inferomedial translation of the proximal tibial epiphysis. All patients were treated by realignment of the proximal tibia by distraction osteogenesis with an external circulator fixator, and it is suggested that this is the optimal method for correction of this complex deformity. There are differences in the radiological features and management between conventional infantile Blount’s disease and this ‘slipped upper tibial epiphysis’ variant

I. Five cases of dislocation of the head of the radius associated with fracture of the upper end of the ulna in children are reported. It is important that fractures of the upper end of the ulna, especially those with some varus deformity in children, should arouse suspicion of the possible co-existence of a dislocation of the head of the radius. 2. The association of the injury to the elbow with a fracture of the lower end of the radius and ulna in three of our cases indicates the necessity for keeping in mind the possibility of this combination. 3. Closed reduction seems to be the best method of treatment. 4. Our five cases were seen during a period ofonly three years. We therefore believe that this injury is not as unusual as appears from the literature

A case of excision of a chondrosarcoma of the upper end of the femur with replacement by a prototype internal prosthesis has been followed for eighteen years

Haematogenous osteomyelitis in newborns and infants usually occurs in the long bones and is rare in the short or flat bones. We present two neonates with osteomyelitis of the upper cervical spine affecting the second to fourth cervical vertebrae and the first and second cervical vertebrae, respectively. Despite some delay in diagnosis, both responded successfully to conservative treatment with antibiotics, a cervical collar and needle puncture. The latest follow-up at six and seven years, respectively, showed no persistent neurological deficit and a normal diameter of the cervical spinal canal on MRI

Eight slipped upper femoral epiphyses in patients who had had radiotherapy are described. These cases involved five patients in an "at risk" population of 48. This increased incidence is highly significant

We have used a modified technique of cervical osteotomy to treat a consecutive series of 23 patients with chronic slip of the upper femoral epiphysis. It has been successful in correcting both moderate and severe deformities with a low incidence of avascular necrosis, comparable to that seen after subtrochanteric osteotomies. We describe the operative details and discuss the features which make cervical osteotomy technically superior to intertrochanteric and subtrochanteric procedures

1. A series of 226 upper tibial osteotomies is reviewed with special reference to the complications occurring in each of the six different operative techniques that have been used. 2 Wedge osteotomy above the tuberosity is the safest operation, but care must be taken to avoid a fracture into the joint. 3. Wedge osteotomy through the lowest part of the tuberosity may be indicated in the presence of large subarticular cysts or collapse of a tibial condyle. 4. The significance of weakness of dorsiflexion of the foot and the dangers of injury to the anterior tibial artery in osteotomies below the tuberosity are discussed

There are many causes of paraspinal muscle weakness which give rise to the dropped-head syndrome. In the upper cervical spine the central portion of the spinal cord innervates the cervical paraspinal muscles. Dropped-head syndrome resulting from injury to the central spinal cord at this level has not previously been described. We report two patients who were treated acutely for this condition. Both presented with weakness in the upper limbs and paraspinal cervical musculature after a fracture of C2. Despite improvement in the strength of the upper limbs, the paraspinal muscle weakness persisted in both patients. One ultimately underwent cervicothoracic fusion to treat her dropped-head syndrome. While the cause of the dropped-head syndrome cannot be definitively ascribed to the injuries to the spinal cord, this pattern is consistent with the known patho-anatomical mechanisms of both injury to the central spinal cord and dropped-head syndrome

1. A series of eighty-one hips with slipped upper femoral epiphysis in sixty-three patients is reviewed. 2. The importance of early diagnosis is emphasised. 3. Conservative treatment is condemned. 4. In attempting reduction violent manipulation and strong traction must be avoided. 5. In cases of slight displacement pinning in the position of displacement gives the best results. 6. Three or four small pins are recommended for fixation. 7. When the amount of slip is 50 per cent or more of the diameter of the head gentle manipulation should be tried and, if successful, followed by fixation with three or four pins. 8. The hip with an irreducible slip of 50 per cent or more should be treated by pertrochanteric or subtrochanteric osteotomy

The results of open reduction of the severely slipped upper femoral epiphysis are reported for 115 hips with an average follow-up of 12 years 11 months (range 2 to 33 years). In 70 hips with a chronic slip and an open growth plate the incidence of complications was low: two developed avascular necrosis, five chondrolysis, and one had both. There were more complications in the 38 hips with an acute-on-chronic slip: six developed avascular necrosis, one chondrolysis, and three had both. Of the seven hips operated upon with a partially fused plate, only one did well. All these complications were obvious within the first year but there were also three hips in the series in which osteoarthritis developed between 10 and 20 years after operation

Evidence is presented to support the contention that after slipping of the upper femoral epiphysis there is a potential for the bony epiphysis to grow back to its pre-slipped position. A suggestion is made as to how this recovery may occur

Simple pinning to fix the epiphysis in those patients in whom the position is acceptable is a valuable surgical procedure. It is safe and gives good results. It eliminates the danger of further displacement, promotes fusion of the epiphysial plate and allows the patient to return to full activity within one month, thus avoiding joint stiffness, muscle atrophy, osteoporosis and interference with growth at other sites. Fixation by small pins is preferable to the use of the trifin nail, the latter giving excessive trauma and predisposing to subtrochanteric fracture. Gentle replacement of the epiphysis, when loose, into an acceptable position is a valuable method of treatment. It is essential that replacement is not undertaken by force. The problem of major displacement of the epiphysis which cannot be so replaced is unsolved. Conservative treatment in this group is useless and harmful. Intra-articular osteotomy can give good results in most cases but is risky and may cause stiffening of the hip. Subtrochanteric osteotomy does not give a good anatomical result but in most cases the function of the hip is satisfactory. Slipping of the upper femoral epiphysis, however slight, should be regarded as a surgical emergency

1. The results of thirty-five acutely slipped upper femoral epiphyses, treated from 1950 to 1969, are presented. Avascular necrosis of the femoral head occurred in five cases. 2. Skin traction with medial rotation, followed in three to four days by internal fixation, without further manipulation, is recommended so that this iatrogenic complication may be avoided

Four cases of slipped upper femoral epiphyses in patients with intracranial tumours causing hypopituitarism and chiasmal compression are presented. Detailed endocrine studies in three cases showed severe deficiencies of growth hormone as well as of gonadotrophin and sex hormones. The literature is reviewed and the aetiology is discussed with special reference to Harris's hypothesis that an increase in growth hormone relative to oestrogen predisposes to slipping of the upper femoral epiphysis in humans, which these cases do not seem to support. In all cases the slip was bilateral, and it is emphasised that surgical treatment can provide only temporary fixation because fusion is dependent on correct hormonal therapy

Aims. In this prospective observational study, we investigated the time-dependent changes and correlations of upper arm performance tests (ten-second test and Simple Test for Evaluating Hand Function (STEF), the Japanese Orthopaedic Association (JOA) score, and the JOA Cervical Myelopathy Evaluation Questionnaire (JOACMEQ) in 31 patients with cervical myelopathy who had undergone surgery. . Patients and Methods. We hypothesised that all the indices correlate with each other, but show slightly different recovery patterns, and that the newly described JOACMEQ is a sensitive outcome measure. Results. Peak recoveries were achieved one month post-operatively in the ten-second test and JOACMEQ upper extremity function (UEF) subscale, and at three months in the JOA and STEF scores. The recoveries of all indices were maintained until six months post-operatively. The upper extremity function (UEF) subscale in the JOACMEQ showed the strongest correlation with STEF although all the indices correlated with each other. Patients with ≥ 20 and < 20 acquired points in the UEF subscale were classified into the UEF-improved and UEF-unimproved groups. Comparisons between the groups showed that pre-operative evaluation of “coordinated motion” of the STEF was significantly low in the UEF-unimproved group. . Conclusion. These results indicate that the JOACMEQ is a concise, sensitive, patient-based outcome measure for evaluating functional recovery in patients with cervical myelopathy who have undergone surgery. Cite this article: Bone Joint J 2016;98-B:990–6

We report the case of a 12-year-old boy with polyostotic fibrous dysplasia of the upper femur in whom a massive customised polyethylene prosthesis functioned successfully for more than fifty years

Intertrochanteric osteotomy gives compensatory correction for the severely slipped upper femoral epiphysis without endangering its blood supply. The results of thirty-five such osteotomies carried out over an eighteen-year period are reviewed. The indication for operation was a chronic slip of a third or more of the growth plate in the lateral radiograph. The mean age at operation was fourteen years and the mean follow-up period seven and a half years. The results showed that even a moderate correction of deformity as shown by the radiograph could produce a hip with a functionally satisfactory range of movement. Chondrolysis was the most serious complication and occurred in four hips. The radiological results are discussed in relation to details of operative technique and also to long-term prognosis

1. Five cases of greenstick fracture of the upper end of the ulna with dislocation of the radio-humeral joint are described. 2. Although the direction of angulation of the fracture and the corresponding displacement of the upper end of the radius may be lateral, medial or anterior, it is suggested that all five cases form a group in which the mechanism of injury is essentially the same. This mechanism is considered to be a fall on the outstretched hand with the forearm held in supination. 3. The complications of the injury are described

Several authors have reported complications from screw removal after treatment of slipped upper femoral epiphysis by single screw fixation, and have attributed these to poor screw design. We have developed a simple and reliable method of screw removal which uses a cannulated 8.0 mm end-threaded cancellous screw (Smith & Nephew Richards Medical, Memphis, Tennessee) and a specially designed cannulated trephine. The method has been successful, with minimal complications, and a limited surgical exposure

We report the complications of prophylactic pinning of slipped upper femoral epiphysis with Crawford Adams pins in 95 cases. Complications of pin placement were seen in 13.7%. Although seven hips had penetration of the joint, there were no cases of chondrolysis or avascular necrosis. Excavation of the lateral femoral cortex was required at pin removal in 12.5% of cases. Analysis of the growth around pins allowed recommendations to be made regarding pin protrusion. The use of improved fixation devices may reduce the need for multiple pins

This paper reports a prospective study of 72 consecutive patients with fractures or fracture-dislocations of the upper end of the humerus, treated during 1981. Most were elderly and treatment was conservative. Of the 72 patients 64 were followed up for a period of six months. Observations were made on the type of fracture, the speed and pattern of recovery of shoulder movements, on the time of commencement of physiotherapy, and on its duration. We found that with conservative treatment alone, 94% of our patients had good or satisfactory results at six months from injury. The criteria for manipulation are discussed and the literature is reviewed

We have compared the functional outcome after glenohumeral fusion for the sequelae of trauma to the brachial plexus between two groups of adult patients reviewed after a mean interval of 70 months. Group A (11 patients) had upper palsy with a functional hand and group B (16 patients) total palsy with a flail hand. All 27 patients had recovered active elbow flexion against resistance before shoulder fusion. Both groups showed increased functional capabilities after glenohumeral arthrodesis and a flail hand did not influence the post-operative active range of movement. The strength of pectoralis major is a significant prognostic factor in terms of ultimate excursion of the hand and of shoulder strength. Glenohumeral arthrodesis improves function in patients who have recovered active elbow flexion after brachial plexus palsy even when the hand remains paralysed

1. One hundred patients with fractures of the upper end of the femur were investigated clinically and radiographically to ascertain the incidence and site of deep venous thrombosis during convalescence. 2. The technique of phlebography used has its own inherent dangers, but we believe that familiarity with the technique reduces the risk of complications. 3. The investigation revealed thrombi that were clinically unsuspected and indicates a need for further investigation of factors such as manipulation and retraction that may promote deep thrombosis. 4. The study has provided a control series for an investigation of the effect of prophylactic anticoagulants upon the incidence of deep venous thrombosis and pulmonary embolism after fractures about the hip

1. Avascular necrosis of the bony epiphysis or necrosis of the articular cartilage of the hip joint–without bony necrosis–can occur after a slipped upper femoral epiphysis. 2. In avascular necrosis of the bony epiphysis the prognosis depends upon the degree of revascularisation that occurs and upon survival of the articular cartilage. The articular cartilage can survive and a good functioning hip result especially if aided by mobilisation without weight bearing. 3. The prognosis after necrosis of the articular cartilage is poor. This complication occurs more often when conservative treatment is used. 4. A certain number of hips will show poor results no matter what treatment is used. 5. Nutrition of the articular cartilage is probably by the synovial fluid. 6. Strong traction may damage the soft-tissue structure of the hip joint. 7. It is not advisable to perform an osteotomy soon after a slip of the epiphysis. It is better to wait until good function is assured in the joint

1. By questionnaire, an attempt has been made to ascertain the characteristics of a hundred cases of slipping of the upper femoral epiphysis. 2. The principal object has been to see whether an etiological classification would be possible pending an assessment of the results of treatment. 3. Proper statistical analysis has proved impossible because of the incompleteness of the data. 4. As usual, boys predominated and were usually affected as much as three years older than the girls. 5. It was exceptional to find epiphysial slipping in a girl once she had begun to menstruate. 6. Nearly a quarter of the cases were bilateral, or became so after six to twenty-four months or more. 7. Little information came from an enquiry about dietary fads, the estimation of urinary ketosteroid excretion in twenty-three of the patients, or some minor pathological investigations. 8. No convincing evidence was found of skeletal retardation or of general thickening of epiphysial discs, such as might perhaps be expected in a hormonal disturbance characterised by defective epiphysial maturation. 9. From each child with the necessary data, indices of height, weight and build were ascertained, which would indicate his expectation of finding a place among a hundred physically normal children of his own sex and age, and, if so, where that place would be. From these studies four groups of children seemed to emerge: I) what may be called abnormally heavy children who would not find a place among a hundred, or somestimes a thousand, physically "normal" children of their own age and sex; 2) unusually heavy children who would find a place in the heaviest minority of the normal hundred; 3) a very small group of abnormally small people, among whom might be expected the subjects of pituitary infantilism; and 4) a large group of children of average physique for their sex and age. 10. From this information and from clinical evidence in the case returns, it appeared that a quarter of the assessable boys and nearly two-thirds of the assessable girls showed evidence of endocrine defect, quite apart from those who were merely unusually fat. 11. By distinguishing these two groups of children from a third group of constitutionally "normal," an attempt has been made to see whether there is any correlation between evident endocrine defect and such characteristics as bilateral affection, delayed epiphysial maturation, a history of relevant injury and its nature, and sudden or gradual epiphysial slipping. 12. No relationship was established between any of these characteristics and endocrine type: bilateral affection was no commoner in the endocrine group; delayed maturation was not demonstrated in either; a history of relevant injury was equally common, and its nature identical, in both; slipping might be sudden or gradual in either indiscriminately. 13. There was a history of seemingly relevant injury in half the patients, and it was much commoner with sudden slipping than with gradual slipping. Sudden slipping was often preceded by symptoms of gradual slipping, or sudden slipping of one epiphysis was sometimes followed by gradual slipping of the other. 14. In gradual slipping the cardinal symptoms were pain and limp, usually starting synchronously and gradually; the pain was usually intermittent and referred much more often to the hip than the knee; the limp was usually continuous. 15. Of signs, demonstrable wasting seemed to be absent as often as present, but shortening was usual. Lateral rotation deformity was usually present, adduction often, and flexion sometimes. In more than a third of the cases limitation of movement was slight enough to be easily missed. 16. The radiographic observations confirmed the seeming widening at the affected epiphysial disc, the greater displacement revealed by the lateral view, and the difficulty of identifying avascular necrosis before collapse. 17. Treatment was delayed in thirty-four cases—a third of the whole; the reasons have been analysed; diagnostic failure was the cause in nineteen. 18. A few cases outside the series have been mentioned briefly because of special points of interest: slipping in gross pituitary disease—in pituitary giantism, and(at the age of thirty-three) in pituitary hypogonadism; slipping with defect of the opposite lower limb—infantile paralysis of the leg, and Legg-Calvé-Perthes disease of the hip; familial affection—slipping in two brothers. 19. The results of treatment in the present cases, supplemented by others, have been studied by Dr John Hall and related to some of the clinical features. His paper appears separately

1. Seventy-six patients with fracture of the upper end of the femur were examined phlebographically for evidence of thrombosis. The patients were randomly divided into two groups : one was given phenindione post-operatively ; the other acted as a control. 2. Analysis of the select series showed that the incidence of venous thrombosis in the anticoagulation group (19 per cent) was significantly less than that in the control group (48 per cent). 3. However, analysis of the complete series failed to show that the incidence of venous thrombosis in the anticoagulation group was significantly less than in the control group. 4. The number of bleeding complications in the anticoagulation group (47 per cent) exceeded those in the control group (16 per cent). The only life-endangering haemorrhage occurred in a patient who had not received an anticoagulant for five months. 5. We were unable to show that the fracture significantly influenced the site or the incidence of venous thrombosis. 6. No correlation was found between the clinical and phlebographic diagnosis of venous thrombosis. 7. It is concluded that the early use of a prophylactic anticoagulant is an effective means of reducing the incidence of venous thrombosis in patients with a fracture about the hip

A series of ten infants is reported, seven of whom showed evidence of osteomyelitis of the upper end of the femur; the remaining three did not, but presented with an acute subluxation of the hip in a febrile illness. Four sequelae among the seven more severe cases were: 1) destruction of the capital epiphysis with dislocation at the hip; 2) destruction of the capital epiphysis, the femoral neck remaining in the acetabulum; 3) destruction of the epiphysial plate with the femoral head, remaining in the acetabulum, connected to the femoral neck by a fibrous union; 4) recovery with coxa magna but no other deformity. The streptococcus plays a greater part in this osteomyelitis of infancy than in osteomyelitis of older children, but various other organisms were identified. The organism should be sought by blood culture as well as from the local lesion. Aspiration of the hip, treatment of the hip in abduction and the use of the appropriate antibiotic are recommended. If there is marked swelling and induration, freer release of the pus is strongly advised. Controlled abduction osteotomy plays a useful part in stabilising the femoral neck in the acetabulum or in stabilising the femoral neck beneath the capital epiphysis, but may usefully be preceded by an arthrograph because late ossification of a detached head sometimes occurs

1. Two new cases of obstetrical separation of the upper femoral epiphysis are described. 2. Diagnosis in the first instance must be largely clinical, because radiological confirmation of the injury may be delayed. 3. The simple method of longitudinal traction is the treatment recommended. 4. It is notable that in our first case the ossification centre of the femoral head appeared at the exceptionally early age of fifteen days

An experimental method is described which permits observations on the early stages of repair after acute displacement of the upper femoral epiphysis. Because the epiphysis is intra-articular, displacement brings about avascular necrosis which is slowly repaired by ingrowth of callus and blood vessels from the stump of the neck. As the bulk of the epiphysial plate remainsattached to the epiphysis, it acts as a barrier to successful revascularisation. Deliberate removal of the epiphysial cartilage allows earlier revascularisation. It is suggested that in clinical cases reduction be done through the epiphysial plate rather than through the neck, and that it be accompanied by curettage of the remaining part of the epiphysial plate from the under surface of the head

1. Two cases of lateral dislocation of the radio-humeral joint with greenstick fracture of the upper end of the ulna are described. 2. One case was complicated by a radial nerve lesion. 3. Treatment was by reduction under general anaesthesia and resting the elbow in a collar and cuff sling. Full recovery was present in six weeks

We performed postoperative venography on 84 consecutive patients who had undergone upper tibial osteotomy for medial compartment osteoarthritis of the knee. Deep-vein thrombosis was demonstrated in 41%. Only 15% of the cases were diagnosed clinically, all in the calf veins. Cases of proximal thromboses (3) and mixed-vein thromboses (12) were only revealed by venography

We reviewed the radiological and clinical long-term results after the nailing in situ of slipped upper femoral epiphysis in 59 hips in 43 patients. The displacement of the epiphysis had been measured as the ‘slipping angle’ before operation and related to the results at follow-up at a mean of 30.9 years (27 to 34). The mean age at follow-up was 44.2 years (39 to 50). Radiographic re-examination of 41 hips with slipping angles of ≤30° at the time of operation showed that eight (20%) had developed mild osteoarthritis and one had severe changes. For 18 hips with slipping angles ranging from 31 to 50° at surgery six (33%) had mild osteoarthritis and three had severe changes. The differences did not quite achieve statistical significance (p = 0.09). Clinical re-examination of the 41 hips with slipping angles of ≤30° showed fair or poor results (Harris hip score < 90) in three (7%). In the 18 hips with slipping of 31 to 50°, four had fair or poor results (22%) (p= 0.13). We conclude that nailing in situ for slipping of ≤30°, using one thin nail, can give excellent long-term results. At present we recommend that hips with slips ranging from 31 to 50° should also be nailed in situ, but further long-term studies are required, especially on the choice between nailing in situ and corrective osteotomy for slips in excess of 50°

Aims

Preoperative talar valgus deformity ≥ 15° is considered a contraindication for total ankle arthroplasty (TAA). We compared operative procedures and clinical outcomes of TAA in patients with talar valgus deformity ≥ 15° and < 15°.

The stages in adolescent slipping of the upper femoral epiphysis are classified in relation to treatment. The operation of open replacement of the displaced femoral head is described, and the results of a personal series of seventy-three such operations are presented. Open replacement is excellent treatment for severe chronic slipping so long as the growth plate is still open. The greater incidence of avascular necrosis in acute-on-chronic cases is probably due to damage to the blood supply of the head at the time of the acute slip or kinking of the vessels before replacement. Prolonged traction before operation may increase the risk of chondrolysis. Late onset of osteoarthritis when neither avascular necrosis nor chondrolysis has occurred may be due to misfitting of the articular cartilage because of inaccurate reduction

We reviewed 14 patients (16 hips) treated by open reduction and upper femoral derotation osteotomy for congenital dislocation of the hip. Nine patients with 11 treated hips had growth deformities of the proximal femur; in all of them the top screw of the fixation plate lay within the cartilaginous precursor of the greater trochanter. In the five control hips the top screw was more distal. In the nine patients (mean follow-up 10.8 years) there was an increase of 14 degrees in the neck-shaft angle (p = 0.01) and of 18 degrees in the angle between the capital femoral physis and the shaft (p = 0.01) compared to the control group. This indicates that growth disturbance of the greater trochanteric apophysis as a result of plate fixation leads to long-term deformity

We reviewed the long-term results of the treatment of slipped upper femoral epiphysis (SUFE) using realignment procedures in 36 patients (37 hips) at an average follow-up of 33.8 years (26 to 42). There were serious short-term complications in seven of the 22 hips treated by subcapital osteotomy, three of the 11 hips treated by intertrochanteric osteotomy and three of the four hips treated by manipulative reduction. At re-examination, the clinical and radiological results were excellent or good in 41% of the hips treated by subcapital osteotomy, in 36% treated by intertrochanteric osteotomy and in none treated by manipulative reduction. In all, seven hips (19%) had had arthrodesis or total hip replacement. The natural history of SUFE was probably not improved by any of the treatments used in our study. We therefore discourage the use of subcapital and intertrochanteric osteotomy as well as manipulative reduction in the primary treatment of chronic SUFE

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

Two cases of bilateral slipping of the upper femoral epiphysis in boys with end-stage renal failure due to megacystis and mega-ureter with severe renal osteodystrophy are reported. In one patient the lesion emerged after a dystonic reaction to drugs and in the other after bilateral nephro-ureterectomy. Neither showed marked elevation of growth hormone levels, but both had evidence of renal rickets with severe secondary hyperparathyroidism. Both had a satisfactory response to bilateral internal fixation. The complication should be borne in mind in all young patients with renal osteodystrophy

The development of genu valgum in a child after a fracture of the upper metaphysis of the tibia with a medial gap is due to the interposition of a flap of fibrous tissue consisting of pes anserinus and periosteum avulsed from the lower fragment. The ensuing biomechanical disturbance induces bowing of the shaft and asymmetrical growth at both ends of the bone. Four cases of established deformity are reported, together with two cases of fresh fracture successfully treated by surgical clearance of the fibrous tissue from the gap

Forty-eight consecutive patients (53 hips) were treated for moderate or severe slips of the upper femoral epiphysis between 1974 and 1984; 46 patients (96%) returned for clinical and radiological assessment at a mean of five years after operation. Twenty-three patients (23 hips) underwent a Dunn's open reduction and 25 patients (30 hips) were treated by epiphysiodesis and surgical osteoplasty as advocated by Heyman and Herndon. The results of the two methods of treatment are compared. Analysis revealed that 11 hips with moderate slip (30 degrees to 50 degrees) treated by the Heyman-Herndon procedure did significantly better than the 18 hips with severe slip (greater than 50 degrees) treated by the same method. Furthermore, when these hips with severe slip were compared to the hips treated by Dunn's open reduction, all of which were displaced greater than 50 degrees, the latter fared significantly better. The authors conclude that the Heyman-Herndon procedure gave consistently good results for moderate slips, but Dunn's open reduction gave better results for hips with severe slips

We reviewed, at an average age of 46 years, a series of 61 patients treated for unilateral slipped upper femoral epiphysis. At maturity there had been slipping of the contralateral hip in 11 patients (18%) and another 14 (23%) had originally had evidence of bilateral slipping when the primary radiographs were reviewed. In only two of these 25 patients (8%) was the slipping of the contralateral hip symptomatic. The incidence of early osteoarthritis of the contralateral hip was 7 of 36 with no slip, 5 of 16 with an untreated slip and 1 of 9 with a slip pinned in situ. If all 61 contralateral hips had been prophylactically pinned at the primary admission, 36 of the operations (59%) would have been unnecessary. We recommend that prophylactic pinning of the contralateral hip should not be standard, but that lateral radiography by the Billing technique be repeated every third to fourth month until closure of the growth plate begins. Hips in which a slip occurs should be pinned in situ

In the majority of patients with slipped upper femoral epiphysis only one hip is involved at primary diagnosis. However, the contralateral hip often becomes involved over time. There are no reliable factors predicting a contralateral slip. Whether or not the contralateral hip should undergo prophylactic fixation is a matter of controversy. We present a number of essential points that have to be considered both when choosing to fix the contralateral hip prophylactically as well as when refraining from surgery and instead following the patients with repeat radiographs.

Aims

We aimed to retrospectively assess the accuracy and safety of CT navigated pedicle screws and to compare accuracy in the cervical and thoracic spine (C2-T8) with (COMB) and without (POST) prior anterior surgery (anterior cervical discectomy or corpectomy and fusion with ventral plating: ACDF/ACCF).

A case of chordoma affecting the first lumbar vertebra is reported, with comments on its situation, diagnosis and treatment.

Lengthening of the humerus is now an established technique. We compared the complications of humeral lengthening with those of femoral lengthening and investigated whether or not the callus formation in the humerus proceeds at a higher rate than that in the femur. A total of 24 humeral and 24 femoral lengthenings were performed on 12 patients with achondroplasia. We measured the pixel value ratio (PVR) of the lengthened area on radiographs and each radiograph was analysed for the shape, type and density of the callus. The quality of life (QOL) of the patients after humeral lengthening was compared with that prior to surgery. The complication rate per segment of humerus and femur was 0.87% and 1.37%, respectively. In the humerus the PVR was significantly higher than that of the femur. Lower limbs were associated with an increased incidence of concave, lateral and central callus shapes. Humeral lengthening had a lower complication rate than lower-limb lengthening, and QOL increased significantly after humeral lengthening. Callus formation in the humerus during the distraction period proceeded at a significantly higher rate than that in the femur.

These findings indicate that humeral lengthening has an important role in the management of patients with achondroplasia.

We describe a management strategy for upper- and lower-limb fractures with associated arterial injury and report the results in 113 cases treated over a period of 18 years. Primary amputation was performed in 23 patients and of those who underwent primary vascular repair, 27 needed secondary amputation, two-thirds of them within a week of the injury. Of those requiring secondary amputation, 51.8% had ischaemia exceeding six hours, 81.4% had severe soft-tissue injury and 85.2% had type III open fractures. The patients whose limbs had been salvaged were followed up for an average of 5.6 years. The eventual outcome depended on the severity of the fracture, the degree of soft-tissue damage, the length of the ischaemic period, the severity of neurological involvement, and the presence of associated major injuries. There was a 30% incidence of long-term disability in the salvaged limbs, largely due to poor recovery of neurological function. Prompt recognition of such combined injuries is vital and requires a high index of suspicion in patients with multiple injuries and with certain fracture patterns. We recommend a multidisciplinary approach, liberal use of pre-operative angiography in upper-limb injuries and selective use of intra-operative angiography in lower-limb injuries. Stable external or internal fixation of the fractures and re-establishment of limb perfusion are urgent surgical priorities to reduce the period of ischaemia which is critical for successful limb salvage.

1. Forty patients out of sixty-nine operated upon between 1932 and 1952 by displacement osteotomy for congenital dislocation of the hip, ununited fracture of the neck of the femur, and osteoarthritis of the hip have been reviewed and the results analysed.

2. The factors responsible for the success of the operation are discussed and the technique of operation is described.

Of 34 consecutive proximal tibial osteotomies for secondary degenerative arthritis in patients under 40 years of age, 33 were evaluated at least three years (mean 7.5 years) after operation. In all 73% were satisfactory, with four failures in 21 procedures in men and five failures in 12 procedures in women. The primary abnormalities were medial meniscectomy (11), medial and lateral meniscectomy (4), osteochondritis dissecans (3), osteochondritis dissecans with medial meniscectomy (4) and fracture (11). All four knees with both medial and lateral meniscectomy had unsatisfactory results despite obtaining anatomical alignment. Eight patients needed subsequent surgery; five of them had total knee replacement, four within four years of the osteotomy. Proximal tibial osteotomy in younger patients with secondary arthritis gives similar results to those for older patients with primary osteoarthritis. If it fails, this is generally within the first four years after the operation.

This series, albeit consecutive and unselected, is very small; conclusions must therefore be tentative. The results do however suggest that the dangers of late manipulative reduction properly performed may have been exaggerated. Attempted without undue force it proved a harmless procedure, often successful even in cases of long duration. When it succeeds, the results in slips of unacceptable degree are at least as good as those following the more major surgical procedures, which can thus be avoided. Even when the displacement is minor its correction should on theoretical grounds at least decrease the prospects of later osteoarthritis. The only absolute contra-indication is a fused epiphysial plate. The degree of slip and above all the duration of symptoms should not preclude an attempt at manipulative reduction.

1. A brief description is given of normal epiphysial growth of the human femur.

2. Some ways in which abnormality of the growth plates may affect the shape and length of the human femur are described.

3. The influence of the blood supply on growth is discussed with particular reference to the etiology and treatment of congenital coxa vara.

I have attempted to call attention briefly to an operation that has proved to be of use in many patients with non-union of the neck of the femur and have tried to point out not only the indications but also the contra-indications, and to stress some of the precautions in the technique and after-care of the operation. This trochanteric reconstruction operation may help to solve some of the problems related to the ununited hip fracture.

We investigated the predictive value of intra-operative neurophysiological investigations in obstetric brachial plexus injuries. Between January 2005 and June 2011 a total of 32 infants of 206 referred to our unit underwent exploration of the plexus, including neurolysis. The findings from intra-operative electromyography, sensory evoked potentials across the lesion and gross muscular response to stimulation were evaluated. A total of 22 infants underwent neurolysis alone and ten had microsurgical reconstruction. Of the former, one was lost to follow-up, one had glenoplasty and three had subsequent nerve reconstructions. Of the remaining 17 infants with neurolysis, 13 (76%) achieved a modified Mallet score > 13 at a mean age of 3.5 years (0.75 to 6.25). Subluxation or dislocation of the shoulder is a major confounding factor. The positive predictive value and sensitivity of the intra-operative EMG for C5 were 100% and 85.7%, respectively, in infants without concurrent shoulder pathology. The positive and negative predictive values, sensitivity and specificity of the three investigations combined were 77%, 100%, 100% and 57%, respectively.

In all, 20 infants underwent neurolysis alone for C6 and three had reconstruction. All of the former and one of the latter achieved biceps function of Raimondi grade 5. The positive and negative predictive values, sensitivity and specificity of electromyography for C6 were 65%, 71%, 87% and 42%, respectively.

Our method is effective in evaluating the prognosis of C5 lesion. Neurolysis is preferred for C6 lesions.

Cite this article: Bone Joint J 2013;95-B:699–705.

Transepiphyseal separation of the neck of the femur following grand mal seizures is described in two children with cerebral palsy. Closed reduction and percutaneous fixation was followed by a period in a hip spica. Although the incidence of avascular necrosis of the femoral head is high following such injury, this has not occurred in these patients at a follow-up of 18 months.

1. Degenerative lesions of the shoulder joint can often be demonstrated radiographically before there is actual rupture of the musculo-tendinous cuff.

2. The characteristic pathological, clinical and radiographic features of degenerative lesionsare described.

3. All injuries of the shoulder joint, however trivial, occurring in patients over middle age, should be studied carefully by radiographic examination.

4. In injuries of the shoulder joint the presence of a degenerative lesion prolongs the duration of symptoms, and the prognosis is less satisfactory than when there is no radiographic evidence of abnormality.

1. A case of giant-cell tumour of the proximal end of the humerus treated by resection and fibular grafting twenty-nine years ago is reported. An excellent functional result has been maintained.

2. The literature is reviewed and the results claimed by earlier workers are noted.

3. The present field of application of the operation is probably in cases of advanced or recurrent giant-cell tumour of bone.

Techniques are described by which metal implants can be designed and produced to fit precisely a bony site at a subsequent operation. CT scans and solid modelling were used to produce an accurate three-dimensional representation of the surface of the bone. These techniques were applied to the production of an internal fixation device for shoulder arthrodesis after the resection of a neoplasm of the proximal humerus. The reconstruction utilised a free vascularised fibular graft between the scapula and the distal humeral remnant, fixation being secured with the custom-made implant.

Aims. The aim of this study was to investigate the impact of the level of upper instrumented vertebra (UIV) in frail patients undergoing surgery for adult spine deformity (ASD). Methods. Patients with adult spinal deformity who had undergone T9-to-pelvis fusion were stratified using the ASD-Modified Frailty Index into not frail, frail, and severely frail categories. ASD was defined as at least one of: scoliosis ≥ 20°, sagittal vertical axis (SVA) ≥ 5 cm, or pelvic tilt ≥ 25°. Means comparisons tests were used to assess differences between both groups. Logistic regression analyses were used to analyze associations between frailty categories, UIV, and outcomes. Results. A total of 477 patients were included (mean age 60.3 years (SD 14.9), mean BMI 27.5 kg/m. 2. (SD 5.8), mean Charlson Comorbidity Index (CCI) 1.67 (SD 1.66)). Overall, 74% of patients were female (n = 353), and 49.6% of patients were not frail (237), 35.4% frail (n = 169), and 15% severely frail (n = 71). At baseline, differences in age, BMI, CCI, and deformity were significant (all p = 0.001). Overall, 15.5% of patients (n = 74) had experienced mechanical complications by two years (8.1% not frail (n = 36), 15.1% frail (n = 26), and 16.3% severely frail (n = 12); p = 0.013). Reoperations also differed between groups (20.2% (n = 48) vs 23.3% (n = 39) vs 32.6% (n = 23); p = 0.011). Controlling for osteoporosis, baseline deformity, and degree of correction (by sagittal age-adjusted score (SAAS) matching), frail and severely frail patients were more likely to experience mechanical complications if they had heart failure (odds ratio (OR) 6.6 (95% CI 1.6 to 26.7); p = 0.008), depression (OR 5.1 (95% CI 1.1 to 25.7); p = 0.048), or cancer (OR 1.5 (95% CI 1.1 to 1.4); p = 0.004). Frail and severely frail patients experienced higher rates of mechanical complication than ‘not frail’ patients at two years (19% (n = 45) vs 11.9% (n = 29); p = 0.003). When controlling for baseline deformity and degree of correction in severely frail and frail patients, severely frail patients were less likely to experience clinically relevant proximal junctional kyphosis or failure or mechanical complications by two years, if they had a more proximal UIV. Conclusion. Frail patients are at risk of a poor outcome after surgery for adult spinal deformity due to their comorbidities. Although a definitively prescriptive upper instrumented vertebra remains elusive, these patients appear to be at greater risk for a poor outcome if the upper instrumented vertebra is sited more distally. Cite this article: Bone Joint J 2024;106-B(11):1342–1347

Aims. To determine whether side-bending films in scoliosis are assessed for adequacy in clinical practice; and to introduce a novel method for doing so. Methods. Six surgeons and eight radiographers were invited to participate in four online surveys. The generic survey comprised erect and left and right bending radiographs of eight individuals with scoliosis, with an average age of 14.6 years. Respondents were asked to indicate whether each bending film was optimal (adequate) or suboptimal. In the first survey, they were also asked if they currently assessed the adequacy of bending films. A similar second survey was sent out two weeks later, using the same eight cases but in a different order. In the third survey, a guide for assessing bending film adequacy was attached along with the radiographs to introduce the novel T1-45B method, in which the upper endplate of T1 must tilt ≥ 45° from baseline for the study to be considered optimal. A fourth and final survey was subsequently conducted for confirmation. Results. Overall, 12 (86%) of 14 respondents did not use any criteria to assess the bending film adequacy; the remaining two each described a different invalidated method. In total, 12 (86%) of the respondents felt T1-45B was easy to learn and apply. There was fair to substantial intra-rater reliability (k = 0.25 to 0.88) which improved to fair to almost perfect (k = 0.38 to 0.88) post-introduction of the guide. Inter-rater reliability varied considerably among the rater groups but similarly increased following introduction of the guide (k. S1. = 0.19 to 0.34, k. S2. = 0.33 to 0.43 vs k. S3. = 0.49 to 0.5, k. S4. = 0.35 to 0.43). Conclusion. Many surgeons and radiographers do not assess spinal bending films for adequacy. We propose that the change in the plane of the upper endplate of T1 on side-bending can be used in this evaluation. In the T1-45B method, a change of ≥ 45° on side bending qualifies as an adequate bend effort. Cite this article: Bone Jt Open 2023;4(9):689–695