Background: Current treatment for Perthes disease aims at preventing deformation of the femoral head during the active stage of the disease by obtaining containment of the femoral head. To effectively pre-empt femoral head deformation, one needs to know, when during the disease irreparable femoral head deformation occurs. This study was undertaken to attempt to clarify this.

Methods: Records and 2634 pairs of radiographs (AP and lateral) of 610 patients with Perthes’ disease were reviewed. The evolution of the disease was divided into seven stages (Stages Ia, Ib, IIa, IIb, IIIa, IIIb & IV) based on plain radiographic appearances. Intra-observer and inter-observer reproducibility of this new classification system was assessed. The duration of each stage of the disease was noted. The stage at which epiphyseal extrusion and widening of the metaphysis occurred and the stage at which metaphyseal and acetabular changes appeared were identified. The shape and the size of the femoral head, the extent of trochanteric overgrowth and the radius of the acetabulum were assessed in hips that had healed.

Results: The reproducibility of the new classification system of the evolution Of Perthes’ disease was good. The median duration of each stage varied between 95 and 326 days. Epiphyseal extrusion and metaphyseal widening was modest in Stages Ia, Ib and IIa but increased dramatically after Stage IIb. > 20% extrusion occurred in 70% of the hips by Stage IIIa. Metaphyseal changes were most frequently encountered in Stage IIb, while acetabular changes were most prevalent in Stage IIIa. At healing, only 24% of untreated patients had spherical femoral heads, while 52% had irregular femoral heads.

Conclusions: The new classification of the stages of evolution of Perthes’ disease helps to identify when crucial events occur during the course of the disease. The timing of epiphyseal extrusion, metaphyseal widening and the appearance of adverse metaphyseal and acetabular changes suggest that femoral head deformation occurs by Stage IIIa in untreated hips. Hence, if containment were to succeed, it should be achieved before this stage.

Rapidly progressive osteoarthritis of the hip (RPOH) is an unusual subset of osteoarthritis. It is characterized by rapid joint space loss, chondroly­sis, and sometimes marked femoral head and acetabular destruction as a late finding. The exact pathogenetic mechanism is unknown. Potential causes of RPOH include subchondral insufficiency fracture resulting from osteoporosis, increasing posterior pelvic tilt as a mechanical factor, and high serum levels of matrix metalloproteinase (MMP)-3 as biological factors. This study was aimed to identify some markers that associate with the destructive process of RPOH by analyzing the proposed pathological factors of the disease, MMP-3, pelvic tilt, and osteoporosis. Of female patients who visited our hospital with hip pain from 2012 through 2018, this study enrolled female patients with sufficient clinical records including the onset of hip pain, age and body mass index (BMI) at the onset, a series of radiographs during the period of >12 months from the onset of hip pain, and hematological data of MMP-3 and C-reactive protein (CRP). We found the hip joints of 31 patients meet the diagnostic criteria of RPOH, chondrolysis >two mm in one year, or 50% joint space narrowing in one year. Those patients were classified into two groups, 17 and 14 patients with and without subsequent femoral head destruction in one year shown by computed tomography, respectively. Serum MMP-3 and CRP were measured with blood samples within one year after the hip pain onset. The cortical thickness index (CTI) as an indicator of osteoporosis and pelvic tilt parameters were evaluated on the initial anteroposterior radiograph of the hip. These factors were statistically compared between the two groups. This study excluded male patients because RPOH occurs mainly in elderly females and the reference intervals of MMP-3 are different between males and females. There was no difference in age at onset or bone mass index between the RPOH patients with and without subsequent femoral head destruction. Serum levels of MMP-3 were significantly higher in the RPOH patients with the destruction (152.1 ± 108.9 ng/ml) than those without the destruction (66.8 ± 27.9 ng/ml) (P = 0.005 by Mann-Whitney test). We also found increased CRP in the patients with femoral head destruction (0.725 ± 1.44 mg/dl) compared with those without the destruction (0.178 ± 0.187 mg/dl) (P = 0.032 by Mann-Whitney test). No difference in the duration between the hip pain onset and the blood examination was found between the two groups. There was no significant difference in CTI or pelvic tilt between the two groups. The pathological condition that may increase serum MMP-3 and CRP could be involved in femoral head destruction after chondrolysis of the hip in patients with RPOH

This study identifies variations in presentation and demographics between structural and non-structural (muscle patterning) shoulder instability. We analysed 1020 unstable shoulders (855 patients) from our institution database. Demographic details, direction and aetiology were obtained from medical records. Anterior dislocations comprised 67%, posterior 31% and inferior 2% of all directions of instability and 75 shoulders had multidirectional instability. Structural causes were dominant in anterior instability (traumatic 39% and atraumatic 38%) and muscle patterning in posterior (81%) and inferior (90%) instability. Males accounted for 64% of all patients (73% of all structural patients and 53% of muscle patterning patients. Mean age at presentation was 25 years old (structural patients 28 years and muscle patterning patients 21 years old). There were 690 unilaterally unstable shoulders (57% right- and 43% left-sided); the dominant arm was affected in 58% overall, in 42% of all left-handers and only 33% of left-handers with muscle patterning. Bilateral shoulder instability occurred in 19% of all patients (12% of patients with structural instability and 28% of those with muscle patterning instability). For muscle patterning, the mean age at onset of symptoms was 14 years, and mean length of symptoms before presentation was 8 years. There was a trimodal distribution of age at onset of symptoms corresponding to peaks at 6, 14 and 20 years. In the group with onset of muscle patterning under 10 years old, there was a higher proportion of females (71% vs 47%), laxity (63% vs 29%) and bilaterality (54% vs 42%), and fewer presenting with pain (17% vs 50%). Muscle patterning instability is associated with a demographic and presentation profile which may help distinguish it from structural forms of instability. As age at presentation increased, pain increased and joint laxity decreased. Bilaterality did not appear to be associated with gender, the presence of laxity or pain

This study identifies variations in presentation and demographics for different forms of shoulder instability. We analysed 1020 unstable shoulders (855 patients) from a previously presented database. Demographic details, direction and aetiology were obtained from medical records. Anterior dislocations comprised 67%, posterior 31% and inferior 2% of all directions of instability and 75 shoulders had multidirectional instability. Structural causes were dominant in anterior instability (traumatic 39% and atraumatic 38%) and muscle patterning in posterior (81%) and inferior (90%) instability. Males accounted for 64% of all patients (73% of all structural patients and 53% of muscle patterning patients. Mean age at presentation was 25 years old (structural patients 28 years and muscle patterning patients 21 years old). There were 690 unilaterally unstable shoulders (57% right- and 43% left-sided); the dominant arm was affected in 58% overall, in 42% of all left-handers and only 33% of left-handers with muscle patterning. Bilateral shoulder instability occurred in 19% of all patients (12% of patients with structural instability and 28% of those with muscle patterning instability). For muscle patterning, the mean age at onset of symptoms was 14 years, and mean length of symptoms before presentation was 8 years. There was a trimodal distribution of age at onset of symptoms corresponding to peaks at 6, 14 and 20 years. In the group with onset of muscle patterning under 10 years old, there was a higher proportion of females (71% vs 47%), laxity (63% vs 29%) and bilaterality (54% vs 42%), and fewer presenting with pain (17% vs 50%). As age at presentation increased, pain increased and joint laxity decreased. Bilaterality did not appear to be associated with gender, the presence of laxity or pain. Muscle patterning instability is associated with a demographic and presentation profile which may help distinguish it from structural forms of instability

Purpose of the study: The purpose of this retrospective study was to analyze clinical datao n pigmented villon-odular synovitis (PVSN) of the knee as well as outcome after treatment in order to define the diagnostic stages, the surgical treatment, and follow-up modalities for this rare benign proliferative disease of the synovial which predominantly affects the knee joint. Material and methods: Between 1996 and 2004, 28 patients were managed in our department, 13 men and 15 women, diffuse PVNS in 20 and localized PVNS in 8. IN the localized forms, symptoms were similar to those observed in knees with intra-articular foreign bodies or a meniscal lesion (75%) was present for 14 months on average at the first consultation. Mean age at onset of therapeutic management was 40 years (range 20–62). Localized arthroscopic or open resection was performed. For the diffuse forms, symptoms had been present for 15 months on average at the first consultation. Patients sought medical care because of spontaneous hemarthrosis or diffuse knee pain with no specific signs. Mean age at onset of therapeutic management was 38 years (range 15–59). Bony lesions were observed in 20%. Synoviorthesis or surgical synovectomy were performed. Mean follow-up was 97 months (range 12–309). Outcome was analyzed separately for the localized and diffuse forms. Results: For the localized PVNS, there were no complications after surgical treatment but the relapse rate reached 12.5%. For diffuse PVNS, the cumulative rate of relapse was 50%, recurrence being noted on average 37 months after treatment. A stiff joint developed in 14% after open synovectomy. Surgical treatment was necessary in four cases (total arthroplasty in three) seen late after development of bony lesions; the clinical outcome was good with good gain in flexion. Discussion: MRI is essential for the topographic diagnosis and to guide surgery. For diffuse PVNS seen at an advanced stage or after several recurrences, adjuvant synoviorthesis can be useful 4 to 8 months after surgery. Conclusion: Appropriate treatment of PVNS of the knee depends on the presentation but usually involves a surgical procedure. The risk of recurrence for diffuse PVNS warrants annual MRI for four years

Purpose. To investigate associations between sagittal thoracolumbar spine shape with sex and measures of adiposity throughout adulthood. Methods. Thoracolumbar spine shape was characterised using statistical shape modelling on lateral dual-energy x-ray absorptiometry images, recorded for vertebral fracture analysis, of the spine from 1529 participants of the MRC National Survey of Health and Development, acquired at age 60–64 years. Associations between spine shape modes (SM) and 1) sex, 2) contemporaneous measures of overall and central adiposity (indicated by body mass index and waist circumference, respectively), 3) changes in total and central adiposity during earlier stages of adulthood and age at onset of overweight, were investigated. Results. Four of the first eight spine modes (SM) describing lumbar spine shape differed by sex; on average, women had more lordotic spines than men with relatively smaller but caudally increasing anterior-posterior (a-p) vertebral diameters. Greater BMI and waist circumference and earlier onset of overweight were associated with uneven (or snaking) spinal curvatures (SM2) and larger a-p vertebral diameters (SM3). Central adiposity was also associated with larger caudal disc heights (SM4) in women, especially increases between 36–43 years. Conclusions. Sagittal spine shapes differed by sex and associations with overall and central adiposity also differed. Overweight and greater central adiposity earlier in adulthood were particularly important, and were associated with a straighter but more unevenly curved spine with larger vertebrae and caudal discs heights, possibly explained by a chronic effect of increased mechanical loading on the spine. Conflicts of interest: None. Funding received from MRC

Introduction:. Paley et al has developed a multiplier method for calculating both leg length and total height. In the development of this algorithm, they evaluated the effect of factors including bone age and sex. They established that sex had a significant impact, but adjusting for bone age did not improve accuracy. Bone age and menarche have been shown to improve other height prediction models. Purpose:. We used a large prospective cohort to evaluate if the multiplier is independent of physiological age using menarche as a proxy. Methods:. Using the ALSPAC dataset we determined the accuracy of the Paley multiplier for predicting total height and leg length, and assed weather if the date of first menses increased the accuracy of the multiplier. Female patients over the age of 8, with documented final height and final sub-ishial leg length over the age of 15 and a date of first menses were evaluated. Predicted final height was compared with actual final height at all data points. Results:. There were 28332 data points in 3062 girls prior to skeletal maturity in the total height cohort and 8395 data points in 2300 girls in the leg length cohort. When age was corrected using the difference in age at onset of menarche from average, the accuracy of multiplier decreased for both measurements. When a correction of 50% was used, there was an improvement in the accuracy of multiplier predictions, reducing the average error by up to 24%. Conclusions:. Previous studies have failed to demonstrate that the accuracy of the multiplier is improved when adjusted for bone age. We have used the date of first menses as a proxy for bone age and established that making a 50% correction for physiological age improves the accuracy of this method. Significance:. This will potentially allow more accurate prediction of leg length discrepancy, and total height in girls with early menarche

Aims

Perthes’ disease is an uncommon hip disorder with limited data on the long-term outcomes in adulthood. We partnered with community-based foundations and utilized web-based survey methodology to develop the Adult Perthes Survey, which includes demographics, childhood and adult Perthes’ disease history, the University of California Los Angeles (UCLA) Activity Scale item, Short Form-36, the Hip disability and Osteoarthritis Outcome Score, and a body pain diagram. Here we investigate the following questions: 1) what is the feasibility of obtaining > 1,000 survey responses from adults who had Perthes’ disease using a web-based platform?; and 2) what are the baseline characteristics and demographic composition of our sample?

Aims

Avascular femoral head necrosis in the context of gymnastics is a rare but serious complication, appearing similar to Perthes’ disease but occurring later during adolescence. Based on 3D CT animations, we propose repetitive impact between the main supplying vessels on the posterolateral femoral neck and the posterior acetabular wall in hyperextension and external rotation as a possible cause of direct vascular damage, and subsequent femoral head necrosis in three adolescent female gymnasts we are reporting on.

There is conflicting information regarding the recommendations of bracing, physical therapy and cessation of sports for young athletes with symptomatic spondylolysis. The purpose of this study was to identify factors affecting the prognosis and to find the optimal method of non-operative treatment. The patients in our study were athletes who visited our children's hospital for low back pain with lumbar spondylolysis and were treated non-operatively from 1990 to 2002. Clinical and radiological outcomes were reviewed retrospectively. The effects of bracing, physical therapy, cessation of sports, duration of symptoms before the first hospital visit, lateralisation of spondylolysis, age, gender, onset of low back pain after lumbar trauma during sports, bone scan uptake, vertebral level of the lesion, associated scoliosis or spina bifida and radiological bony healing were analysed using univariate and multivariate analysis with logistic regression. The mean age of patients was 13 years (range 7 to 18 years). The mean follow-up was 4.2 years (range 1.2 to 12 years). Of 132 patients, 48 patients had excellent results with no pain during sports, 76 good, 6 fair, and 4 poor. Cessation of sports, early non-operative intervention, and a unilateral spondylolysis appeared to be factors associated with excellent outcomes. However, bracing, physical therapy, age, gender, level of lesion, history of trauma, increased uptake on bone scan, or associated scoliosis or spina bifida were not factors. Bony healing was not related to the clinical outcome. The non-operative treatment of spondylolysis in children can yield excellent clinical outcomes, and the absence of bony healing has no influence on clinical outcome. Factors in this study found to correlate with an excellent outcome include unilateral spondylolysis, acute spondylolysis, and treatment with cessation of sports for 12 weeks

Introduction. Ankle fusion presents a difficult problem in the presence of infection, inadequate soft tissue, poor bone stock and deformity. Nonunion and infection remains a problem even with internal fixation. Ilizarov frame provides an elegant solution to the problem with stable remote fixation while allowing lengthening, deformity correction and weight bearing. Patients and methods. Twenty-one consecutive patients were studied. The mean age at onset of disease was 52 years (range 4-70). Mean duration of the problem was 59.9 months (6-372). Aetiology included traumatic arthritis in 5, traumatic arthritis with osteomyelitis in 1, failed ankle fusion in 8, septic arthritis in 1, infected ankle fracture nonunion in 1, avascular necrosis of talus in 1, congenital deformity in 3 and failed ankle arthroplasty in 1. 15 patients had deformity of the ankle at the time of presentation. 15 of the 21 patients had either clinical or radiological evidence of infection. Treatment principles involved local excision, deformity correction with good alignment and soft tissue management. Static Compression was achieved with an Ilizarov frame while dynamic fixation was performed in 3 cases for lengthening. Antibiotics treatment was continued until union in the infected cases. On achieving union the frame was removed and a below knee cast was applied for 4 weeks. Results. Fusion was achieved in all cases at an average time of 5 months. One patient had below knee amputation for chronic pain. There was no recurrence of infection. Complications included pin site infection, lateral impingement, drug reaction and hind-foot pain. The results were assessed in terms of SF36 and Modified foot and ankle score. Conclusion. The Ilizarov ankle fusion is a reliable salvage procedure in difficult ankle problems

Introduction. This study was to investigate the association of developmental dysplasia of the hip (DDH) and primary protrusion acetabuli (PPA) with Vitamin D receptor polymorphisms TaqI and FokI and oestrogen receptor polymorphisms Pvu II and XbaI. Methods. 45 patients with DDH and 20 patients with PPA were included in the study. Healthy controls (n=101) aged 18-60 years were recruited from the same geographical area. The control subjects had a normal acetabular morphology based on a recent pelvic radiograph performed for an unrelated cause. DNA was obtained from all the subjects from peripheral blood. Genotype frequencies were compared in the three groups. The relationship between the genotype and morphology of the hip joint, severity of the disease, age at onset of disease and gender were examined. Results. The oestrogen receptor XbaI wild-type genotype (XX, compared with Xx and xx combined) was more common in the DDH group (55.8%) than controls (37.9%), though this just failed to achieve statistical significance (p=0.053, odds ratio=2.1, 95% CI=0.9-4.6). In the DDH group, homozygosity for the mutant TaqI Vitamin D receptor t allele was associated with higher acetabular index (Mann-Whitney U-test, p= 0.03). Pvu II pp oestrogen receptor genotype was associated with low centre edge angle (p=0.07). Conclusion. This study suggests a possible correlation between gene polymorphism in the oestrogen and vitamin D receptors and susceptibility to, and severity of DDH. The TaqI vitamin D receptor polymorphisms may be associated with abnormal acetabular morphology leading to DDH while the XbaI oestrogen receptor XX genotype may be associated with increased risk of developing DDH. No such correlations were found in the group with PPA

We aimed (1) to determine the factors which influence outcome after surgery for CES and (2) to study CES MRI measurements. 56 patients with evidence of a sphincteric disturbance who underwent urgent surgery (1994-2002) were identified and invited to clinic. 31 MRIs were available for analysis and randomised with 19 MRIs of patients undergoing discectomy for persistent radiculopathy. Observers estimated the percentage of spinal canal compromise and indicated whether they thought the scan findings could produce CES and whether the discs looked degenerate. Measurements were repeated after two weeks. (1) 42 patients attended (mean follow up 60 months; range 25–114). Mean age at onset was 41 years (range 24–67). 26 patients were operated on within 48 hours of onset. Acute onset of sphincteric symptoms and the time to operation did not influence the outcomes. Leg weakness at onset persisted in a significant number at follow-up (p<0.005). Bowel disturbance at presentation was associated with sexual problems (<0.005) at follow-up. Urinary disturbance at presentation did not affect the outcomes. The 13 patients who failed their post-operative trial without catheter had worse outcomes. The SF36 scores at follow-up were reduced compared to age-matched norms in the population. The mean ODI was 29, LBOS 42 and VAS 4.5. (2) No significant correlations were found between MRI canal compromise and clinical outcome. There was moderate to substantial agreement for intra- and inter-observer reproducibility. Conclusions. Due to small numbers we cannot make the conclusion that delay to surgery influences outcome. Based on the SF36, LBOS and ODI scores, patients who have had CES do not return to a normal status. Using MRI alone, the correct identification of CES has sensitivity 68%, specificity 80% positive predictive value 84% and negative predictive value 60%. CES occurs in degenerate discs

Introduction: Spinal deformities (scoliosis, kyphosis or kyphoscoliosis) in children under 10 years of age result from congenital, neuromuscular and idiopathic etiologies. The progression of the deformity is affected by its nature, location and age of onset. Spinal arthrodesis is the procedure of choice in patients with progressive deformities. The use of instrumentation facilitates curve correction and arthrodesis rates. Pediatric spinal surgery is technically demanding, and is still considered controversial. The advent of reduced size spinal instrumentation allowed surgeons to expand their use to pediatric patients. The use of spinal instrumentation in children with various spinal deformities has not been well documented. Objective: To assess the safety and efficacy of spinal arthrodesis in young patients with progressive spinal deformities. Patients and Methods: We retrospectively reviewed the medical charts and radiographs of 25 patients younger than 10 years of age who underwent corrective surgery for various spinal deformities. Radiographic outcome, fusion rates and complication were compared between instrumented and non instrumented patients. Results: At two years of follow up instrumented corrective procedures resulted in superior correction compared to non-instrumented patients and in solid arthrodesis in all. Complications were infrequent. Conclusions: The use of reduced size spinal instrumentation in young patients with progressive spinal deformities is safe and effective. Curve correction, length of bracing and fusion rates are all in favour of instrumentation, wile complication rates are acceptable. The use of spinal instrumentation in young patients requires expertise and patience

The aim of the study is to evaluate the prognostic value of Herring’s classification for treatment planning of Perthes Disease and predicting the final outcome of the disease. We analysed 45 patients treated in our department in the period of 1992 – 2005. The analysis consisted of determining the lateral pillar collapse in fragmentation stage and the containment of the femoral head in the residual stage. We did retrospective analysis of the x-rays in fragmentation stage and classified the patients according to Herring’s classification. Group A included 10 patients, group B – 20 patients and group C included 15 patients. We used Hayman – Herndon Acetabulum – Head Index (AHI) to analyse the x- rays in the residual stage. The statistical analysis of the results included the analysis of the differences between the lateral pillar collapse among the groups and the differences between affected hip and the contralateral control hip. Correlation between the degree of lateral pillar collapse and the AHI in the residual stage was also analyzed. Correlation between the age of onset of the disease and AHI was determined for each group, too. The results show significant differences between the lateral pillar collapse in Herring groups, and among the affected and control hips. Differences of AHI values were also significant between the groups. Correlation between the AHI and lateral pillar collapse for each group shows moderate connection just as the one between AHI and age. Herring’s classification is reliable in classifying patients with Perthes disease. It enables good prediction of the natural course of the disease and thus influences the treatment decision-making

Introduction: Ankle fusion presents a difficult problem in the presence of infection and poor bone stock. Ilizarov method provides stability with remote fixation and allows weight bearing. Patients and Methods: Fourteen consecutive patients were studied. The mean age at onset of disease was 50 years(range 4–70). 13 of the patients had either clinical or radiological evidence of infection prior to ankle fusion surgery. Mean duration of problem was 52 months(range 8–372). Aetiology included traumatic arthritis in 5, failed fusion in 6, septic arthritis in 1, infected ankle fracture nonunion in 1 and avascular necrosis of talus in 1. There were 10 males and 4 females. Local excision was followed by Ilizarov frame compression. Diagnosis of infection was based on microbiology and histology. Antibiotics treatment was continued until union. On radiological evidence of union the frame was dynamized and removed. Below knee cast was applied for 4 weeks. Results: 13 of 14 patients had complete ankle fusion at a mean period of 5 months. 1 patient who had partial fusion of the ankle had recurrence of infection requiring amputation. Complications included pin site infection, lateral impingement, deep infection, hind-foot pain and neuroma at amputation site. Conclusion: The Ilizarov ankle fusion is a reliable salvage procedure in difficult ankle problems

Introduction Ankle fusion presents a difficult problem in the presence of infection and poor bone stock. The Ilizarov method provides stability with remote fixation and allows weight bearing. Patients and method Fourteen consecutive patients were studied (10 males, 4 females). The mean age at onset of disease was 50 years (range 4–70). Thirteen of the patients had either clinical or radiological evidence of infection prior to ankle fusion surgery. Mean duration of problem was 52 months (range 8–372). Aetiology included traumatic arthritis in five, failed fusion in six, septic arthritis in one, infected ankle fracture non-union in one and avascular necrosis of talus in one. Local excision was followed by Ilizarov frame compression. Diagnosis of infection was based on microbiology and histology. Antibiotic treatment was continued until union. On radiological evidence of union the frame was dynamized and removed. A below-knee cast was applied for 4 weeks. Results At a mean period of 5 months, complete ankle fusion was found in 13/14 patients. One patient who had partial fusion of the ankle had recurrence of infection requiring amputation. Complications included pin site infection, lateral impingement, deep infection, hind-foot pain and neuroma at amputation site. Conclusion The Ilizarov ankle fusion is a reliable salvage procedure in difficult ankle problems

Charcot neuroarthropathy is a progressive, destructive process occurring in the presence of neuropathy. We report the outcome of neuropathic foot joints presenting to our clinic over a 12 year period. Methods. Cases were identified from the Diabetic Foot Clinic Register, 1989–2001. We studied patient demographics, clinical presentation, distribution, treatment and outcome. Results. Twenty-eight episodes of arthropathy occurred in 23 patients. Age at onset ranged from 40 to 79 years. Presentation was acute in 14 and subacute in the others. Sites affected included 23 mid foot, 4 ankle and 1 MTP. Nine feet were ulcerated at presentation, eight had a history of ulcer, nine have no ulcer history. Infection complicated the Charcot process in 15. Mean Hba1c at presentation was 9.3%. Treatments. Total contact casting 23, 4 “scotch cast” boots and 1 Air-cast walker. Pamidronate was given to 10 patients. Outcomes. Three patients died. Two had below knee amputations. Casts were required for up to 12 months. Three required orthopaedic foot reconstructions. All ulcers present initially healed. Conclusion. Charcot arthropathy remains uncommon. In our series treatment was successful in all but two patients in terms of preserved limbs, mobility and freedom from ulceration

Introduction: To determine the factors which influence outcome after surgery for cauda equina syndrome. Method: 56 patients with evidence of sphincteric disturbance who underwent urgent surgery between 1994 and 2002 were identified and invited to follow up. Outcomes consisted of history and examination, and several validated questionnaires. Results: 42 patients attended with a mean follow up of 60 months (range 25–114). Mean age at onset was 41 years (range 24–67) with 23 males and 19 females. 26 patients were operated on within 48 hours of onset. Urinary disturbance at presentation did not affect the outcomes. Bowel disturbance at presentation was associated with sexual problems (< 0.005) and abnormal rectal tone (p< 0.05) at follow up. There was a weak association between delay to operation and bowel disturbance (p< 0.05) at follow up. Eight patients had faecal soiling and faecal incontinence at follow up and this was associated with sudden onset of symptoms, initial abnormal rectal tone and time to operation (p< 0.05). The 12 patients who failed their postoperative trial without catheter had worse outcomes. The SF36 scores at follow up were reduced compared to age matched norms in the population. The mean ODI was 29, LBOS 42 and VAS 4.5. Discussion: In our series the duration of symptoms and speed of onset prior to surgery appears to influence bowel but not bladder outcome two years after surgery. Based on the SF36, LBOS and ODI scores, patients who have had CES do not return to a normal status

This is the largest reported natural history study of frozen shoulder. 500 patients were identified from a specialist shoulder clinic register with a diagnosis of frozen shoulder based on Codman’s criteria. 273 patients with primary frozen shoulder replied to a detailed postal questionnaire regarding their condition. Mean follow up from symptom onset was 52 months (range 12–240months), with 89% of shoulders followed up for a minimum of 3 years. A positive family history was identified in 20% (n=45) of 1st degree relatives. The relative risk to siblings compared with a control population was 4:1. Patients with mild to moderate symptoms recovered more quickly than those with severe or unbearable symptoms. The mean age of onset was 53 years (range27–85yrs). The female to male ratio was 1.6:1. The condition was bilateral in 20%, with no incidence of ipsilateral recurrence. 22% of patients reported a history of minor trauma to the upper limb prior to the onset of symptoms. 16% were diabetic and 4% reported a history of Dupuytren’s contracture. Right and left arms were affected equally with no relationship to hand dominance. 61% reported slow, and 39% reported sudden onset of symptoms. Generally pain and stiffness improved with time but at 3 and 4 years after onset 13% and 9% respectively still had symptoms. Frozen shoulder affects people mainly in their 6th decade. Genetic factors play an important role in the aetiology. The natural history is for improvement with time, with the less severe symptoms at onset improving most quickly. 9% of patients were still symptomatic at 4 year follow up