Aims

The aim of this study was to determine whether closed suction drain (CSD) use influences recovery of quadriceps strength and to examine the effects of drain use on secondary outcomes: quadriceps activation, intra-articular effusion, bioelectrical measure of swelling, range of movement (ROM), pain, and wound healing complications.

We used gadolinium-enhanced fat-suppressed MRI to investigate 67 patients with persistent pain after lumbar discectomy. Twenty-five patients had reoperations for lesions diagnosed in this way. Eleven were for recurrent disc prolapse at the same level and sciatica was relieved by all but one. Five operations were for prolapse at an adjacent level and all were successful. The diagnosis of sepsis was less precise, but extension of tissue enhancement into the operated disc space was found to be significant. Only three patients had evidence of arachnoiditis which suggests that this condition has been too often diagnosed as a cause of persisting low back pain.

We report a prospective study of the influence of various factors on the six-month mortality of 531 patients with subcapital hip fractures. We performed univariate and multivariate analyses on the 403 patients treated surgically. The most significant predictors of the six-month mortality were dementia, postoperative chest infection, malignant neoplasia, old age and deep-wound infection, in that order. A simple test of mental ability was the most significant prognostic indicator and this test should be included in future studies of the management of hip fractures in the elderly.

High definition computed cervical myelograms have been made in flexion and extension in 13 patients with Morquio-Brailsford's disease. We observed that: 1) odontoid dysplasia was present in every case, with a hypoplastic dens and a detached distal portion which was not always ossified; 2) atlanto-axial instability was mild, and anterior atlanto-axial subluxation was absent in most cases; 3) severe spinal cord compression, when present, was due to anterior extradural soft-tissue thickening; 4) this compression was not relieved by flexing or extending the neck and was manifested early in life; 5) posterior occipitocervical fusion resulted in disappearance of the soft-tissue thickening and normalisation of subsequent development of the dens. We conclude that the severity of neurological involvement at the craniovertebral junction was determined by soft-tissue changes, not by the type of odontoid dysplasia nor by subluxation. Posterior occipitocervical fusion proved to be an effective treatment.

A prospective study of factors which might help to predict mortality in patients with intracapsular fractures of the femoral neck has been undertaken. A multivariate analysis technique was used to analyse the collected data, and it was found that mental ability was the most significant variable; this factor had the greatest effect on outcome.

Cervical myelopathy is an uncommon but potentially fatal complication of rheumatoid atlanto-axial subluxation. Computerised myelotomography with three-dimensional reconstruction shows that rheumatoid pannus, together with the odontoid peg, contributes significantly to anterior cervico-medullary compression. These findings were the basis for treatment by transoral anterior decompression and posterior occipitocervical fusion, which removes both bony and soft-tissue causes of compression and allows early mobilisation without major external fixation. We report encouraging results from this combined approach in 14 patients who had progressive neurological deterioration.

1. The distribution of isotope following a single injection of either Ca⁴⁵ or C¹⁴-proline has been studied in young rats in which one tibia had previously been removed, killed and reimplanted.

2. The dead tibia took up about 25 per cent as much Ca⁴⁵ or C¹⁴ as did the living tibia and the possible processes by which this occurred are discussed.

3. Determination of the "accretion rate " by kinetic analysis of the Ca⁴⁵ data showed that this was much too high unless the physico-chemical process of uptake of isotope by bone was taken into account.

4. Under the conditions of the experiment it was not possible to estimate the rate of bone matrix formation using C¹⁴-proline as a tracer.

1. The radiographs of paired living and dead rat tibiae, obtained in an experiment previously reported, have been examined by densitometry.

2. The dead bone became progressively less dense than the living bone as the duration of the implantation increased.

3. The change in density was related to the quantity, but not to the quality, of the bone tissue examined.

1 . A preliminary report is presented of a clinical trial to compare the results of early and late weight bearing in randomly selected patients of comparable age groups whose displaced femoral neck fractures were treated by internal fixation with a sliding nail-plate.

2. When 124 patients were assessed at three months and 107 at six months after operation there was no significant difference between those who started unguarded weight bearing two weeks after operation and those who avoided weight bearing for three months.

3. Early weight bearing appears to have no harmful effect on the early post-operative stability of this fracture when a sliding nail-plate is used for fixation.

4. Further information is necessary before any conclusion can be reached about the effect of early weight bearing on the ultimate fate of the fracture and of the femoral head. For this reason, and also to increase the numbers of patients in the series, the trial is continuing and the patients are being followed up for a three-year period.

1. It is now more than three years since a group of ninety-one patients with transcervical fracture of the neck of the femur were examined for osteoporosis at the time of injury using a histological or a radiographic technique, or a combination of both methods.

2. After patients with basal fractures were excluded, ninety fractures in eighty-eight patients were available for review and sixty-six (74 per cent) were adequately followed up.

3. In this series the fate of the fracture did not appear to be influenced by the presence or absence of osteoporosis, or by the degree of osteoporosis.

4. The incidence of osteoporosis increased with advancing age, but this increased incidence did not appear to be responsible for the greater proportion of failures after the age of sixty-five.

5. In this series of patients examination for osteoporosis was made by methods which were believed to be the best available at the time. The possibility that these are not absolutely reliable cannot be ruled out.

1. Recently described histological and radiographic methods of diagnosing osteoporosis have been applied to patients with transcervical and intertrochanteric fractures of the femur.

2. Both methods indicate a higher incidence of osteoporosis in such patients than in a control series, especially in older women with intertrochanteric fractures.

3. A discrepancy between the results of biopsy and radiographic examination was encountered, the explanation of which is not yet clear.

1. Some physical properties of living and dead bone have been studied in rats; most of these are interrelated and ultimately depend upon the composition of the tissue.

2. Dead bone, remaining within the body, does not take up measurable amounts of mineral from the tissue fluid but retains its original physical properties of radiographic density, specific gravity, strength and composition.

3. The altered radiographic density of avascular bone seen in clinical practice is almost certainly relative unless there has been concomitant appositional new bone formation.

4. Some other explanation must be sought for the finding that dead bone takes up significant amounts of bone-seeking isotopes in radioactive tracer studies.

A patient with Paget's sarcoma of the femur, alive and well seven years after amputation, is reported. Long survival in two previously reported cases is also mentioned.