Between 1972 and 2002 74 patients were treated under the combined care of the orthopaedic oncology service and lymphoma clinic with primary bone lymphoma. We reviewed the seventeen cases affecting the upper limb (23%). Of the seventeen patients nine remain alive. Assessment of the patient’s clinical presentation, histopathological definition, treatment and function outcome was made. The nine survivors were assessed clinically and with the Oxford shoulder score and the Toronto extremity salvage score.

Average time from first presentation to diagnosis was 7 months. All seventeen were diagnosed as a B –cell non-Hodgkin’s lymphoma, fifteen cases were high grade and two cases were low grade. The scapula was involved in six, humerus eight and clavicle three cases. Seven patients sustained pathological fractures three of which were at presentation; of these two were treated surgically. Eight patients have subsequently died of their disease. Functional outcome in surviving patients after medical treatment was very good with average TESS score of 79% (52%–99%) and OSS of 27 (12–52).

The presentation of lymphoma of the shoulder girdle may mimic benign shoulder conditions and lead to a delay in radiological and histopathological diagnosis. Pathological fracture is a common presentation and complication of treatment, however these fractures have a high chance of healing with medical treatment alone. Although shoulder stiffness remains a problem following medical treatment, overall upper limb function is good. There is little evidence that these patients require surgery in the short to medium term.

Two cases of assymptomatic hip dislocation discovered incidentally are presented.

Case 1- A 63-year old lady had an uncemented primary total hip replacement of the left hip for painful osteoarthritis in July 1993. She made an uneventful recovery post-operatively. This lady had no neurological abnormality and was mobilising independently. In April 2001,8 years later she was admitted as an emergency for suspected diverticulitis of the colon. Plain radiographs performed showed dislocated hip prosthesis.

Case 2- This 75-year old lady, an active farmer, had right hip arthroplasty in July 1990 for painful osteoarthritis and made an uneventful recovery subsequently. She also did not have any neurological abnormality and was mobilising independently too. Dislocated prosthesis was discovered radiologically in December 2001 during a pre-operative work-up for the left hip (the other hip) arthroplasty.

Discussion: Late dislocation is more common than was thought previously. Several separate processes, some distinct from those associated with early dislocation, can lead to late dislocation. It can occur in association with a long-standing problem with the prosthesis that manifests late (such as malposition of the implant or recurrent subluxation), it can occur in association with a new problem (such as neurological abnormality, trauma or polyethylene wear), or it can occur in association with combination of these factors.

Both these patients were mobilising independently and did not suffer from any neurological abnormality. Both these patients had asked to be discharged after an initial 2-year follow-up. They had not experienced any problem with the hip replacement. These dislocated prosthesis were discovered incidentally. Revision arthroplasty was carried out successfully in both these patients

These cases emphasise the need for long-term clinical and radiological follow-up in hip arthroplasty patients as hip dislocations can be assymptomatic and not detected by clinical examination. Radiological review alongside evaluation using scoring systems is recommended.

Dupuytren’s contracture (DC) is a non-lethal disabling disease, characterised by a progressive fibrosis of the deep palmar fascia, produced by an increased deposition of collagen within the extracellular matrix (ecm). Matrix metalloproteinases (MMPs) are a family of zinc-dependent endopeptidases that degrade ecm proteins. Their activity is regulated by growth factors, cytokines and by specific tissue inhibitors (TIMPs). An imbalance in the normal relationship between expression of MMPs and TIMPs is believed to contribute to the pathogenesis of other fibroproliferative diseases.

We have performed a detailed immunohistochemical analysis of DC tissue which provides the most comprehensive profile to date of the MMP and TIMP expression in DC. Sections were immunostained using antibodies against a panel of MMPs and TIMPs. Normal palmar fascia from patients undergoing carpal tunnel release or from cadaveric hands was used as controls.

There was a marked increase in the expression of MMPs and TIMPs within the different areas of DC tissue compared with controls. Both MMPs and TIMPs were expressed in an angiocentric pattern within areas of hypercellularity (corresponding to the proliferative stages of nodules). In some hypercellular areas expression of TIMP1 and TIMP2 exceeded that for the MMPs. Hypocellular cords, which were predominantly composed of collagen, were weakly immunopositive for MMP-2 and MMP-9, but were immunonegative for TIMPs.

Areas of MMP-1 and MMP-2 expression were more intense in the stroma surrounding nodules, and also within the “invading” DC tissue at the dermo-epidermal junction (DEJ) of the skin. Here expression of MMPs was observed around abnormally high numbers of small blood vessels, beneath the rete ridges of the epidermal layer, and also within foci of inflamation.TIMP1 and TIMP-2 were not expressed within the DEJ. These changes were most marked where clinically there was obvious ‘skin pit’ involvement.

Currently the only treatment for DC is surgical. Alternative non-surgical therapeutic protocols might involve manipulating the fibrotic process pharmacologically, for example by seeking to regulate expression of MMPs and their inhibitors.

To devise an operative approach to the management of acute posterior fracture-dislocation of the shoulder which restores or retains normal proximal humeral anatomy and allows the early restoration of a complete, stable range of motion.

Since 1996 we have treated four male patients (five shoulders) aged between 19 and 54 years at the time of first dislocation with autogenous iliac grafting of the anterior humeral head defect for acute and acuteon-chronic posterior dislocation of the shoulder. Two patients had epilepsy: one of these patients had bilateral dislocations. Two patients had motorbike RTAs. The deltopectoral approach with vertical division of the subscapularis tendon was used in all cases. The defects comprised 20– 25% of the volume of the humeral head at the equator after preparation for grafting. Grafts were fixed with compression screws. The subscapularis tendon was repaired anatomically. Active-assisted rehabilitation was started immediately, restricting external rotation to the neutral position for six weeks, thereafter allowing full rotation and elevation as comfort allowed.

The patient with bilateral dislocations died of unrelated causes 18 months after surgery. He was reported to have had no further dislocations, complete pain free functional use of both shoulders and no complications of the procedure. The remaining three patients were reviewed at a minimum of 20 months after surgery (average 35 months). All grafts had incorporated. There was no graft collapse or boundary arthrosis. The absolute Constant scores were 85.1, 90.9, and 89.2; the subjective shoulder scores were 98%, 90%, and 99%; the Oxford rating scale for pain scores were 14 out of 60, 13 out of 60, and 14 out of 60; and the Oxford rating scale for instability scores were 14 out of 60, 15 out of 60 and 15 out of 60. There were no redislocations, or complications of the procedures.

Posterior stability appears more dependant on surface arc of contact than on capsular integrity, in contrast to the anteriorly unstable shoulder. Restoration of the articular surface arc of contact by segmental autogenous grafting retains normal humeral anatomy, allows normal motion with excellent cuff function, and a return to normal daily activities. The procedure has been shown to be safe at a minimum of 20 months.

Mucormycosis is an opportunistic infection that very occasionally causes osteomyelitis and avascular necrosis of bone. The infection may prove fatal if not diagnosed promptly. If early treatment is instituted the prognosis is good.

We perfused 16 human femora with a 50% barium sulphate suspension and studied the intra-osseous vessels by microfocal radiography and histology. There were few anastomoses between the vessels of the greater trochanter and those of the adjacent cancellous bone of the shaft. Ischaemia of the trochanter may contribute to nonunion after trochanteric osteotomy.

We report the results of conservative treatment of stage III and stage IV avascular necrosis of bone (AVN) affecting the hip or knee in renal transplant patients. Twenty-nine patients were followed for a mean period of five years. Conservative management was successful in controlling symptoms in 40% of those with AVN of the hip and in 70% of those with AVN of the knee. Knowledge of the natural history of AVN is important because of the long survival times after renal transplantation.

An eight-year-old boy presented with massive pseudomalignant heterotopic ossification around the upper femur. The mass was completely excised because of severe pain, systemic illness and a flexion contracture at the hip. Symptomatic improvement was swift, but two weeks later the mass had recurred and was even more extensive. During the subsequent 18 months of conservative management he has been free of pain and there has been progressive resorption and remodelling of the heterotopic bone. There is now no limitation of physical activity and movement at the hip is full.

The occurrence of osteonecrosis following renal transplantation is well recognised but its pathogenesis remains unknown. We have quantified the number of empty osteocytic lacunae in the subchondral bone of femoral heads from a control group of patients, and compared these with femoral heads from a group of renal transplant recipients without evidence of overt osteonecrosis. There is a significant increase in empty osteocytic lacunae in renal transplant patients. We conclude that loss of osteocytes precedes other manifestations of osteonecrosis.

The clinical and pathological findings in a case of early avascular necrosis of the femoral head following renal transplantation are described. Regions of subchondral bone distant from the principal lesions showed increased numbers of empty osteocytic lacunae. This has been quantified and it is suggested that a loss of osteocytes is perhaps one of the earliest lesions leading to established avascular necrosis.

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