Between 1990 and 1996 we performed 20 consecutive ulnohumeral arthroplasties for primary osteoarthritis of the elbow.

The outcome was assessed using the Disabilities of Arm, Shoulder and Hand Score (DASH) and the Mayo Elbow Performance Score (MEPS) at a mean follow-up of 75 months (58 to 132). There were excellent or good results in 17 elbows (85%) using the DASH score and in 13 (65%) with the MEPS (correlation coefficient 0.79). The mean fixed flexion deformity had improved by 10° and the range of flexion by a mean of 20°.

In 16 elbows (80%) the benefits of surgery had been maintained, and of 16 patients working at the time of operation, 12 (75%) had returned to the same job.

There was no correlation between radiological recurrence of degenerative changes and the amount of fixed flexion deformity, the flexion arc, or the elbow scores.

The movements of the carpal bones during the scaphoid shift test were evaluated radiographically in 60 wrists. The clinical results were graded according to the degree of subluxation of the scaphoid and pain on the dorsum of the wrist. Lateral radiographs at rest and under stress were taken and the relative movements of the scaphoid with respect to the radius and lunate, and the rotation of the scaphoid and lunate were calculated.

Dorsal displacement of the scaphoid with respect to the radius was significantly associated with the clinical grade of subluxation. There was correlation between the amount of pain and the displacement of the scaphoid from the lunate, but not from the radius. The wrists with a painful shift test had greater relative displacement of the scaphoid from the lunate than those with painless subluxation.

These observations support the view that pain associated with subluxation of the scaphoid during the shift test is a significant finding, and that radiographic analysis of the test may confirm a positive result when dynamic scaphoid instability is suspected.

Seven patients with chronic insufficiency of the triceps were treated by either a rotation flap using anconeus (4) or an allograft of tendo Achillis (3). The latter procedure was selected for patients with a large defect in whom the anconeus muscle had been devitalised. Five disruptions were in patients who had previously undergone an elbow replacement. The patients were assessed for subjective satisfaction, pain, range of movement and strength, and the results were graded using the Mayo Elbow Performance Score (MEPS). The mean follow-up was for 33 months (9 to 63).

One rotation flap failed six months after operation. At the most recent follow-up, the remaining six patients had no or slight pain, restoration of a functional arc of movement and normal or slightly decreased power of extension. All six were satisfied with the outcome and were able to resume their daily activities with no limitations other than those imposed by the previous elbow replacement. The final MEPS was 100 points in five patients and 75 in one.

We have performed a clinical and radiological analysis of 105 shoulder arthroplasties in patients with rheumatoid arthritis. The clinical results showed improvements in the Constant-Murley and Association of Shoulder and Elbow Surgeons score of 21 and 35, respectively. Both were statistically significant (p < 0.001). This improvement was maintained over a period of 8.8 years. There was no statistically significant difference in the scores after hemiarthroplasty and those after total arthroplasty. The presence of an intact rotator cuff was associated with improved function in both groups.

In spite of the use of an uncemented humeral stem, no implant was radiologically loose or at risk. There was lucency in a single zone in 14 implants. One glenoid component was at risk and 16 had lucency in a single zone. There was, however, a significant difference in the amount of lucency which was associated with pegged and keeled glenoid components (p = 0.005). In the group with hemiarthroplasty, two or more years after surgery there was superior migration of the humeral component by more than 5 mm in 18 shoulders (28%) and medial migration by more than 2 mm in eight (16%). Both superior and medial migration had an effect on the outcome. Revision was undertaken in four patients for persistent pain relating to medial migration. With revision taken as the endpoint for survival after eight years, 92% were found to be still in situ.

We randomly selected 39 patients undergoing excision of the trapezium for osteoarthritis of the first carpometacarpal joint into two groups, with mobilisation either at one or at four weeks after operation. The patients were reviewed at a median of six months (6 to 8). The clinical details, the severity of the disease and the preoperative clinical measurements of both groups were similar.

Excision of the trapezium resulted in significant improvement in objective and subjective function. Comparison of the outcomes of the two groups showed no differences except that patients found early mobilisation significantly more convenient. Although there was no significant difference in the range of movement between the groups, there was a small loss of movement at the metacarpophalangeal joint in the late mobilisation group.

Our findings show that simple excision of the trapezium is an effective procedure for patients with carpometacarpal osteoarthritis of the thumb and that prolonged splintage is neither necessary nor desirable.

We present 12 patients with synovial osteochondromatosis of the elbow treated by synovectomy. Histological review showed that seven cases were primary and five secondary osteochondromatosis. The patients with primary disease had a mean improvement in the flexion arc from a preoperative value of 40° to 123° to 5° to 128° when reviewed at a mean of nine years after operation. The secondary group had a mean improvement in the flexion arc from a preoperative value of 21° to 98° to 4° to 131° at a mean of 6.8 years after operation. There was recurrence in two of seven patients in the primary group and three of five in the secondary group. Osteoarthritis developed in six elbows in the primary and in three in the secondary group. Osteoarthritis secondary to synovial osteochondromatosis is progressive. In the established condition, the distinction between primary and secondary disease may be of greater histological than clinical relevance.

Although the outcome of fractures of the distal radius is traditionally assessed using objective clinical variables such as grip strength and range of movement of the wrist, the extent to which they reflect function and outcomes of importance for the patient is uncertain. This may cause considerable inconsistencies in the assessment of outcome using current scoring systems. We prospectively studied 31 patients recovering from unstable fractures of the distal radius in order to investigate the association between objective variables and the level of post-traumatic disability of the wrist as measured by the patient-rated wrist evaluation (PRWE) score.

Multiple regression showed considerable differences in the extent to which limitations in specific objective clinical variables reflected the level of disability of the wrist. Grip strength was shown to be a significant predictor of the PRWE score (regression coefficient −1.09, 95% confidence interval −1.76 to −0.42, p < 0.01) and thus appears to be a sensitive indicator of return of function of the wrist. Forearm rotation and flexion and extension of the wrist were not significantly associated with the PRWE score. These observations should be taken into account during the evaluation of methods of treatment and in constructing future clinical outcome scoring systems.

We undertook a prospective, randomised study to compare the analgesic effect of injection of steroid and of extracorporeal shock-wave therapy (ESWT) for the treatment of tennis elbow. Group 1 received a single injection of 20 mg of triamcinolone with lignocaine while group 2 received 2000 shock waves in three sessions at weekly intervals. After six weeks there was a significant difference between the groups with the mean pain score for the injection group falling from 66 to 21 compared with a decrease from 61 to 35 in the shock-wave group (p = 0.05). After three months, 84% of patients in group 1 were considered to have had successful treatment compared with 60% in group 2.

In the medium term local injection of steroid is more successful and 100 times less expensive than ESWT in the treatment of tennis elbow.

We have reviewed 20 patients stage-IIIB and stage-IV Kienböck’s disease in order to examine the efficacy of two forms of radial osteotomy, namely radial wedge osteotomy and radial shortening. Lateral closing wedge osteotomies and radial shortenings were carried out on 11 and nine patients, respectively. There were no preoperative differences with respect to age, gender, and radiological stage.

After a mean follow-up of 29 months, all patients, in both groups, had either a good or an excellent outcome. After the lateral closing wedge osteotomy, the radioscaphoid angle significantly increased and the St̊hl index significantly decreased. Progression of the degenerative changes at the radioscaphoid joint was found in two patients in this group. By contrast, there were no significant changes in any radiological parameters after radial shortening. Both procedures gave acceptable clinical results in stage-IIIB and stage-IV Kienböck’s disease.

Lack of full extension of the elbow is a common abnormality in patients with achondroplasia. We studied 23 patients (41 elbows) clinically and radiologically. Extension of the elbow was assessed clinically and the angle of posterior bowing of the distal humerus was measured from lateral radiographs.

There was limited extension of the elbow in 28 (68.3%) and the mean loss of extension was 13.1°. Posterior bowing of the humerus was seen in all elbows with a mean angle of 17.0°. There was a positive correlation between these two measurements. Posterior bowing greater than 20° caused a loss of full elbow extension. Posterior dislocation of the radial head was seen in nine elbows (22.0%). The mean loss of extension of the elbows was 28.7° which was significantly greater than that of these elbows in which the head was not dislocated (8.7°), although posterior bowing was not significantly different between these two groups (19.3° and 16.3°).

Posterior bowing of the distal humerus is a principal cause of loss of extension of the elbow. Posterior dislocation of the radial head causes further limitation of movement in the more severely affected joints.

Our aim was to determine if a tourniquet placed on the forearm has any advantage in clinical practice over the usual position on the upper arm. We randomised 50 patients who were undergoing an open operation for carpal tunnel syndrome under local anaesthesia into two groups. One had a tourniquet on the upper arm and the other on the forearm. The blood pressure, pulse, and level of pain were recorded at intervals of five minutes during the operation. The surgeons were also asked to evaluate the quality of the anaesthesia, the bloodless field, and the site of the tourniquet.

The patients tolerated the tourniquet on the upper arm and forearm equally well. The surgeons had some difficulties when it was placed on the forearm. We therefore recommend placement of a tourniquet on the upper arm for operations on the hand and wrist which are carried out under local anaesthesia.

We present the results of 525 primary Souter elbow arthroplasties undertaken in 406 patients between 1982 and 1997. There were 372 women and 34 men with a mean age of 57 years; 119 patients had a bilateral procedure. The elbows were affected by chronic inflammatory disease, usually rheumatoid arthritis, which had been present for a mean of 24.7 years (2 to 70). In about 30% the joints were grossly destroyed with significant loss of bone. In 179 elbows the ulnar components were metal-backed and retentive; in the remaining 346, with better bone stock, non-retentive, all-polyethylene prostheses were used.

Because of complications, 108 further operations were required in 82 patients. During the early years the incidence of complications was higher. Dislocation was the indication for 30 further procedures in 26 patients. Thirty patients underwent 33 revision procedures for aseptic loosening, 12 had 29 operations because of deep infection, two for superficial infection, and 14 further operations were done for other reasons. The cumulative rate of success, without aseptic loosening, five and ten years after surgery, was 96% and 85%, respectively.

The incidence of loosening of a cemented glenoid componentin total shoulder arthroplasty, detected by means of radiolucent lines or positional shift of the component on true anteroposterior radiographs, has been reported to be between 0% and 44%. Radiolucent lines are, however, difficult to detect and to interpret because of the mobility of the shoulder girdle and the obliquity of the glenoid which hinder standardisation of radiographs. We examined radiolucencies around cemented glenoid components in 48 patients, with a mean follow-up of 5.3 years, and found progressive changes to be present predominantly at the inferior pole of the component. This may hold a clue for the mechanism of loosening of this implant.

In five patients we performed an additional analysis of loosening of the glenoid component using digital roentgen stereophotogrammetric analysis (RSA). After three years, three of the five implants had loosened (migration 1.2 to 5.5 mm). In only one, with gross loosening, were the radiological signs consistent with the RSA findings.

When traditional radiographs are used for assessment, the rate of early loosening is underestimated. We recommend that RSA be used for this.

The patterns of laxity of normal wrists subjected to dorsal and volar stresses were analysed. Dorsal and volar displacement tests were carried out on both wrists of 50 subjects under image-intensifier control. Lateral projections in neutral, and dorsal and volar stress positions were taken to analyse the behaviour of the carpal bones. Varying degrees of capitolunate subluxation under dorsal and volar stress were noted. Dorsal displacement of the capitate appeared to be more prominent than volar displacement. The lunate either extended or subluxed dorsally in response to a dorsal stress, suggesting a different pattern of laxity for the radiolunate joint. These observations provide a baseline for the interpretation of dorsal and volar stress views in the symptomatic wrist.

We studied 57 patients with isolated lunotriquetral injuries treated by arthrodesis, direct ligament repair, or ligament reconstruction. The outcomes were compared by using written questionnaires, the Disabilities of the Arm, Shoulder and Hand (DASH) score, range of movement, strength, morbidity and rates of reoperation. Isolated lunotriquetral injury was confirmed by arthroscopy or arthrotomy. The mean age of the patients was 30.7 years (15.4 to 53.7) and the injuries were subacute or chronic in 98.2%. Eight patients underwent lunotriquetral reconstruction using a distally-based strip of the tendon of extensor carpi ulnaris, 27 had lunotriquetral repair and 22 had lunotriquetral arthrodesis. The mean follow-up was 9.5 years (2 to 22).

The probability of remaining free from complications at five years was 68.6% for reconstruction, 13.5% for repair, and less than 1% for arthrodesis. Of the lunotriquetral arthrodeses, 40.9% developed nonunion and 22.7% developed ulnocarpal impaction. The probability of not requiring further surgery at five years was 68.6% for reconstruction, 23.3% for repair and 21.8% for arthrodesis. The DASH scores for each group were not significantly different. Objective improvements in strength and movement, subjective indicators of pain relief and satisfaction were significantly higher in the lunotriquetral repair and reconstruction groups than in those undergoing arthrodesis.

Osteoarthritis of the wrist is a complication of a number of common traumatic conditions. Arthrodesis of the radiocarpal joint, proximal row carpectomy and excision of the scaphoid, combined with midcarpal arthrodesis, have all been reported as surgical options. There have been no randomised studies comparing these procedures, and the feasibility of conducting this type of trial is limited.

We used decision analysis to compare the three surgical techniques. The variables for the model used were based principally on data from the literature. Extensive sensitivity analyses were carried out to test the impact of the values given to these variables on the outcome of the model. The model indicated that the preferred treatment is proximal row carpectomy.

Decision analysis allows a comparison between alternative treatments, when evidence from a randomised trial is lacking or unobtainable. The decision-analysis model may also provide insight into aspects of a problem which would be difficult, or impossible, to evaluate by a cohort study.

The Souter-Strathclyde prosthesis was used in 52 revisions of total elbow replacements (TERs) between August 1986 and May 1997. Of these, 50, carried out in 45 patients, were prospectively followed for a mean of 53 months (14 to 139). The procedure produced reliable relief of pain, and the range of movement was preserved. There was a considerable incidence of adverse events associated with revision (30%), and 12 further procedures have been required. Nonetheless, a revision is the preferred salvage procedure for failed primary arthroplasty in the absence of sepsis.

We present the short- and medium-term clinical results of thermal shrinkage in selected groups of patients with multidirectional or capsular stretch-type instability. We treated 56 patients (61 shoulders) by laser-assisted capsular shrinkage (LACS) and 34 patients (38 shoulders) by radiofrequency (RF) capsular shrinkage. The two groups were followed for mean periods of 40 months and 23 months, respectively.

In the LACS group the mean Walch-Duplay score improved to 90 points 18 months after the operation, but then declined to a plateau of about 80 points; 59% of patients considered their shoulders to be ‘much better’ or ‘better’ but there was a failure rate of 36.1%. For the RF group the mean Walch-Duplay and Constant scores were 80 points at the various follow-up times; 76.3% of patients considered their shoulder to be ‘much better’ or ‘better’. RF failed in nine shoulders (23.7%). These results match some clinical series of patients with multidirectional instability, undergoing open inferior capsular shift, with a similar rate of failure. We believe that the minimal morbidity involved makes thermal shrinkage a viable alternative to open capsular shift in this difficult group of patients.

We studied, retrospectively, 131 patients who had undergone an open operation for the carpal tunnel syndrome (CTS) in 229 hands. The symptoms were present on both sides in 59% of patients when first seen. Neurophysiological impairment of the median nerve was observed in 66% of the asymptomatic hands, and 73% of patients in this group developed symptoms of CTS after the opposite side had been operated on. Follow-up of patients with unilateral CTS showed that the subsequent development of disease in the unaffected hand is very common. We conclude that CTS is a bilateral disorder and that it becomes more evident as time passes. There is a correlation between the duration of symptoms and bilateral occurrence.

The outcome of 260 repairs of the radial and posterior interosseous nerves, graded by Seddon’s modification of the Medical Research Council Special Committee’s system, was analysed according to four patterns of injury; open ‘tidy’, open ‘untidy’, closed traction, and those associated with injury to the axillary or brachial artery. We studied the effect on the outcome of delay in effecting repair and of the length of the defect in the nerve trunk.

Of the 242 repairs of the radial nerve we found that 30% had good results and 28% fair; 42% of the repairs had failed. The violence of injury was the most important factor in determining the outcome. Of the open ‘tidy’ repairs, 79% achieved a good or fair result, and 36% of cases with arterial injury also reached this level. Most repairs failed when the defect in the nerve trunk exceeded 10 cm. When the repairs were carried out within 14 days of injury, 49% achieved a good result; only 28% of later repairs did so. All repairs undertaken after 12 months failed. Of the 18 repairs of the posterior interosseous nerve, 16 achieved a good result.

We have established a reference standard for the cross-sectional area (CSA) of supraspinatus as measured by diagnostic ultrasound. The influence of hand dominance and of ageing on the CSA was also assessed. We examined 72 subjects aged from 20 to 79 years. Standard values of the CSA were determined with a high measure of interobserver reliability. Although the CSA on the dominant side was significantly larger (p < 0.001) by 0.16 cm² (95% CI 0.072 to 0.249) than that on the non-dominant side, this difference had no clinical significance. The CSA of supraspinatus decreased significantly with ageing.

Age-related localised deposition of amyloid in connective tissue has been found in degenerative articular and periarticular tissue. Biopsies of the supraspinatus tendon of 28 patients undergoing repair of the rotator cuff were analysed histologically for the presence of localised deposition of amyloid. There was a long history of impingement in 20 patients, and eight patients had suffered an acute traumatic tear with no preceding symptoms. Localised deposition of amyloid identified by Congo Red staining was detected in 16 samples (57%). Amyloid was present in 14 (70%) of the degenerative tears, but in only two (25%) of the acute tears. Immunohistochemical staining showed that the amyloid deposits were positive for P component, but negative for κ and λ light chains, prealbumin, and β2 microglobulin. Critical electrolyte staining revealed highly-sulphated glycosaminoglycans at sites of deposition of amyloid. The presence of localised deposition of amyloid in tears of the rotator cuff is likely to represent irreversible structural changes. These findings support the theory that impingement and tears are due to intrinsic degenerative changes within the tendons of the rotator cuff.

We present nine patients (five men and four women) who underwent surgical excision of clinically significant heterotopic ossification at the elbow. They also received perioperative radiation therapy using total doses between 600 and 1000 cGy. Five received fractionated radiotherapy, with two fractions of 500 cGy applied on the first two postoperative days, and the remaining four were irradiated with single doses of 600 and 700 cGy.

After a mean period of observation of 7.7 months (6 to 13) none had radiological recurrence of heterotopic ossification and eight showed clinical improvement. Assessment of the functional outcome showed a mean improvement in the Morrey score from 33.3 to 84.5 points indicating a high therapeutic efficacy of prophylactic irradiation.

The results of a cadaver dye-infusion experiment suggested that the hand has ten muscle compartments and that the volar interossei occupy a separate anatomical compartment from the adjacent dorsal interossei. This is not supported by clinical findings. With various minor modifications, we repeated the experiment, infusing Omnipaque into the second dorsal interosseus muscle of four cadaver hands. We used real-time CT imaging to monitor the spread of contrast medium and side-ported needles to measure compartmental pressures. In all four hands, the tissue barrier between dorsal and volar interossei became incompetent at pressures of less than 15 mmHg.

Our data indicate that, although cadaver infusion studies can delineate potentially significant musculoskeletal barriers, their physiological relevance must be confirmed clinically.

We compared the long-term outcome in 61 patients (62 fractures) treated operatively or conservatively for an acute fracture of the carpal scaphoid. A total of 30 fractures was randomised to conservative treatment using a cast and 32 to operative treatment using a Herbert bone screw.

The duration of sick leave was shorter for patients treated by operation, but this was only significant in patients with blue-collar occupations. There were no differences between the groups in respect of function, radiological healing of the fracture, or carpal arthritis after follow-up at 12 years. Those managed by operation showed radiological signs of arthritis of the scaphotrapezial joint more often, but this finding did not correlate with subjective symptoms.

Operative treatment of an acute fracture of the scaphoid allows early return of function and should be regarded as an alternative to conservative treatment in patients in whom immobilisation in a cast for three months is not acceptable for reasons related to sports, social life or work.

The different attributes of the Patient Evaluation Measure (PEM) questionnaire were investigated in 80 patients with a fracture of the scaphoid. Assessments were made at 2, 8, 12, 26 and 52 weeks. Reliability was assessed by measurement of the internal consistency of the different questions in 275 completed PEM forms.

Cronbach’s alpha, which needs to lie between 0.7 and 0.9, was 0.9 for the PEM. Pain, tenderness, swelling, wrist movement and grip strength correlated with the PEM score confirming the validity of the assessment. Changes in the different variables between visits correlated significantly with changes in the PEM score; its effect size and standardised response mean were comparable to those of grip strength and movement, confirming the responsiveness of this questionnaire. Gender, dominance and the side injured did not influence the scores. Older patients had a poorer outcome as assessed by the score which appeared to be a true effect and not age bias. Our study confirmed that the PEM is a reliable, valid and responsive instrument in assessing outcomes of disorders of the hand.

We have analysed the results of repair of traumatic lesions of the musculocutaneous nerve in 85 patients, which were graded by Seddon’s modification of the Medical Research Council system into three types of injury: open ‘tidy’, open ‘untidy’and closed ‘traction’. They were also correlated with associated arterial injury.

There were 57 good, 17 fair and 11 poor results. The type of injury was the most important factor in determining the result; 12 of 13 open-tidy lesions gave good results compared with 30 of 48 closed-traction lesions. The results were better when the nerves were repaired within 14 days of injury and when grafts were less than 10 cm long. They were worse in the presence of associated arterial or bony injury.

We have reviewed 66 consecutive Souter-Strathclyde arthroplasties of the elbow implanted in 59 patients between 1982 and 1993. Thirteen patients (15 elbows) (19.6%) died. Sixteen elbows (24.2%) were revised, six for aseptic loosening (9%), four (6%) because of fracture or loosening after a fracture, three (4.5%) for infection and three (4.5%) for dislocation. Four patients refused to attend for review.

In 33 elbows with a follow-up of 93 months (60 to 167) complete relief of pain was achieved in 22 (67%) when seen at one year. After ten years or more 36% of the elbows were painfree and 64% had occasional slight pain especially under loading or stress. The mean gain in the arc of movement was 16°, but a mean flexion contracture of 33° remained. The main early complications were intraoperative fractures of the epicondyles (9%), postoperative dislocation (4.5%) and ulnar neuropathy. The incidence of ulnar neuropathy before operation was 19%. After operation 20 patients (33%) had an ulnar neuropathy, in seven of which it had been present before operation, and of these weakness of the hypothenar muscle occurred in two. The probability of survival of the Souter-Strathclyde elbow prosthesis based on the Kaplan-Meier calculation is 69% at ten years.

Radiographs of the shoulders of 84 asymptomatic individuals aged between 40 and 83 years were evaluated to determine changes in 23 specific areas. Two fellowship-trained orthopaedic radiologists graded each area on a scale of 0 to II (normal 0, mild changes I, advanced changes II). Logistic regression analysis indicated age to be a significant predictor of change (p < 0.05) for sclerosis of the medial acromion and lateral clavicle, the presence of subchondral cysts in the acromion, formation of osteophytes at the inferior acromion and clavicle, and narrowing and degeneration of the acromioclavicular joint. Gender was not a significant predictor (p > 0.05) for radiological changes. Student’s t-test determined significance (p < 0.05) between age and the presence of medial acromial and lateral clavicular sclerosis, subchondral acromial cysts, inferior acromial and clavicular osteophytes, and degeneration of the acromioclavicular joint.

Radiological analysis in conditions such as subacromial impingement, pathology of the rotator cuff, and acromioclavicular degeneration should be interpreted in the context of the symptoms and normal age-related changes.

We describe a technique for arthroscopy of the wrist which is carried out without traction and with the arm lying horizontally on the operating table. The wrist is not immobilised, which makes it possible to assess the extent of instability after a ligamentous tear. In a prospective study of 30 patients we compared this technique with conventional wrist arthroscopy, performing the new method first followed by conventional arthroscopy.

The advantages are that the horizontal position of the arm allows the surgeon to proceed directly from arthroscopic diagnosis to treatment, and that no change of position is required for fluoroscopy.

In terms of diagnostic sensitivity, we found our technique matched that of conventional arthroscopy. We had no difficulty in carrying out minor surgical procedures such as debridement and suturing.

We present the results of a retrospective series of 41 Sauve-Kapandji procedures carried out for complications of fractures of the distal radius. All the operations were undertaken by one surgeon with a mean follow-up of 32 months. A total of 37 patients was available for clinical review.

The indications for surgery were pain on the ulnar side of the wrist and decreased rotation of the forearm. Intraperiosteal and extraperiosteal techniques were used for resection of the ulna, with no difference in outcome. Patients were assessed for pain, rotation of the forearm and complications. A Mayo Modified Wrist Score was used.

Pain was improved in 25 of the 37 patients, and unchanged in ten. Rotation of the forearm returned to within 7° of the uninjured side. The results are discussed in relation to the presence of preoperative malunion of the distal radius, age and the functional outcome. Age is not a contraindication for this procedure.

We have used a modified technique in five patients to correct winging of the scapula caused by injury to the brachial plexus or the long thoracic nerve during transaxillary resection of the first rib. The procedure stabilises the scapulothoracic articulation by using strips of autogenous fascia lata wrapped around the 4th, 6th and 7th ribs at least two, and preferably three, times.

The mean age of the patients at the time of operation was 38 years (26 to 47) and the mean follow-up six years and four months (three years and three months to 11 years). Satisfactory stability was achieved in all patients with considerable improvement in shoulder function. There were no complications.

We report the results of a series of 59 unconstrained total arthroplasties of the elbow after a mean follow-up of 6.5 years (4 to 10). All the patients had rheumatoid arthritis. The indication for surgery was pain in all but one. Outcome was assessed by the Mayo Elbow Performance Index (MEPI).

Of the 59 arthroplasties, two were lost to follow-up. Ten patients died, but as two of their arthroplasties were failures we included them in the results. The outcome in the remaining 49 was excellent in 26 (53%), good in 15 (31%), fair in one (2%) and poor or a failure in seven (14%). There was an improvement in the pain score (p < 0.001), movement (p < 0.001) and function (p < 0.001). Two patients developed instability, but neither required further surgery. There was a mean increase of 21° in flexion and of 7° in extension.

The overall rate of complications was 33.9%. Lesions of the ulnar nerve, one of which did not recover, occurred in four patients, deep infection in two and stiffness in five. The rates of complications were similar to those in recent reports of other elbow arthroplasties.

We carried out a radiological analysis of 39 arthroplasties which showed radiolucent lines around the humeral component in 22 and the ulnar component in 15. There were lower scores on the MEPI for those with radiolucent lines around the humeral component.

We diagnosed 50 patients (58 shoulders) with a mean age at presentation of 17.3 years, as having involuntary positional instability of the shoulder. They were managed by a programme consisting of a careful explanation, analysis of abnormal muscle couples and then muscle retraining carried out by a specialist physiotherapist. The mean follow-up was two years. Six shoulders had a poor result, but 52 were graded as good to excellent. Nine patients (12 shoulders) relapsed and required further episodes of retraining.

In our experience, involuntary positional instability of the shoulder causes symptoms which interfere with normal activities; these can be controlled by a treatment plan of retraining of the muscle pattern with functional benefit. Only 19 of the patients were referred with a diagnosis of positional instability. There should be more awareness of this rather uncommon condition. Surgery is not indicated in these patients.

We present three cases of recurrent instability of the elbow in association with the Ehlers-Danlos syndrome. The pattern of instability has not previously been reported. We describe our procedure for achieving stability using a bone graft to the olecranon fossa which gave a functional range of movement.

We evaluated scapular dysplasia and malposition in 15 patients with the Sprengel deformity using three-dimensional CT (3D-CT). The shape, height-to-width ratio, the areas of both scapulae, the anterior curvature of the supraspinous portion and glenoid version were assessed on scapular posterior, medial and inferior views. The degree of rotation and superior displacement were measured on the trunk posterior view. The omovertebral connection was also assessed and correlated with the operative findings.

Most of the affected scapulae had a characteristic shape with a decrease in the height-to-width ratio and were larger than the contralateral scapulae. There was an inverse relationship between scapular rotation and superior displacement. The typical curve of the supraspinous portion of the scapula was seen in only three cases. There was no significant difference in glenoid version. The point of tethering of the omovertebral connection may determine the shape, rotation and superior displacement of the scapula. 3D-CT was helpful in delineating the deformity in detail, and in planning scapuloplasty.

Between June 1991 and May 1996 we carried out arthrodesis on 15 patients with flail or partially flail wrists using an AO/ASIF dynamic compression plate (DCP) without a bone graft. The wrist was approached through the second extensor compartment. The minimum follow-up was for 24 months with a mean of 34.2 months. All 15 wrists fused without major complications at a mean of 11.9 weeks. Stabilisation improved the function of the hand affected with paralysis and the appearance of the extensively paralysed upper limb with a flail hand. In the absence of bony abnormality fusion can be obtained with a DCP alone without the need for bone grafting.

Giant-cell tumour of the tendon sheath, also called pigmented villonodular synovitis, is a benign tumour with a high incidence of recurrence. We have tried to identify risk factors for recurrence. Of the 48 patients included in the study, 14 received radiotherapy after surgery. Only two (4%) had a recurrence. This compares favourably with previously reported incidences of between 25% and 45%.

We investigated the function of biceps in 18 patients (19 shoulders) with lesions of the rotator cuff. Their mean age was 59 years. Another series of 18 patients (19 shoulders) with normal rotator cuffs as seen on MRI acted as a control group. Their mean age was 55 years. A brace was used to maintain contraction of biceps during elevation. Anteroposterior radiographs were obtained with the arm elevated at 0°, 45° and 90° with and without contraction of biceps. The distance between the centre of the head of the humerus and the glenoid was compared in the two groups.

We found that in the group with tears there was significantly greater proximal migration of the head of the humerus at 0° and 45° of elevation without contraction of biceps but depression of the head of the humerus at 0°, 45° and 90° when biceps was functioning. We conclude that biceps is an active depressor of the head of the humerus in shoulders with lesions of the rotator cuff.

Over-zealous release of the first dorsal compartment of the wrist for de Quervain’s disease or other lesions such as ganglia, may result in volar subluxation of the tendons of abductor pollicis longus and extensor pollicis brevis. This is usually asymptomatic, but may occasionally become disabling. We describe an operation using part of the extensor retinaculum to stabilise such a subluxation.

We describe our experience with vascularised bone grafting for the treatment of fibrous dysplasia of the upper limb in eight patients, five men and three women, aged between 17 and 36 years. The site was in the humerus in six and the radius in two. Persistent pain, progression of the lesion and pathological fracture with delayed union were the indications for surgical intervention.

We used a vascularised fibular graft after curettage of the lesion. Function and radiological progress were serially monitored. Early radiological union of the graft occurred at periods ranging from 8 to 14 weeks. The mean period for reconstitution of the diameter of the bone was 14 months (12 to 18) predominantly through inductive formation of bone around the vascularised graft, which was a prominent feature in all patients. There were no recurrences and none of the grafts sustained a fracture or failed to unite. After operation function was excellent in three patients and good in five. Vascularised bone grafts provide a safe and reliable means of ensuring good continuity of bone with little risk of recurrence and failure.

We have treated six patients with chronic pain following nerve injury using a cryosurgical probe. All had a significant return of hand function and improvement of pain during a mean follow-up of 13.5 months. Open visualisation of the injured nervous tissue is essential for patients undergoing this technique. Four patients regained normal sensation in the dermatome of the previously injured nerve.

We describe an operation to relieve compression of the lateral antebrachial cutaneous nerve at the elbow. Between 1987 and 1997 we operated on seven patients, one with bilateral compression. In two the compression was associated with injury to biceps. A longitudinal or a transverse incision was carried out and the nerve was released from the deep fascia. Partial excision of the biceps aponeurosis was undertaken in the patients who did not have injury to biceps; some additional procedures were required for those patients with injuries. All patients had symptomatic relief.

We enrolled 34 normal volunteers to test the hypothesis that there were two types of movement of the wrist. On lateral radiographs two distinct patterns of movement emerged. Some volunteers showed extensive rotation of the lunate with a mean range of dorsiflexion of 65°, while others had a mean range of 50°. The extensive rotators were associated with a greater excursion of the centre of articulation of the wrist. It is suggested that dynamic external fixation of a fracture of the distal radius carries with it the risk of stretching the ligaments or causing volar displacement at the site of the fracture.

Patients with short congenital amputations below the elbow often function as if they have had a disarticulation of the elbow. We have reviewed the results in six patients who had lengthening of such stumps by the Ilizarov technique to improve the fitting of prostheses.

The mean lengthening was 5.6 cm (3.4 to 8.4), and in two patients flexion contractures of the elbows were corrected simultaneously. Additional lateral distraction was used in one patient to provide a better surface on the stump. There were no major complications. All six patients were able to use their prosthesis at the latest follow-up after 39 to 78 months.

Between 1986 and 1994, 13 patients with mobile painful arthritic elbows were treated by distraction interposition arthroplasty using fascia lata. The mean period of follow-up was 63 months. An elbow distractor/fixator was applied for three to four weeks to separate the articular surfaces and to protect the fascial graft.

Nine of the 13 patients (69%) had satisfactory relief from pain; eight (62%) had an excellent or good result by the objective criteria of the Mayo Elbow Performance score. Four have required revision to total elbow arthroplasty at a mean of 30 months with good results to date.

Instability of the elbow, both before and after surgery, was found to be associated with unsatisfactory results. The rate of success when the procedure was performed for inflammatory arthritis was similar to that for post-traumatic arthritis, about 67%. Eight complications occurred in six patients, all in the group with post-traumatic arthritis. Two of these required further surgical procedures such as transposition of the ulnar nerve or repair of hernia of the fascia lata.

Although less reliable than prosthetic replacement, distraction interposition arthroplasty is a useful option in the treatment of young, high-demand patients with arthritis of the elbow. It is rarely indicated in the presence of generalised inflammatory arthritis, but may be of value in those patients in whom the disease is limited primarily to the elbow.

We have treated 22 patients with an elbow contracture using a static progressive turnbuckle splint for a mean of 4.5 ± 1.8 months. All had failed to improve with supervised physiotherapy and splinting. The mean range of flexion before splintage was from 32 ± 10° to 108 ± 19° and afterwards from 26 ± 10° (p = 0.02) to 127 ± 12° (p = 0.0001). A total of 11 patients gained a ‘functional arc of movement,’ defined as at least 30° to 130°. In eight patients movement improved with turnbuckle splinting, but the functional arc was not achieved. Six of these were satisfied and did not wish to proceed with surgical treatment and two had release of the elbow contracture. In three patients movement did not improve with the use of the turnbuckle splint and one subsequently had surgical treatment.

Our findings have shown that turnbuckle splinting is a safe and effective treatment which should be considered in patients whose established elbow contractures have failed to respond to conventional physiotherapy.

We treated post-traumatic contracture of the elbow in 13 consecutive patients (14 elbows) by operative release. Through a single medial approach, the posterior oblique bundle of the medial collateral ligament was resected, followed by posterior and anterior capsulectomies. An additional lateral release through a separate incision was required in only four elbows. The results were assessed at a mean interval of 57 months after operation.

Before surgery active extension lacked 43° which improved to 17° after operation. Active flexion before operation was 89°, which improved to 127°. The mean arc of movement increased from 46° to 110°. All 14 elbows showed scarring of the posterior oblique bundle of the medial collateral ligament.

Neither the interval from injury to operative release nor the age of the patient affected the results. A medial approach is useful to reveal and excise the pathological changes in the medial collateral ligament. It is a safe and effective route through which to correct post-traumatic contracture of the elbow.

Dupuytren’s disease may present with well-defined subcutaneous cords or as more diffuse disease with involvement of the skin. Fasciectomy is the procedure commonly carried out for the full range of disease, but is associated with rates of recurrence of up to 66%. We reviewed 143 rays in 103 patients undergoing dermofasciectomy for diffuse disease with involvement of the skin. We found recurrence in 12 rays (8.4% of rays; 11.6% of patients) during a mean follow-up of 5.8 years, eight as cords and four as nodules. We suggest that dermofasciectomy is a better method of disease control than fasciectomy for the more diffuse type of disease with involvement of the skin.

We treated 31 intra-articular fractures of the distal radius by arthroscopically-assisted reduction and percutaneous fixation with Kirschner (K-) wires. Tears of the triangular fibrocartilage (58%), scapholunate (85%) and lunotriquetral (61%) instability and osteochondral lesions (19%) were also treated.

A total of 26 patients was independently reviewed at an average of 19 months. The mean pain score was 1.3/10, the range of movement 79% and the grip strength 90% of the contralateral wrist. Using the New York Orthopaedic Hospital score, 88% were graded excellent to good. On follow-up radiographs, 65% had no step and 31% had a step of ≤1 mm. Pain was significantly related to the size of the step.

There was a significant difference in the incidence of persistent scapholunate diastasis and the Leibovic and Geissler grade (p < 0.01): I (0%), II (0%), III (42%) and IV (100%).

We recommend anatomical reduction and acceptance of a step of < 1 mm since the size of the step is related to the incidence of pain.