We studied 55 patients who had undergone elective removal of forearm plates between 1980 and 1986; 44 plates were removed from the radius and 37 from the ulna. Before removal only 20 patients (36%) had definite symptoms attributable to the plates, but 44 patients (80%) were advised by the surgeon to have the plates removed. In 22 cases (40%) the operation was followed by a significant complication. The complication rate was higher with junior surgeons and was permanent in 50% of cases. It is recommended that forearm plates should be removed only if they are causing significant symptoms, and that the operation should not be delegated to the most junior surgeon.

The results of 132 Attenborough total knee replacements after a follow-up period of from four to 10 years are presented. Long-term relief of pain and improvement in stability and walking distance were maintained in over two-thirds. The cumulative survivorship with the prosthesis in situ, little or no pain and no radiological loosening was 65% at six years. Problems with wound healing were common, and there was a complication rate of 20% in primary replacements, including a deep-infection rate of 3.5%. Almost 20% of the prostheses needed revision because of aseptic loosening, and there is evidence of radiological and clinical loosening in a further 7.5%.

Seven cases of massive osteolysis are presented. The aetiology of this disease is as yet unknown; neither age nor sex seems to be a factor in its incidence, nor are standard bone grafts or radiotherapy successful methods of treatment. However, in this series, operation produced a satisfactory outcome for five patients at a mean follow-up of 17 years; in three of these patients a custom-built prosthesis was inserted, and in one a conventional bone graft was combined with intramedullary nailing.

This paper describes the development, operative technique and results of an unconstrained total elbow arthroplasty. Forty-seven elbow replacements were carried out in 44 patients between 1974 and 1982. There was a high rate of loosening in the early condylar replacements. The results in patients with post-traumatic arthritis were poor. The later design employs an ulnar stem, with a humeral stem if the distal humeral bone stock is poor. When used in carefully selected patients with rheumatoid arthritis, pain is reduced significantly, stability and movement are preserved and function is improved.

This abridged account of a report to the British Medical Research Council describes a long-term investigation of 1,503 subcapital fractures of the femur, almost all of which were treated by reduction and internal fixation. With three exceptions, union occurred in all Garden Stage I and Stage II fractures and in 67% of Stage III and Stage IV fractures, of which only 14-5% were united at six months. In women, late segmental collapse was seen after union had occurred in 16% of Stage I and in 27-6% of Stage III and Stage IV fractures. Delay of up to one week before operation had no significant effect on the incidence of non-union or of late segmental collapse. The incidence of union followed by late segmental collapse was higher in women with normal bone density than in those with osteoporosis. Smith-Petersen nailing was found to be the least effective form of fixation in displaced fractures. The age and physical state of the patient, the accuracy of reduction, and the security of fixation had the greatest influence on union.

As part of the government’s initiative to reduce waiting times for major joint surgery in Wales, the Cardiff and Vale NHS Trust sent 224 patients (258 knees) to the NHS Treatment Centre in Weston-Super-Mare for total knee replacement. The Kinemax total knee replacement system was used in all cases. The cumulative survival rate at three years was 79.2% (95% confidence interval (CI) 69.2 to 86.8) using re-operation for any cause as an endpoint and 85.3% (95% CI 75.9 to 91.8) using aseptic revision as an endpoint. This is significantly worse than that recorded in the published literature. These poor results have resulted in a significant impact on our service.

We studied 21 former top-class competitive javelin throwers to investigate radiological and clinical symptoms in the lumbar spine many years after the end of their athletic careers. The athletes underwent clinical and radiological examinations at an average of 20 years after retiring from athletics. The Hannover questionnaire was used to evaluate functional restrictions in daily living.

Degenerative changes in the lumbar spine were more marked towards the caudal aspect of the spine. Ten athletes also had spondylolisthesis, but with little progression (< 15%) throughout the observation period. Athletes both with and without radiologically demonstrated spondylolisthesis, complained of no more back problems than the normal population (93% for athletes v 86% for controls). Slight progression followed their retirement from athletics.

We assessed 57 total hip arthroplasties in 34 adolescents with juvenile chronic arthritis using standard radiological techniques at an average of 4.7 years (20 months to 9 years) after surgery. The incidence of overall loosening was 24.6% (14 hips), but hips with a follow-up of more than five years had a loosening rate of 43.5% (10 hips; p < 0.01).

We present a study of 67 Oxford bicompartmental total knee replacements performed at a district general hospital. In this general orthopaedic unit, 57 of the knees (85%) had significant relief of pain with a mean flexion range of 95 degrees and a mean flexion deformity of only 9 degrees. There was a noticeable difference between osteoarthritic and rheumatoid knees. Poor results could be directly related to an avoidable postoperative complication. The results of this independent assessment may be compared favourably with the previously published series from the specialist centre at which the prosthesis was designed.

There is a trend away from amputation for limb cancer; salvage procedures are becoming more widespread. We describe one case of interscapulothoracic resection of the shoulder and discuss methods of maximising the residual function of the arm. The procedure is recommended for patients with the correct indications.

High myelomeningocele lesions do not preclude an acceptable level of functional walking provided that an integrated programme of surgical treatment and bracing is adopted. Clinical analysis of 100 patients with myelomeningocele shows that the development of the "swivel walker" and "hip guidance orthosis" has been associated with an improved level of function. Over 30 per cent of patients with thoracic lesions and 68 per cent of those with lumbar lesions achieved independent walking. For this reason the criteria used at present by paediatricians to govern the selection of infants for non-active treatment may require reconsideration.

A boy aged three with indifference to pain was followed up until his death from amyloid disease some twenty-one years later. A full necropsy was done and the neuropathology suggested a sensory neuropathy.

1. The fibrillar networks of adult human articular cartilage, taken from femoral and acetabular specimens, have been systematically examined by scanning electron microscopy. The internal structures revealed by rupturing the tissue were compared with published findings from transmission electron microscope studies.

2. Though this technique demonstrated the internal fibrillar appearance of cartilage to a remarkable degree, it had several attendant limitations. On final drying, specimens generally exhibited shrinkage which varied within wide limits; this could have altered the internal architecture to some extent. In addition, the rupturing technique, which at the time of this investigation was the only satisfactory method of revealing the fibrillar cartilage structure, may well have had a great influence on the fibril orientations.

3. The fibrils revealed no characteristic collagen periodicity and were considerably thicker than those observed by transmission electron microscopy. It is suggested that a coating of mucin on the collagen fibrils might account for this.

4. At low magnifications the torn layers in the fractured surfaces extended radially from the calcified zone and turned obliquely at or near the articular surface to merge with the distinctly layered superficial zone, thus forming arcade-like structures. That these were not artefacts produced by the fracturing technique was shown by their similarity to the classical arcade pattern of light microscopy. However, the factor which governed the direction of these planes of weakness, be it collagen, mucopolysaccharides or cells, could not be satisfactorily determined.

5. At higher magnifications only three regions of distinct fibrillar organisation could be identified: 1) a surface layer consisting of a random fibrillar network; 2) a superficial zone composed of layers of fibrillar network, intersecting and overlapping in planes parallel to the surface; and 3) elsewhere below the superficial zone a network of virtually random fibrils which extended to the calcified region with apparently little variation in thickness or density. There was little variation from this pattern even in aged fibrillated specimens.

6. At the lower magnification range the scanning electron microscope has revealed the arcade pattern described by light microscopy, while at the higher magnifications the fibrillar organisation as seen by scanning electron microscopy correlated well with the concepts developed by transmission electron microscopy, that is, a random network of fibrils overlaid at the articular surface by a membrane-like system of bundled fibrils.

7. A possible role in the transmission of joint forces is outlined for the above fibrillar organisation.

We report a prospective study of 55 patients with acute primary patellar dislocation, all treated by operation and followed up for at least two years. Diagnosis was based on the history of a lateral displacement, with medial tenderness and a positive apprehension test; redislocations were excluded. Before operation, the difference in lateral shift on skyline views of the injured and control patellae was highly significant. At operation, rupture of the medial retinaculum of the patella was seen in all but one case. There were medial marginal fractures of the patella in 23 cases. Subjective results of the operation were excellent or good in 44 of the 55 at two years with a redislocation rate of only 9%. Most patients were able to return to the same level of sporting activity as before the injury.

Electromyographic and clinical studies were performed on patients undergoing total hip replacement by the modified direct lateral (29 hips), the direct lateral (29 hips) and the posterior approaches (21 hips). Assessments were made three months after operation. The Trendelenburg test was positive (Grade II) in eight cases operated upon by the direct lateral route, but in only one of each of the other two groups. Denervation occurred in only five of the 28 hips with abductor weakness without statistical difference between the groups. In the modified direct lateral group, radiological evidence of union of the trochanteric sliver was associated with significantly better abductor function than in those with malunion or non-union.

A retrospective study of 260 industrial amputees was undertaken to determine the long-term functional results of partial foot amputations following trauma. Follow-up ranged from 1 to 68 years with a mean of 16 years. Of 113 partial foot amputees (118 amputations) who had retained their original amputation, the functional end-results were 43% good, 38% fair and 19% poor. Lisfranc and Chopart amputations were better than those at transmetatarsal or digital levels. Of 260 initial amputations 49 (19%) were revised to a Syme's or a below-knee amputation.

A prospective study was made over a three-year period of 900 consecutive unilateral Colles' fractures. The radiographic features at the time of fracture, after reduction and one week later were measured and correlated with grip strength and range of movement at three years. The most significant radiographic feature to influence the outcome was the presence of shortening of the radius one week after reduction of the fracture. Persistent dorsal tilt, radiocarpal joint involvement and ulnar styloid fracture were each associated with reduced range of movement, but had no effect on grip strength. Extension of the fracture into the distal radio-ulnar joint was associated with reduced grip strength but had no effect on range of movement. Radial tilt of the radial fragment did not correlate with any aspect of the result after three years.