From 1979 to 1990 we treated 20 patients with large bone defects or established nonunion of the femur by vascularised fibular grafts. There were 18 men and two women with an average age at operation of 36.6 years (16 to 69). Ten patients had infected nonunion, three had post-traumatic nonunion or a bone defect without infection, four had a defect after tumour resection, and three had other lesions. The mean length of the fibular grafts was 18.1 cm. Postoperative circulatory disturbances needed revision surgery in five patients, including three with circulatory problems in the monitoring flap, but not at their anastomoses. The outcome was successful in 19 of the 20 patients with bone union at means of 6.1 months at the proximal site and 6.6 months at the distal site. Three patients had fractures of the fibular grafts but all these united in two to three months after cast immobilisation

Thirty-five patients were treated for Type III fractures of the intercondylar eminence of the tibia and were followed up for two to seven years. There were 20 Type IIIA fractures and 15 Type IIIB fractures. The avulsed fragment was reduced by operative arthroscopy and maintained either by extension and immobilisation in a cast or by crossed percutaneous pin fixation. Involvement of the medial collateral ligament or lateral meniscus was confirmed by valgus stress radiographs and by arthroscopy. Primary surgical repair through a separate incision was required in a significant number of patients. At follow-up, few patients suffered ligamentous instability, lack of extension, atrophy of the quadriceps, pain or effusion, and symptoms were minimal. Patients requiring surgical repairs of collateral ligaments or of peripheral detachments of the meniscus generally required a longer period of rehabilitation. Arthroscopic reduction and percutaneous pin fixation provided an effective treatment and significantly decreased the time spent in hospital and the morbidity experienced after alternative treatments

We studied prospectively 30 patients who had a Mitchell’s osteotomy secured by either a suture followed by immobilisation in a plaster boot for six weeks, or by a cortical screw with early mobilisation. The mean time for return to social activities after fixation by a screw was 2.9 weeks and to work 4.9 weeks, which was significantly earlier than those who had stabilisation by a suture (5.7 and 8.7 weeks, respectively; p < 0.001). Use of a screw also produced a higher degree of patient satisfaction at six weeks, and an earlier return to wearing normal footwear. The improvement in forefoot scores was significantly greater after fixation by a screw at six weeks (p = 0.036) and three months (p = 0.024). At one year, two screws had been removed because of pain at the site of the screw head. Internal fixation of Mitchell’s osteotomy by a screw allows the safe early mobilisation of patients and reduces the time required for convalescence

Torus (buckle) fractures of the distal radius are common in childhood. Based on the results of a postal questionnaire and a prospective, randomised trial, we describe a simple treatment for this injury, which saves both time and money. Over a six-month period, we randomised 201 consecutive patients with this injury to treatment with either a traditional forearm plaster-of-Paris cast or a ‘Futura-type’ wrist splint. All patients were treated for a period of three weeks, followed by clinical and radiological review. There was no difference in outcome between the two groups, and all patients had a good result. Only one patient did not tolerate the splint which was replaced by a cast. The questionnaire showed a marked variation in the way in which these injuries are treated with regard to the method and period of immobilisation, the number of follow-up visits and radiographs taken. We suggest that a ‘Futura-type’ wrist splint can be used to treat these fractures. The patient should be reviewed on the following day to confirm the diagnosis and to give appropriate advice. There is no evidence that further follow-up is required. This simple treatment has major benefits in terms of cost and reduction of the number of attendances

Between 1994 and 1997 we used the Ilizarov apparatus to treat 12 recurrent arthrogrypotic club feet in nine patients with a mean age of 5.3 years (3.2 to 7). After a mean of three weeks (two to seven) for correction of the deformity and 1.5 weeks (one to four) for stabilisation in the apparatus, immobilisation in a cast was carried out for a mean of 14 weeks (7 to 24). The mean follow-up period was 35 months (27 to 57). Before operation there were one grade-II (moderate), eight grade-III (severe) and three grade-IV (very severe) club feet, according to the rating system of Dimeglio et al. After operation, all the club feet except one were grade I (benign) with a painless, plantigrade platform. Radiological assessment and functional evaluation confirmed significant improvement. Two complications occurred in one patient, namely, epiphysiolysis of the distal tibia and recurrence of the foot deformity. These results suggest that our proposed modification of the Ilizarov technique is effective in the management of recurrent arthrogrypotic club foot in young children

The size and shape of the patella make it suitable for the partial replacement of a femoral or tibial condyle resected for tumour, or destroyed by trauma. It can provide a good articular surface and may give satisfactory knee function. Nineteen cases of patellar grafts are presented, with follow-up from two to nine years. Good consolidation of the graft and fair stability of the joint were obtained; the range of movement was 90 degrees or more in 79% of cases. In contrast with an allograft of a femoral or tibial condyle, the technique described does not need an allograft bank, has a lower risk of infection, and allows better and quicker consolidation and revascularisation of the grafts, as well as a better range of movement at the knee, probably because of the lack of fibrosis from immunological reaction. Merle d'Aubigne's technique, using a patellar graft with a vascular muscle pedicle, is useful only for some cases, requires a longer period of immobilisation and weakens the extensor apparatus. Our series shows that consolidation and revascularisation of a patellar graft can occur in the absence of a pedicle

In talipes equino-varus the diminished bulk of the calf muscle suggests a neuromuscular defect. Accordingly, biopsies were taken from the postero-medial and peroneal muscle groups, and occasionally from abductor hallucis, in sixty patients mostly under the age of five years; 111 were studied histochemically and histologically, and a further fifty-three by electron-microscopy. Histochemical anomalies were revealed in ninety-two specimens; the muscle fibres in the other nineteen varied in size but were abnormal at the ultramicroscopic level, as were all specimens examined with the electron microscope. Evidence of neurogenic disease was seen in most instances and was more obvious in the older patients. The pattern of abnormality was similar in both muscle groups. It is thought that shortening of the postero-medial muscles may result from a small increase of fibrosis due to minor innervation changes occurring in intra-uterine life. There is evidence that immobilisation, stretching or relaxation of muscles does not account for the anomalies observed. This study of the extrinsic muscles in talipes equino-varus indicates a dominant neurogenic factor in its causation

1. A large proportion of fractures were poorly reduced in this series either because the method used was inadequate or because it was inexpertly applied. At first it was thought that immobilisation in plaster gave adequate fixation but it was impossible to be certain that the reduction was not sometimes lost in the interval between manipulation and the check radiograph taken immediately after plaster had been applied. This suggested that in some cases fixation might be lost early although late redisplacement was not seen. 2. The late subjective results in patients with unreduced fractures were good, but there was some loss of thumb mobility partly due to varus deformity of the metacarpal bone and partly due to incomplete compensation for generalised stiffness in and around the joint. 3. Since loss of movement caused little disability and joint involvement rarely produced symptoms due to osteoarthritis, it seems doubtful whether the use of complex methods of treatment is justifiable. 4. Women seem to be predisposed to painful symptoms at the carpo-metacarpal joint of the thumb whether they occur after fracture or in association with non-traumatic osteoarthritis of the joint

Aims

The aim was to compare long-term patient-reported outcome measures (PROMs) after operative and nonoperative treatment of acute Achilles tendon rupture in the context of a randomized controlled trial.

Cancellous inlay bone grafting for delayed union or non-union of the scaphoid bone gives good results in most cases (Table IV). The operation is easy, does not require radiological control and does not damage the dorsal arterial plexus. The indications for the operation are twofold: firstly for patients complaining of disabling symptoms in the wrist joint with an established pseudarthrosis of the scaphoid bone, with neither arthritic changes nor severe avascularity of the proximal fragment; and, secondly, for delayed union in recent fractures despite adequate immobilisation. Union may still occur if conservative treatment is continued further, but because this may take up to eighteen months (during which time most patients would be unable to work), operation is a reasonable alternative. In this series two scaphoid fractures united after operation with some collapse of the proximal fragment. This probably resulted from removal of too much bone (preliminary to inlaying the graft) from an already small fragment with a poor blood supply. The operation can be performed even in the presence of a small proximal fragment and gave a satisfactory result in two out of three such cases

We have reviewed 74 tuberculous hips in 73 children treated from 1950 to 1991. From 1979 to 1991 we treated 28 patients with rifampicin, isoniazid and pyrazinamide given for nine months (series A), using active mobilisation for the more recent cases. Before this, 46 hips had been treated with streptomycin and isoniazid with or without para-aminosalicyclic acid given for a mean of 18 months (series B), and all these patients were immobilised for a mean of 2.2 years. The radiological appearances at presentation as classified by Shanmugasundaram (1983) predicted the outcome. Most hips were of the 'normal' type (50% and 59% of series A and B respectively) followed by the dislocating type (25% and 13%) and the atrophic type (8% and 9%). There were good or excellent results in 93% of the 'normal' type. All the atrophic type had poor results. The dislocating type had a poor result if the joint space was narrow after reduction of the hip. Early mobilisation had no effect on the outcome of the 'normal' type of disease. The newer drug regimens allowed for shorter courses of treatment, but did not necessarily give a better outcome

Comminuted and displaced fractures of the inferior pole of the patella are not easy to reduce and it is difficult to fix the fragments soundly enough to allow early movement of the knee. We have evaluated the clinical effectiveness of the separate vertical wiring technique in acute comminuted fractures of the inferior pole of the patella. A biomechanical study was also performed using ten pairs of embalmed cadaver knees. A four-part fracture was made on the inferior pole of the patella and fixed by two separate vertical wires on one side and two pull-out sutures after partial patellectomy on the other. The ultimate load to failure in the first group was significantly higher than in the second (250.1± 109.7 N v 69.7 ± 18.9 N, p< 0.002), as was the stiffness (279.9 ± 76.4 N/mm v 23.2 ± 11.4 N/mm, p< 0.001). The separate wire technique was used in 25 patients with comminuted fractures of the inferior pole of the patella who were followed up for a mean period of 22 months (10 to 50). All the fractures healed at a mean of seven weeks (6 to 10). No breakage of a wire or infection occurred. The mean grading at the final follow-up was 29.5 points (27 to 30) using the Böstman method. This technique preserved the length of the patella, fixed the comminuted fragments of the inferior pole and avoided long-term immobilisation of the knee

1. Three cases of infantile pseudarthrosis of the tibia treated successfully by delayed autogenous by-pass graft are reported. 2. The delayed autogenous graft is stouter, stronger and more easily handled and has enhanced osteogenic properties than a graft transferred immediately. 3. The by-pass graft commends itself, firstly, because it does not disturb the pseudarthrosis, which in consequence helps the immobilisation of the graft; secondly, because it is well embedded in healthy bone above and below, well away from the abnormal bone; thirdly, because it lies under compression and, ideally, is vertically disposed between the knee and the ankle; and fourthly, because there is no devitalising stripping of periosteum or introduction of foreign bodies. 4. Support to the grafted leg is needed for at least five years, but only by a polythene splint after four to six months. 5. With early grafting the deformity straightens out and shortening is overcome, as there is early return to normal use of the limb. 6. Prolonged follow-up is called for lest the basic lesion in the tibia should extend. 7. Fibrous dysplasia and similar fibrous lesions of bone account for many cases of infantile pseudarthrosis of the tibia. Many of these lesions are congenital and subsequently lead to fracture. 8. Postponement of surgery should not be countenanced

We randomised prospectively 60 consecutive patients who were undergoing internal fixation of similar fractures of the ankle into two groups, one of which was treated by immobilisation in a below-knee cast and the other by a functional brace with early movement. All were instructed to avoid weight-bearing on the affected side. They were seen at 6, 12, 26 and 52 weeks. The functional rating scale of Mazur et al was used to evaluate the patients at each follow-up and we recorded the time of return to work. After one year the patients completed the SF-36 questionnaire. By then 55 patients remained in the study, 28 (mean age 45.5 years) in group 1 and 27 (mean age 39.5 years) in group 2. Those in group 2 had higher functional scores at each follow-up but only at six weeks was this difference significant (p = 0.02). They also had higher mean SF-36 scores, but this difference was significant only for two of the eight aspects investigated. For patients gainfully employed, not on workers’ compensation, the mean time from surgery to return to work was 53.3 days for group 2 and 106.5 days for group 1; this difference was significant (p = 0.01). No patient developed a problem with the wound or had loss of fixation. Our findings support the use of a functional brace and early movement after surgery for fractures of the ankle

Dynamic muscle-tendon substitution for acute anterior cruciate deficiency in the dog was studied using the semimembranosus muscle-tendon. Nineteen mongrel dogs each had a semimembranosus transfer in one knee; as a control, the anterior cruciate ligament and the semimembranosus were released in the opposite knee. No postoperative immobilisation was used. The anterior drawer sign was assessed before and after operation and when the dogs were killed five months later. Dogs were excluded from the study if they developed infections or contractures of the hind legs. At five months, 11 dogs were available for study. The operated knees were examined histologically and evaluated using a reproducible index of arthritis based on: the macroscopic discoloration of the articular cartilage, the cellularity of the cartilage, the microscopic appearance of the articular surface, the loss of proteoglycans, the formation of osteophytes and the degree of subchondral osteosclerosis. There was no significant difference in the anterior drawer sign or the degree of arthritic changes between knees with a semimembranous transfer and the controls. Examination showed that a muscle-tendon transfer into the tibia was equivalent to transferring the muscle into the posterior capsule--the intra-articular tendon being weak but histologically viable. The transfer did not prevent the anterior drawer sign becoming positive nor the development of osteoarthritis. A second control group, in which three dogs had an arthrotomy and semimembranosus release in both their hind legs, showed that a semimembranosus release alone did not cause osteoarthritis

1. Almost all patients with osteoarthritis of the hip who consult the surgeon do so because they wish to be relieved of pain. They all have limitation of movement in varying degrees but most of them will be either unaware of it or will have accepted it. What is more important, they would not have sought medical advice because of stiffness if there had been no pain. The primary objective of operative treatment must therefore be to relieve pain. 2. Displacement osteotomy will give substantial relief from pain in a high proportion of cases and the relief is lasting. Perhaps that explains why this operation, advocated by McMurray and Malkin twenty-five years ago, is being practised more widely than ever to-day while its competitors (neurectomy, capsulectomy, arthroplasty) have steadily diminished in popularity. 3. The disadvantages of the operation are all related to post-operative immobilisation in plaster, which may induce further stiffness of the hip, even to the extent of ankylosis, or stiffness and pain in the knee. These disadvantages may be overcome to a considerable degree by internal fixation followed by sling suspension and early active movement. But when, under anaesthesia, the range of hip flexion is reduced to 45 degrees or less, the operation is always liable to result in ankylosis, and it is wise in these circumstances to take this possibility into account and warn the patient beforehand

1. Fifty-nine patients with various inter-carpal dislocations have been reviewed. 2. In this series trans-scapho-perilunar fracture-dislocation was the commonest injury. Early cases can be reduced by closed manipulation but in late cases operative reduction is usually advisable. When the injury is more than three months old, arthrodesis of the wrist joint is indicated. 3. When trans-scapho-perilunar fracture-dislocation was complicated by avascular necrosis of the proximal scaphoid fragment, the results in a small series treated by early excision were approximately equal to those treated by continued immobilisation. The results of grafting the scaphoid were poor. 4. Dislocations of the lunate seen within ten days of injury could usually be reduced with good results; no such case developed Kienböck's disease within the period of review. In late cases excision gave satisfactory results. 5. Forward dislocation of the lunate with half the scaphoid gave good results when manual reduction succeeded, but the results of excision of fragments were less satisfactory. 6. There was one case of forward dislocation of the lunate together with the distal half of the scaphoid. 7. Subluxation of the scaphoid is disclose in antero-posterior radiographs by a typical gap between it and the lunate bone. The subluxation may become recurrent and present a characteristic syndrome. 8. Other rare dislocations of the carpal bones are described

1. Between 1936 and 1945, 525 patients with sciatic pain were treated at the Princess Elizabeth Orthopaedic Hospital, Exeter. Of these, 225 had neurological signs and they were selected for review; 147 were traced. 2. Of these, 123 were treated by means of plaster jackets and twenty-four were treated by other methods. The late results of treatment in the two groups were about the same, roughly one-third being "cured," one-third "relieved," and one-third "not relieved.". 3. Nevertheless examination of the immediate results suggests that protection by means of a plaster jacket had at least a palliative effect, relieving acute symptoms and allowing early rehabilitation. Moreover it should be emphasised that in limiting the investigation to cases of sciatica with evidence of nerve root pressure only the more severe cases have been included. 4. Permanent relief after immobilisation in plaster was greatest when the duration of symptoms was short, and when the patient was treated during his first attack. It was least in patients who showed all three signs of nerve root pressure—diminished ankle jerks, hypo-aesthesia, and muscle hypotonicity. 5. Absence of tendon reflexes due to nerve root pressure, and areas of hypo-aesthesia, tend to remain permanently; but diminution of reflexes and loss of muscle power may recover

Most brachial plexus palsies are due to trauma, often resulting from motorcycle accidents. When nerve repair and physiotherapy are unsuccessful, muscle transfer may be considered. Paralysis of the deltoid and supraspinatus muscles can be addressed by transfer of the trapezius. Between March 1994 and June 1997 we treated 38 patients with brachial plexus palsy by trapezius transfer and reviewed 31 of these (7 women, 24 men) after a mean follow-up of 23.8 months (12 to 39), reporting the clinical and radiological results and subjective assessment. The mean age of the patients was 29 years (18 to 46). The operations had been performed according to the method of Saha described in 1967, involving transfer of the acromion with the insertion of the trapezius to the proximal humerus, and immobilisation in an abduction support for six weeks. Rehabilitation started on the first postoperative day with active exercises for the elbow, hand and fingers, and electrical stimulation of the transferred trapezius. All 31 patients had improved function with a decrease in multidirectional instability of the shoulder. The average increase in active abduction was from 7.3° (0 to 45) to 39° (25 to 80) at the latest review. The mean forward flexion increased from 20° (0 to 85) to 44° (20 to 90). Twenty-nine of the 31 were satisfied with the improvement in stability and function. Trapezius transfer for brachial plexus palsy involving the shoulder improves function and stability with clear subjective benefits

1. A study is reported of 190 femora in 174 patients in whom self-curing acrylic cement had been present in the medullary cavity of the upper end of the femur for the fixation of an endoprosthesis for an average period of four years. 2. The bone remained radiologically normal in 81 per cent of cases. 3. Improvement in the thickness of the cortex from pre-existing atrophy was noted in 2·6 per cent. 4. In 4·7 per cent the bone showed some atrophy after insertion of the cement. This exceeded 10 per cent in only two cases. All were originally osteoporotic from polyarthritis; all were satisfactory as regards the arthroplasty itself, and the atrophy could usually be explained by disuse resulting from the state of the opposite lower extremity, or the knee on the same side. 5. In 9·4 per cent there was fusiform hypertrophy of the femoral cortex, the bony texture remaining normal. This appearance was considered physiological and benign. 6. In 2·2 per cent there were changes for which the most likely explanation is chronic non-suppurative osteitis, though no collateral evidence of infection was found. 7. In 44·8 per cent there was a thin line of condensation in the cancellous bone demarcating the outer limits of the cement. This is considered to be physiological and not to indicate failure of immobilisation. 8. In 37·2 per cent there was slight resorption of the cut surface of the calcar femorale. This is considered to be physiological and to confirm the efficacy of weight transmission by cement lower down in the medullary cavity