We have reviewed 103 of 126 Chiari osteotomies carried out in our department between 1956 and 1987. The cases were graded radiologically, using the Japanese Orthopaedic Association (JOA) system, into a pre/early osteoarthritis (OA) group and an advanced OA group. In the pre/early group there were 86 hips. The mean follow-up was for 17.1 years (4 to 37). Preoperatively, 51 hips had an average JOA clinical score of 78.6 ± 8.4 points and the final mean JOA clinical score was 89.4 ± 12.5 points. Advanced degenerative change developed in 33.7% and one hip required a total replacement arthroplasty (TRA). Chiari osteotomy alone, without accompanying intertrochanteric osteotomy, was performed on 62 hips. For these the median survival time was 26.0 ± 2.5 years, using as the endpoint progression to advanced OA. Differences in survivorship curves related significantly to the severity of the preoperative OA, the shape of the femoral head and the level of osteotomy. In the advanced OA group, we followed up 17 hips for a mean of 16.2 years (1 to 27). Before operation, the mean JOA clinical score in 13 hips was 63.2 ± 7.9 points and the final score 84.0 ± 12.0 points. TRA was eventually carried out on four hips.

Our findings suggest that the Chiari osteotomy remains radiologically effective for about 25 years. The procedure is best suited to subluxated hips with round or flat femoral heads and early or no degenerative change. Intra-articular osteotomy can lead to osteonecrosis, and should be avoided. In hips with advanced OA, the Chiari procedure creates an acetabulum which facilitates later TRA, and may delay the need for this procedure in younger patients.

Between 1987 and 2006 we performed a modified Thompson’s quadricepsplasty on 40 fracture-related stiff knees and followed the patients for a mean of 7.9 years (2 to 11.1). The factors affecting the final gain of movement were investigated. A total of 15 knees required lengthening of the rectus femoris. The mean flexion gain was 70.2° (42.3° to 112.5°). According to Judet’s criteria, the results were excellent in 30 knees, good in seven, and fair in three. The range of movement which was achieved intra-operatively was related to the gain of knee flexion on univariate analysis. Five patients had complications: deep infection in one, recurrent patellar dislocation in one, and rupture of the extensor mechanism in three. This modified technique gives satisfactory results. Achieving maximum knee flexion intra-operatively seems to be the most important factor in enhancing the outcome in patients with stiffness of the knee following fracture.

We enrolled 98 patients (107 hips) with a mean age of 47 years (SD 8.6) into a prospective study of the Madreporic Lord THR; 34 hips had primary and 73 secondary osteoarthritis.

After ten years, the survival rate using revision as the endpoint for failure was 70% (±9) for the cup and 98% (±0.3) for the stem. The combined clinical and radiological survival rates were 46% (±11) and 81% (±10), respectively. Osteoporosis due to stress-shielding was observed in the proximal femur. Hips with radiologically dense bone postoperatively showed the most pronounced bone loss.

We recommend continued radiological follow-up of patients with this type of implant to allow revision to be performed before there is severe bony destruction of the pelvis.

We reviewed 18 hips in 17 patients at a mean of five years after performing Sugioka's transtrochanteric anterior rotational osteotomy for avascular necrosis. The results were satisfactory in only three hips (17%). Twelve hips had been revised by hip replacement, revision was pending in one and two others were unsatisfactory. Hip replacement was not compromised by the previous Sugioka osteotomy. Fifteen hips (83%) had shown further collapse of the femoral head, and we conclude from this and from isotope scans that the osteotomy may have impaired the residual blood supply of the femoral head. It seems that ethnic origin may be a factor in the outcome of this procedure; we have abandoned its use.

Radiographs of the scaphoid after injury are difficult to interpret, and bone scintigraphy is widely used to increase the accuracy of diagnosis, though many fractures suspected on scintigraphy cannot be confirmed radiologically. We have reviewed the clinical consequences, after one year, of managing suspected scaphoid fractures according to the bone-scan results. We studied 160 patients, 35 of whom had initially positive radiographs and were treated in a cast for 12 weeks. The other 125 had bone scintigraphy and were managed according to the result. After a minimum of one year 119 patients were reviewed. Scintigraphically suspected scaphoid fracture could not be confirmed radiologically in 25%. There were no cases of nonunion. The long period of immobilisation in patients with positive radiographs or positive bone scans did not influence the frequency or severity of late symptoms compared with those with a normal bone scan.

We reviewed 31 of 33 consecutive patients with intra-articular fractures of the knee at 6 to 22 years (average 14). Of these, 77% had excellent or good results; the others had various degrees of degenerative osteoarthritis. There was no significant difference between the results after surgical or conservative treatment. Secondary degeneration was not related to cause or type of fracture, but its incidence increased with the patient's age at the time of injury, though not with the length of follow-up. Early mobilisation appeared to be beneficial in preventing later degenerative changes.

We present a series of 114 patients with microbiologically-proven chronically-infected total hip replacement, treated between 1991 and 2004 by a two-stage exchange procedure with antibiotic-loaded cement, but without the use of a prolonged course of antibiotic therapy. The mean follow-up for all patients was 74 months (2 to 175) with all surviving patients having a minimum follow-up of two years. Infection was successfully eradicated in 100 patients (87.7%), a rate which is similar to that reported by others, but where prolonged adjuvant antibiotic therapy has been used. Using the technique described, a prolonged course of systemic antibiotics does not appear to be essential and the high cost of the administration of antibiotics can be avoided.

We report 12 patients with infiltrating muscular lipomas of the lower limbs all treated by wide resection. During follow-up averaging seven years, the tumour recurred in five patients. Our results and those reported by others suggest that, in order to avoid recurrence, this tumour, although benign, should be treated by total excision of the muscle or by compartmental resection. Hormonal imbalance was suspected in 9 of the patients but an oestrogen receptor analysis of the histological samples proved negative.

We have reviewed a series of 94 Chiari pelvic osteotomies carried out from 1966 to 1982. In 83 hips the indication for surgery had been pain, and of these patients 73 (88%) had appreciable relief within one year of operation. The other 11 hips were all in children and were painless; in them the osteotomy had successfully stabilised progressive subluxation of the hip. At review after a mean follow-up of 10 years (range, 2 to 18 years) 68 previously painful hips were reassessed. Although function of the hips had deteriorated slowly with time, four of the seven cases with 18 years' follow-up had good function and only minor symptoms. A detailed analysis of the radiographic changes produced by the Chiari osteotomy was made, using computerised analysis of variance. The beneficial effects of the osteotomy resulted from complex changes, among which the provision of a stable fulcrum for the hip seemed to be the most important.

A subjective, objective and radiographic study of 21 patients with comminuted calcaneal fractures showing severe involvement of the subtalar joint is reported. The average follow-up was 14.6 years (range 8 to 29 years). Only patients with unilateral closed fractures and no associated injuries to either lower limb were admitted to the study. All were treated by early active mobilisation of the ankle, and the subtalar and the midtarsal joints. Seventy-six per cent of the patients achieved a good result with minor symptoms which did not interfere with their occupation or leisure requirements. Although two-thirds of the patients reached a point of maximal recovery at two to three years, 24% continued to improve for six years. None of the patients experienced any deterioration after this time. Neither the degree of clinical stiffness nor the degeneration of the subtalar joint, assessed radiographically, correlated with the severity of symptoms or functional disability. The role of the soft tissues in the aetiology of residual symptoms is discussed.

Between 1971 and 1976 eight patients underwent excision of the carpal lunate for pain from Kienbock's disease. The bone was replaced by a silicone rubber implant. An average of 84 months had elapsed when they were reviewed in December 1980. All eight were very satisfied with their operations. Objectively, the clinical results were good, but radiographs showed the presence of degenerative change in the region of the wrist and alteration of the position of the prosthesis on ulnar deviation of the hand. No implant has had to be removed.

1. The late consequences of stable fractures of the thoracic and lumbar spine have been assessed in a series of workmen. The incidence of symptoms has been recorded and an attempt made to assess the degree of associated incapacity.

2. It has been found that most patients continue to have some symptoms attributable to the back injury and that approximately one in five of the patients who attended for review was partially or completely incapacitated as a consequence of such symptoms.

3. The persistence of symptoms was found to be unrelated to the severity of fracture, to its level, to the presence of radiological evidence of degenerative change, or to the age of the patient.

4. Persistent symptoms were found more commonly in those patients who had received more treatment. The implications of this observation are discussed.

1. The results have been reported of total hip replacement by a low-friction technique using high-density polyethylene for the acetabular component in 379 primary interventions, performed between November 1962 and December 1965 and followed for between four and seven years.

2. Apart from failures due to infection, the rate of which in the era under review was 3·8 per cent, late failures from mechanical causes were unusual after total hip replacement by this technique. When the socket was cemented in position, which is now routine, the late mechanical failure from all causes was only 1·3 per cent in 210 cases.

3. As regards the quality of the results and their maintenance over the years, the results were so good (Table X) that it was unnecessary to distinguish an intermediate class of "improvement" between success and failure.

4. As regards relief of pain and ability to walk, the average final rating, on a scale numbered 1 to 6, was 5·9 for both, indicating 90 per cent of patients in Grade 6 (excellent) and only 10 per cent in Grade 5 (good).

5. The average recovery of movement was not as spectacular and was influenced considerably by the pre-operative range, but in all cases that range was improved on. Even starting with the stiffest of hips about one patient in four regained a right angle of flexion movement. There was no tendency to lose movement with the passage of time.

6. As regards late infection (2·2 per cent out of a total of 3·8 per cent), the various findings tend to exonerate cement as a cause.

7. The mechanical details of the technique became stabilised in the period 1959 to 1962 in the Teflon era, and with the exception of improved methods of reattachment of the greater trochanter, they are identical with our current practice in 1971.

We performed rotational acetabular osteotomy in order to treat dysplasia of the hip in five ambulatory adults with cerebral palsy. There was one man and four women, with a mean age of 21 years (16 to 27) who were followed up for a mean of 12 years and two months.

The mean Sharp angle improved from 52° to 43°, the mean acetabular index from 30.2° to 2.8°, the mean centre-edge angle from −5.6° to 29.2°, and the mean acetabular head index from 49.2 to 88.2. There was no progression of joint degeneration and relief from pain was maintained.

Our results suggest that rotational acetabular osteotomy is a valuable option for the treatment of acetabular dysplasia in adults with cerebral palsy who have incapacitating pain in the hip.

We examined an39 patients (45 knees) who had undergone Elmslie-Trillat procedure for recurrent or habitual dislocation of the patella with a follow-up of more than ten years. The mean age at the time of surgery was 18.4 years; the mean follow-up was 161 months (120 to 238). Using Fulkerson’s functional knee score, 41 knees (91%) had an excellent or good result at a mean follow-up of 45 months, and this was maintained in 29 (64%) at the final review.

The main cause of deterioration in the clinical results was the onset or worsening of patellofemoral joint pain, not patellar instability.

We performed a prospective study in 186 patients with a minimum follow-up of two years in order to attempt to predict successful major re-implantation of the upper limb. There were 137 men and 49 women with 24 amputations of the palm, 75 of the wrist, 50 of the forearm, 9 disarticulations through the elbow, and 28 amputations through the upper arm.

The degree of injury to the amputated segment and the stump were good predictors of the rate of success and the final outcome. Adequate preservation, contraction of the muscle in the amputated part after stimulation, the level of injury and a smoking habit were fair indicators, but the serum potassium concentration in the amputated segment was the best objective predictor. When it is higher than 6.5 mmol/l 30 minutes after re-perfusion, re-implantation should be avoided. A high systemic venous serum potassium concentration was also found before clinical signs of the re-perfusion syndrome were seen.

We reviewed 25 children who presented consecutively with voluntary (habitual) subluxation of the shoulder. Thirty-six shoulders were involved and symptoms had been present for an average period of 12 years. Eighteen children were managed by 'skillful neglect': all these had become fully active in the profession of their choice and were satisfied with the outcome. Two of them had required shoulder surgery in adult life but only after trauma. Seven children (ten shoulders) had undergone stabilising operations during childhood with the aim of preventing later degenerative arthritis. These patients were also active in their selected professions, but only three (five of the ten shoulders) had good results: two shoulders had recurrent instability, two were painful and one was stiff. None of the shoulders in either group had developed osteoarthritic changes. There was no association with emotional or psychiatric problems. We conclude that voluntary subluxation of the shoulder in children has a favourable prognosis and that there is no indication for surgical intervention during childhood.