Twenty-nine patients with avascular necrosis of the femoral head after injury have been treated by operation. Multiple drilling of the femoral head was performed, necrotic bone removed and a muscle-pedicle bone graft implanted into the head and neck of the femur. In 17 of the patients the necrosis was associated with an un-united femoral neck fracture, in 11 it occurred after the fracture had united, and one case followed reduction of a dislocated hip. The hips became painless soon after operation. The patients were young (average age 35 years), and full weight-bearing was not allowed for several months. The follow-up period ranged from 22 to 64 months. The results were excellent in 20 patients, good in five, fair in three and poor in one

We compared 63 hips (Catterall Groups 3 and 4) contained by femoral osteotomy with 85 untreated hips and found that 50.7 per cent of treated patients developed congruous spherical femoral heads in contrast to 14.1 per cent of those untreated. We have also considered certain other features relevant to the outcome. We suggest that the indications should not be modified on the grounds of early age of onset. Relief from weight-bearing does not appear to improve the results of containment. We have assessed the shortening which follows femoral osteotomy and conclude that this is only significant when there is growth disturbance at the capital epiphysis. These changes are at least as frequent in untreated patients

It has been shown by mechanical analysis that by using cement to bond the stem of a femoral head prosthesis to bone two advantages are obtained when the conditions are compared with conventional methods. 1. "Fretting" between the implant and the living bone is eliminated. This source of persistent relative movement is probably the most important starting point for the progressive loosening of weight-bearing implants. 2. When cement is used the bond with the bone is exposed to stresses which are of an order three hundred times less than the shear strength of bone. The conventional prostheses expose the bond to compressive stresses which are near to the failure limits of the compressive strength of bone, especially in elderly patients with atrophic cortical bone in the femoral neck

We studied nine patients who had had a transtrochanteric anterior rotational osteotomy, as developed by Sugioka, for osteonecrosis of the femoral head. At a mean of 2.5 years after the initial operation we carried out a histological study of the previously necrotic femoral head which had not shown collapse of the new primary weight-bearing site. In seven joints, there was proliferation of fibrous tissue in the dead trabeculae with vascular ingrowth. New bone covering dead trabeculae created the characteristic appearance of ‘creeping substitution’. However, these changes were limited and did not extend over the entire necrotic area. Dead bone remained in all the cases. In the other two heads we did not observe proliferation of fibrous tissue or vascular ingrowth, only dead trabeculae and dead bone marrow

We have reviewed 11 patients with idiopathic transient osteoporosis of the hip; the six who were women all developed the condition during pregnancy. Both simultaneous and sequential bilateral involvement were seen, but biochemical studies were consistently normal and one synovial biopsy showed only non-specific inflammation. Radioisotope bone scans and CT scans were useful to aid diagnosis. Treatment by limiting weight-bearing relieved symptoms, and spontaneous resolution was paralleled by radiographic remineralisation, usually within a few months. One patient developed a stress fracture of the hip and other areas of transient osteoporosis. A hip involved by the condition should be protected from overloading until bone density has recovered

One hundred and seventy feet have been reviewed after operations for hallux valgus; eighty-five had had arthrodesis of the first metatarso-phalangeal joint and eighty-five had had Keller's operation. Footprints were made in order to assess the patterns of weight-bearing on the big toe and on the lesser metatarsal heads. After arthrodesis the big toe bore weight in 80 per cent compared with 40 per cent after Keller's operation. The ability to bear weight on the big toe is related to the presence of metatarsalgia and excessive weight bearing on the lesser metatarsal heads. These complications were seen more commonly after Keller's operation (particularly when more than one-third of the phalanx had been excised) than after arthrodesis

1. Degenerative arthritis has been produced consistently in adult rabbits by the injection of the proteolytic plant enzyme papain into the hip joint. Arthritic changes were recognisable radiographically after six weeks. 2. A progression of changes occurred, from loss of acid mucopolysaccharide staining in the matrix, fibrillation, fissuring and erosion of articular cartilage with death of chondrocytes in the weight-bearing areas, to secondary bony changes of subchondral sclerosis, occasional cysts and osteophyte formation. 3. Synovial inflammation occurred with accumulation of cartilage and bone debris in the inferior capsule and later capsular thickening. 4. It is suggested that this arthritis is sufficiently similar to human osteoarthritis to be useful as a model for further studies of the pathogenesis of the disease and the effects of different methods of treatment

To assess the stability of the hip after acetabular fracture, dynamic fluoroscopic stress views were taken of 41 acetabular fractures that met the criteria for non-operative management. These included roof arcs of 45°, a subchondral CT arc of 10 mm, displacement of less than 50% of the posterior wall, and congruence on the AP and Judet views of the hip. There were three unstable hips which were treated by open reduction and internal fixation. The remaining 38 fractures were treated non-operatively with early mobilisation and delayed weight-bearing. At a mean follow-up of 2.7 years, the results were good or excellent in 91% of the cases. Three fair results were ascribed to the patients’ other injuries. Dynamic stress views can identify subtle instability in patients who would normally be considered for non-operative treatment

We have analysed retrospectively the relationship between the axial parameters of alignment of the lower limb and the recurrence of varus deformity after high tibial osteotomy. We studied 29 patients (37 knees) with a mean age at surgery of 66 years. The mean follow-up was for 7.4 years (5 to 10.5). Recurrence of varus deformity was defined as an increase in the femorotibial angle of 3° or more, compared with that obtained six months after the operation. There were four patients (four knees) with recurrence of varus deformity. They had a greater varus inclination of the distal femur than those without varus recurrence. An association between varus inclination of the distal femur and horizontal obliquity of the joint surface was observed. Excessive obliquity prevents the shift of weight-bearing to the lateral compartment, and may cause a recurrence of varus deformity after high tibial osteotomy

Aims

Eight-plates are used to correct varus-valgus deformity (VVD) or limb-length discrepancy (LLD) in children and adolescents. It was reported that these implants might create a bony deformity within the knee joint by change of the roof angle (RA) after epiphysiodesis of the proximal tibia following a radiological assessment limited to anteroposterior (AP) radiographs. The aim of this study was to analyze the RA, complemented with lateral knee radiographs, with focus on the tibial slope (TS) and the degree of deformity correction.

The Fulkerson osteotomy has proved to be a reliable treatment for subluxation of the patella due to malalignment. Aggressive rehabilitation in the early postoperative period is unwise since the proximal tibia is weakened by the oblique osteotomy. Early weight-bearing and unrestricted activity have caused fractures in a few patients. Even late in the postoperative period the osteotomy may adversely influence the biomechanical properties of the proximal tibia. We describe two athletes who sustained a fracture of the proximal tibia, during recreational activities, six months after a Fulkerson osteotomy. Both had been bearing full weight for about ten weeks without complaint. Bony healing of the osteotomy had been demonstrated on plain radiographs at ten and at 12 weeks. After a Fulkerson osteotomy, jogging and activities which impose considerable impact force should be discouraged for at least nine to 12 months

In a prospective, randomised trial of 81 patients with fractures of the ankle of AO types A, B and C we compared two regimes of postoperative management after internal fixation. The patients were mobilised either non-weight-bearing with crutches or weight-bearing in a below-knee walking plaster. We found a temporary benefit in subjective evaluation only (65 v 50 points, Mann-Whitney test, cft, p = 0.02) for those with a below-knee walking plaster. There were no significant differences between the groups in the loaded dorsal range of movement (25° v 23°, Mann-Whitney test, cft, p = 0.16) or in the overall clinical result. Both treatments were considered to be satisfactory and their choice depends on the ability to mobilise non-weight-bearing, wound healing, the type of work and personal preference

Aims

The diversity of femoral morphology renders femoral component sizing in total hip arthroplasty (THA) challenging. We aimed to determine whether femoral morphology and femoral component filling influence early clinical and radiological outcomes following THA using fully hydroxyapatite (HA)-coated femoral components.

Between November 1983 and December 1992, 136 hips (119 patients) with coxarthritis were operated on using joint-preserving techniques based on the rationale of Pauwels’ osteotomy. The criterion for selection was a patient in whom the height of the joint space in the weight-bearing area of the hip was less than 1 mm. The mean age at operation was 48 years and the mean follow-up 109 months (60 to 171). Hips were categorised using Bombelli’s classification of osteoarthritis, into atrophic and non-atrophic types. The endpoint was defined as that at which the height of the joint space became less than 1 mm again. The Kaplan-Meier curve showed that the rate of survival of the non-atrophic group was significantly better than that of the atrophic group. Cox’s proportional hazard model indicated that the factors influencing the results of joint-preserving operations included Bombelli’s classification, postoperative incongruence of the joint and the height of the joint space

Aims

Bone demonstrates good healing capacity, with a variety of strategies being utilized to enhance this healing. One potential strategy that has been suggested is the use of stem cells to accelerate healing.

Of 135 consecutive patients admitted with subtrochanteric fractures of the femur, 104 were studied; half had internal fixation with a Zickel nail and half had a nail-plate device. Fractures treated with a Zickel nail had significantly less blood loss during operation and took less time to walk with full weight-bearing, but the incidence of technical error at operation was higher. Errors included malalignment of the cross-pin, penetration of the femoral cortex and comminution of the greater trochanter. There was mechanical failure within one year of surgery in 17% of the nail-plate series but no implant failures in the Zickel nail group within the same period. The total time spent in hospital was similar in both groups. The Zickel nail provides better fixation for subtrochanteric fractures than a simple nail-plate but, because of technical difficulty, its use should be reserved for surgeons of reasonable experience

The stability of union following the conservative treatment of tibial shaft fractures has been examined in 157 patients by a non-invasive method. With this technique it is possible to ascertain when the fragments are united and whether the strength of union is sufficient for full weight-bearing without protection. The mean time required for union was 14.0 +/- 9.2 weeks, with a range of 4 to 48 weeks. In 31 cases union was judged to be delayed; in 22 of these, intended operations were avoided because repeated stability determinations indicated progressive union. Of nine fracture variables examined, the only ones which significantly affected the time required to achieve union were the age and the weight of the patient. Irrelevant factors were the type and level of the fracture, the energy of trauma, soft-tissue injury and the presence of multiple injuries

Bone is a dynamic tissue with a quarter of the trabecular and a fifth of the cortical bone being replaced continuously each year in a complex process that continues throughout an individual’s lifetime. Bone has an important role in homeostasis of minerals with non-stoichiometric hydroxyapatite bone mineral forming the inorganic phase of bone. Due to its crystal structure and chemistry, hydroxyapatite (HA) and related apatites have a remarkable ability to bind molecules. This review article describes the accretion of trace elements in bone mineral giving a historical perspective. Implanted HA particles of synthetic origin have proved to be an efficient recruiting moiety for systemically circulating drugs which can locally biomodulate the material and lead to a therapeutic effect. Bone mineral and apatite however also act as a waste dump for trace elements and drugs, which significantly affects the environment and human health.

Cite this article: Bone Joint Res 2020;9(10):709–718.

We examined clinically and radiologically the knees of 46 patients (27 females and 19 males) with diastrophic dysplasia. The age of the patients varied from newborn to 38 years. A total of 18 patients was followed during their growth until adolescence. The knees of two legally aborted fetuses appeared on examination to be macroscopically normal and congruous. Excessive valgus deformity of the tibiofemoral weight-bearing angle with a mean of 14° was noted in infancy. Most of the patients had marked instability of the knees. The range of movement of the knee began to decrease before the age of five years. There were signs of early degeneration and deformation of the bony epiphyses before the age of six years. The patellofemoral joint was abnormal from an early age. A marked patella infera, often associated with a lateral position of the patella with bony fragmentation, was noted. The knee in diastrophic dysplasia is basically unstable, showing early deformation of the subchondral bone and degeneration of the joint

It has been shown that in the puppy, two infarcts separated by an interval of four weeks produce a disorder of long duration which results in flattening and broadening of the femoral head and which reproduces the radiological changes seen in Perthes' disease in man. The histological appearances produced by two infarcts are characteristic. In this study the histological appearance of fifty-seven femoral head biopsy specimens in Perthes' disease in man have been studied. In 51 per cent of hips histopathological changes characteristic of double infarction were present, and there were grounds for postulating that double infarction might eventually occur in all cases. The findings support the concept that the deformation of the femoral head and the chronicity of Perthes' disease in man may be due at least as much or even more to repeated episodes of infarction and the ensuing abnormalities of growth as to mechanical factors related to weight-bearing