1. At an operation for recurrent posterior dislocation of the shoulder observations were made on the mechanism, head defect, method of reduction, and the position of greatest stability. 2. Experimentally, avulsion of the glenoid labrum in a monkey was shown to be capable of sound repair without operation. 3. In the treatment of primary posterior dislocation it is suggested that the position of abduction, lateral rotation and extension is favourable for the approximation of the stripped labrum and capsule to the glenoid rim, and for an effective buttress after cicatrisation. 4. If the risk of recurrence is to be reduced to a minimum the shoulder should be retained in the position of greatest stability for at least four weeks, to allow firm union of the avulsed soft tissues. 5. This position for an optimum buttress would also apply after surgical repair for recurrent posterior dislocation

Disruption of the major ligaments of the knee was seen in six young men, five parachutists and a house painter, after what we have termed abduction-traction injury. This unusual complaint results from the application of a sudden block to the ankle while falling head first, leading to traction and abduction of the knee. All the patients underwent operations, generally with unsatisfactory results. At operation tears of the anterior cruciate ligament, medial collateral ligament and posterior oblique ligament were seen in each case; in four patients the posterior capsule and in three the posterior cruciate ligament also were torn. In one patient the lateral collateral ligament was torn and the lateral meniscotibial ligament was avulsed. The compression component is absent in this type of injury and consequently the menisci and the osteochondral surfaces of the tibia and femur remained intact in each case

Entire human cadaveric cervical spines with the basiocciput were subjected to load in a compression apparatus to simulate the clinical situation of forward dislocation. The movements were recorded by lateral cineradiography. Vertical load was measured by a potentiometric transmitter synchronised with each frame of the cineradiograph. The lower part of the spine was flexed and fixed, and the upper extended and free to move forward. Vertical compression then produced bilateral dislocation of the facets without fracture. If lateral tilt or axial rotation occurred as well, a unilateral dislocation was produced. The maximum vertical load was only 145 kilograms, and coincided with the rupture of the posterior ligament and capsule and the stripping of the anterior longitudinal ligament, but this occurred before dislocation. The low vertical load indicates a peculiar vulnerabiity of the cervical spine in this position and correlates well with the minor trauma often seen in association with forward dislocation

The significance of cobalt as a cause of symptoms after McKee hip arthroplasty is discussed. Seven patients are described in whom such arthroplasties became unsatisfactory after periods varying from nine months to four years. Six of these patients were cobalt-positive but nickel-and chrome-negative on patch testing. Macroscopic and histological necrosis of bone, muscle and joint capsule around the prostheses was found in five patients whose hips were explored. The symptoms were progressive pain, a feeling of instability, and in two cases spontaneous dislocation. Radiological features included acetabular fracture, bone resorption, loosening and dislocation of the prosthesis. Increased cobalt concentrations (determined by atomic absorption spectrophotometry) in the urine of four patients and in a variety of tissues in one patient are presented. Patch testing is recommended in the investigation of patients with troublesome McKee hip arthroplasties

1. The technique of arthrography in congenital displacement of the hip is described. No complications have been encountered in a series of over 200 examinations. The interpretation of the arthrographs is discussed. 2. It is suggested that the abnormal hips may be classified in three degrees: 1) Primary instability; 2) partial displacement without interposition of soft tissue; 3) complete displacement with interposition of soft tissue between head and socket. 3. Two types of complete displacement or dislocation are recognised: 1) the "tight" dislocation; 2) the "loose" dislocation. In the latter there is marked displacement of the femoral head, and arthrography done before reduction demonstrates interposition of a fold of capsule lying in front of the inverted limbus. 4. Arthrography is of special help in making the diagnosis between partial displacement with eversion of the labrum and "tight" dislocation with an interposed limbus. It is helpful too in establishing the cause of failure of reduction

Aims

Vitamin E-infused highly cross-linked polyethylene (E1) has recently been introduced in total knee arthroplasty (TKA). An in vitro wear simulator study showed that E1 reduced polyethylene wear. However there is no published information regarding in vivo wear. Previous reports suggest that newly introduced materials which reduce in vitro polyethylene wear do not necessarily reduce in vivo polyethylene wear. To assist in the evaluation of the newly introduced material before widespread use, we established an in vivo polyethylene wear particle analysis for TKA. The aim of this study was to compare in vivo polyethylene wear particle generation between E1 and conventional polyethylene (ArCom) in TKA.

We studied retrospectively a consecutive series of 547 shoulders in 529 patients undergoing operation for instability. In 41, the cause of instability was considered to be lateral avulsion of the capsule, including the inferior glenohumeral ligament, from the neck of the humerus, the HAGL lesion. In 35, the lesion was found at first exploration, whereas in six it was noted at revision of a previous failed procedure. In both groups, the patients were older on average than those with instability from other causes. Of the primary cases, in 33 (94.3%) the cause of the first dislocation was a violent injury; six (17.4%) had evidence of damage to the rotator cuff and/or the subscapularis. Only four (11.4%) had a Bankart lesion. In patients undergoing a primary operation in whom the cause of the first dislocation was a violent injury, who did not have a Bankart lesion and had no suggestion of multidirectional laxity, the incidence of HAGL was 39%

The Chiari osteotomy and various shelf procedures are used to augment the weight-bearing area in dysplastic acetabula. The new articular surface derives by metaplasia from the acetabular rim and joint capsule, and is therefore of poorer quality than congruous hyaline cartilage. We reviewed 32 patients after augmentation procedures, using conventional radiographs and three-dimensional reconstruction from CT scans. We showed that Chiari osteotomy and shelf procedures generally achieve less than complete cover, especially over the posterolateral quadrant of the femoral head. Our results suggest that alternative methods which reorientate the whole of the acetabulum are the treatment of choice. Augmentation procedures remain as a salvage option when reorientation is inappropriate or the original hyaline cartilage surface is absent, as in subluxed joints with a secondary acetabulum. Computerised assessment is recommended before operation to assess existing cover and the possible extent of provision of new cover

We performed superselective angiography in 28 hips in 25 patients with Perthes’ disease in order to study the blood supply of the lateral epiphyseal arteries (LEAs). Interruption of the LEAs at their origin was observed in 19 hips (68%). Revascularisation in the form of numerous small arteries was seen in ten out of 11 hips in the initial stage of Perthes’ disease, in seven of eight in the fragmentation stage and in five of nine in the healing stage. Penetration of mature arteries into the depths of the epiphysis was seen in four of nine hips in the healing stage. Vascular penetration was absent in the weight-bearing portion of the femoral head below the acetabular roof. Interruption of the posterior column artery was seen where it passed through the capsule in seven hips when they lay either in internal rotation or in abduction with internal rotation. We suggest that in Perthes’ disease the blood supply of the LEAs is impaired at their origin and that revascularisation occurs from this site by ingrowth of small vessels into the femoral epiphysis. This process may be the result of recurrent ischaemic episodes

We have reviewed the literature on the anatomy of the posteromedial peripheral ligamentous structures of the knee and found differing descriptions. Our aim was to clarify the differing descriptions with a simplified interpretation of the anatomy and its contribution to the stability of the knee. We dissected 20 fresh-frozen cadaver knees and the anatomy was recorded using video and still digital photography. The anatomy was described by dividing the medial collateral ligament (MCL) complex into thirds, from anterior to posterior and into superficial and deep layers. The main passive restraining structures of the posteromedial aspect of the knee were found to be superficial MCL (parallel, longitudinal fibres), the deep MCL and the posteromedial capsule (PMC). In the posterior third, the superficial and deep layers blend. Although there are oblique fibres (capsular condensations) running posterodistally from femur to tibia, no discrete ligament was seen. In extension, the PMC appears to be an important functional unit in restraining tibial internal rotation and valgus. Our aim was to clarify and possibly simplify the anatomy of the posteromedial structures. The information would serve as the basis for future biomechanical studies to investigate the contribution of the posteromedial structures to joint stability

One hundred normal fingers were dissected and arthrographs obtained by injection of a chromopaquegelatin mixture, allowing comparison between the radiographic and macroscopic configuration of the synovial capsule. Synovial recesses protruding from each side of every metacarpo-phalangeal joint were found in relation to the collateral ligaments and corresponding exactly with the site of radiological erosions. A group of bursae lying on the superficial aspect of collateral ligaments were also demonstrated. A rudimentary infra-articular meniscus was found. The results of examination of the insertions of the interossei showed differences from traditional descriptions. The cause of rheumatoid deformity was suggested to be the rheumatoid process arising in the lateral recesses and lateral bursae, weakening the collateral ligaments, which give way in the directions of the deforming forces. These are derived from the long flexor tendons, which were shown to exert an ulnar and volar strain on the metacarpo-phalangeal joint of every finger during grip

1. Two cases of recurrent post-traumatic dislocation of the hip are reported. 2. The literature is reviewed and the rarity of the condition is emphasised. Only twenty-two cases have been previously reported, eleven in adults and eleven in children. 3. The sequence of events leading to recurrent dislocation is not understood but the following important facts emerge. The initial incident could not be distinguished from that causing uncomplicated dislocations. There was a significant delay in reduction in a number of cases. Subsequent dislocations followed minor injury. A large defect in the posterior capsule with a large synovial-lined pouch or false joint was found at operation in both our cases. The ligamentum teres was not seen at operation. The surgeon was unable to redislocate the hips during the operation. 4. In both cases reported here treatment was by excision of the posterior pouch and repair of the capsular defect. 5. Based on the above facts some tentative deductions are made

1. The arterial supply of the upper end of the femur has been studied in twenty-four children and twenty adults. 2. The arterial system was demonstrated by injection of radio-opaque material, with Spalteholz' method of clarification, and histological section of the neck and ligamentum teres. 3. The upper end of the femur is supplied by the nutrient artery of the shaft, the retinacular vessels of the capsule, and the foveolar artery of the ligamentum teres. 4. The retinacular vessels consist of three separate groups: postero-superior, posteroinferior, and anterior. These vessels are the chief supply to the epiphysis and femoral head at all ages. 5. The foveolar artery constitutes a small and subsidiary blood supply to the femoral epiphysis. In this series, it penetrated the cartilaginous or osseous head in 33 per cent. of young specimens and 70 per cent. of adult specimens. The foveolar vessels increase in size with age. 6. The site of the vascular pathology in various lesions of the femoral head is considered

Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It includes the piriformis syndrome, the gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome, and the proximal hamstring syndrome. The concept of the deep gluteal syndrome extends our understanding of posterior hip pain due to nerve entrapment beyond the traditional model of the piriformis syndrome. Nevertheless, there has been terminological confusion and the deep gluteal syndrome has often been undiagnosed or mistaken for other conditions. Careful history-taking, a physical examination including provocation tests, an electrodiagnostic study, and imaging are necessary for an accurate diagnosis.

After excluding spinal lesions, MRI scans of the pelvis are helpful in diagnosing deep gluteal syndrome and identifying pathological conditions entrapping the nerves. It can be conservatively treated with multidisciplinary treatment including rest, the avoidance of provoking activities, medication, injections, and physiotherapy.

Endoscopic or open surgical decompression is recommended in patients with persistent or recurrent symptoms after conservative treatment or in those who may have masses compressing the sciatic nerve.

Many physicians remain unfamiliar with this syndrome and there is a lack of relevant literature. This comprehensive review aims to provide the latest information about the epidemiology, aetiology, pathology, clinical features, diagnosis, and treatment.

Cite this article: Bone Joint J 2020;102-B(5):556–567.

Aims

The purpose of this study was to evaluate the relationships between the degree of injury to the medial and lateral collateral ligaments (MCL and LCL) and associated fractures in patients with a posterolateral dislocation of the elbow, using CT and MRI.

Aims

To report the mid-term results of a modified self-growing rod (SGR) technique for the treatment of idiopathic and neuromuscular early-onset scoliosis (EOS).

Of 935 consecutive patients referred with shoulder pain, 50 fitted the criteria for primary frozen shoulder. Twelve patients who failed to improve after conservative treatment and manipulation had excision of the coracohumeral ligament and the rotator interval of the capsule. The specimens were examined histologically, using special stains for collagen. Immunocytochemistry was performed with monoclonal antibodies against leucocyte common antigen (LCA, CD45) and a macrophage/synovial antigen (PGMI, CD68) to assess the inflammatory component, and vimentin and smooth-muscle actin to evaluate fibroblasts and myofibroblasts. Our histological and immunocytochemical findings show that the pathological process is active fibroblastic proliferation, accompanied by some transformation to a smooth muscle phenotype (myofibroblasts). The fibroblasts lay down collagen which appears as a thick nodular band or fleshy mass. These appearances are very similar to those in Dupuytren's disease of the hand, with no inflammation and no synovial involvement. The contracture acts as a check-rein against external rotation, causing loss of both active and passive movement

Aims

To analyze the potential role of synovial fluid peptidase activity as a measure of disease burden and predictive biomarker of progression in knee osteoarthritis (KOA).

Giant-cell tumour of the tendon sheath (GCT-TS) is a benign solitary tumour which usually arises in the limbs. It occurs most often in the hand where local recurrence after excision has been reported in up to 45% of cases. It is less common in the foot where the biological behaviour and risk of local recurrence have not been defined. We have studied 17 cases of GCT-TS of the foot and ankle in which treatment was by excision. Fifteen presented as a solitary, painless, slow-growing soft-tissue swelling. One lesion was associated with sensory deficit of a digital nerve and one with pain on walking. Thirteen cases originated from the periarticular tendon-sheath complex of the small joints of the toes and four from the capsule or long tendons of the ankle. A correct preoperative diagnosis was made in only three cases. MRI proved to be the most useful preoperative investigation as GCT-TS has a characteristic appearance which allows planned local excision to be carried out. None of the patients with histologically confirmed GCT-TS required further surgery. There was no local recurrence in 15 patients who were available for follow-up at a mean of 85 months

Tectoplasty is a new acetabuloplasty which aims to provide an extra-articular weight-bearing surface in cases of dysplastic acetabulum, hip subluxation or dislocation with a false acetabulum. The lateral wall of the iliac bone at the lateral edge of the affected acetabulum is raised as a proximally-based flap and massive bone grafts are inserted to provide a congruous, non-absorbable roof for the capsule and femoral head. An advantage is that the weight-bearing surface can be formed away from the original acetabulum, wherever the dislocated or subluxated femoral head may lie. Of 34 hips with congenital dislocation or severe subluxation treated by this method, 27 were evaluated after an average follow-up of 12 years. At review the patients averaged 35 years of age and satisfactory results with good relief of pain had been obtained in 78%. The results were unsatisfactory when degenerative changes had already developed before operation. Tectoplasty is indicated for pain due to congenital subluxation or dislocation of the hip under the age of thirty, in the absence of advanced osteoarthritis