1. The use of the Metals Research Macrotome for cutting 100 μ thick sections of fresh, unfixed specimens of arthritic human femoral heads and normal goat condyles is described. 2. A technique for isolating living cells from these slices by decalcification followed by enzymic digestion is reported. 3. The microscopic appearances of the fresh slices, the decalcified slices and the isolated cells as seen by incident or transmitted fluorescent lighting, by phase-contrast microscopy, by scanning electron microscopy and by histological and cytological techniques are illustrated. 4. These techniques might be applicable to the examination of biopsy specimens of pathological bone or to basic research on bone cells

Localised Langerhans-cell histiocytosis of bone (eosinophilic granuloma) is a benign tumour-like condition with a variable clinical course. Different forms of treatment have been reported to give satisfactory results. However, previous series all contain patients with a wide age range. Our aim was to investigate the effect of skeletal maturity on the rate of recurrence of isolated eosinophilic granuloma of bone excluding those arising in the spine. We followed up 32 patients with an isolated eosinophilic granuloma for a mean of five years; 17 were skeletally immature. No recurrences were noted in the skeletally immature group even after biopsy alone. By contrast, four of 13 skeletally mature patients had a recurrence and required further surgery. This suggests that eosinophilic granuloma has a low rate of recurrence in skeletally immature patients

Our aim was to assess the local extent of osteocyte death in the proximal femur of 16 patients with osteonecrosis of the femoral head. We performed histological examination of the femoral heads and cancellous bone biopsies from four regions of the proximal femur in patients undergoing total hip arthroplasty. A control group consisted of 19 patients with osteoarthritis. All histological specimens were examined in a blinded fashion. Extensive osteonecrosis was shown in the proximal femur up to 4 cm below the lesser trochanter in the group with osteonecrosis. There was an overall statistically significant difference in the extent of osteocyte death distal to the femoral head between the two groups (p < 0.001). We discuss the implications of these findings as possible contributing factors in regard to the early failure of total hip arthroplasty reported in patients with osteonecrosis of the femoral head

Twenty-one patients with spinal brucellosis were reviewed. The disease is difficult to diagnose, and is often confused with spinal tuberculosis. Our study showed that it was best diagnosed by serology and bacterial culture; radiography and scanning were less helpful in the early stages. After only six weeks' antibiotic treatment, there was a 55% clinical and serological reactivation rate: better results were achieved after at least three months of treatment. The adequacy of treatment was best monitored with repeated agglutination titres, and the duration of treatment proved to be more important than the antibiotic agent itself. Surgical intervention was reserved for biopsy, severe neurological impairment, or for spinal stabilisation

1. This case is presented to illustrate two etiological factors in tendon rupture occurring in one patient. 2. The rupture of the long head of the biceps brachii muscle appears to have been of acute traumatic origin. 3. Bilateral simultaneous rupture of the calcaneal tendons is rare, but it seems probable that the cortico-steroid therapy was the etiological factor in this case. 4. It has been suggested that degeneration in the tendon is caused by ischaemia, secondary to hypertrophy of the tunica media and narrowing of the medium calibre blood vessels. Betamethazone could possibly have aggravated, or may even have caused these changes, and the periarteriolar changes found in the biopsy specimen would tend to support this theory

1. Twenty-nine patients with traction lesions of the brachial plexus have been studied. 2. The methods of study have been by clinical examination, by operative exploration and biopsy and by examination of axon reflexes. 3. Results in each of these sections have been related to the progress of the lesions. 4. The results suggest: a) that the reason for the generally poor prognosis in traction lesions of the brachial plexus is the frequency of intradural preganglionic damage and of tearing apart of the plexus; b) that the former occurrence can with some accuracy be diagnosed by examination of axon reflexes and that the latter can be detected at operation. 5. Indications for operative exploration are given and a plan is outlined for the management of these cases

Aims

Iliac wing (Type I) and iliosacral (Type I/IV) pelvic resections for a primary bone tumour create a large segmental defect in the pelvic ring. The management of this defect is controversial as the surgeon may choose to reconstruct it or not. When no reconstruction is undertaken, the residual ilium collapses back onto the remaining sacrum forming an iliosacral pseudarthrosis. The aim of this study was to evaluate the long-term oncological outcome, complications, and functional outcome after pelvic resection without reconstruction.

We prospectively evaluated the percutaneous injection of autogenous bone marrow for the treatment of active simple bone cysts in ten consecutive children with cysts in the proximal humerus, proximal femur or tibia. The treatment included percutaneous biopsy, aspiration of fluid and the injection of autogenous bone marrow aspirated from the iliac crest. All the patients became painfree after a mean of two weeks and resumed full activities within six weeks. All ten cysts consolidated radiologically and showed remarkable remodelling within four months. Review at 12 to 48 months showed satisfactory healing without complications. Percutaneous injection of autologous bone marrow appears to be an effective treatment for active simple bone cysts

A 13-year-old girl presented with a two-year history of pain in the right thigh and right forearm. Engelmann's disease was diagnosed on the basis of radiological appearances and histological examination of the bone. Her symptoms subsided after biopsy of the bone, but two weeks later she developed severe pain in the left tibia and was unable to walk. Radiological features of Engelmann's disease were found in the left tibia and other long bones although these bones had been radiologically normal one month previously. Treatment with prednisolone gave rapid relief of pain and allowed the patient to become mobile again. Four months later the radiological appearances showed significant improvement. The use of corticosteroids in this disorder is discussed

Continuous technical improvement in spinal surgical procedures, with the aim of enhancing patient outcomes, can be assisted by the deployment of advanced technologies including navigation, intraoperative CT imaging, and surgical robots. The latest generation of robotic surgical systems allows the simultaneous application of a range of digital features that provide the surgeon with an improved view of the surgical field, often through a narrow portal.

There is emerging evidence that procedure-related complications and intraoperative blood loss can be reduced if the new technologies are used by appropriately trained surgeons. Acceptance of the role of surgical robots has increased in recent years among a number of surgical specialities including general surgery, neurosurgery, and orthopaedic surgeons performing major joint arthroplasty. However, ethical challenges have emerged with the rollout of these innovations, such as ensuring surgeon competence in the use of surgical robotics and avoiding financial conflicts of interest. Therefore, it is essential that trainees aspiring to become spinal surgeons as well as established spinal specialists should develop the necessary skills to use robotic technology safely and effectively and understand the ethical framework within which the technology is introduced.

Traditional and more recently developed platforms exist to aid skill acquisition and surgical training which are described.

The aim of this narrative review is to describe the role of surgical robotics in spinal surgery, describe measures of proficiency, and present the range of training platforms that institutions can use to ensure they employ confident spine surgeons adequately prepared for the era of robotic spinal surgery.

Cite this article: Bone Joint J 2020;102-B(5):568–572.

1. A case of solitary plasmocytoma of the thoracic part of the spine, verified by necropsy, is described. 2. A brief review is given of eighteen acceptable cases of solitary plasmocytoma of bone. 3. Of the eighteen patients, fifteen were men; the five spinal tumours were all in men. 4. Diagnosis requires: a) biopsy identification of plasmocytoma; b) exclusion of the possibility of generalised myelomatosis by complete radiography of the skeleton, repeated if necessary at intervals during the ensuing two or three years or longer. 5. A tumour of brief duration, proved to be solitary by careful necropsy, cannot be placed with certainty in the group of truly solitary plasmocytomas; it might have been a precocious first lesion of myelomatosis

We reviewed 33 children with tuberculosis of the knee treated during the period from 1979 to 1991. All were treated with triple chemotherapy, using rifampicin, isoniazid and pyrazinamide for nine months. No patient had a synovectomy; surgery was limited to open biopsy or salvage procedures such as posterior release and arthrodesis for late stages of the disease. The radiological appearance of the knee at presentation predicted the outcome. The 30 patients with stage-1 (normal) or stage-2 (osteomyelitic) disease had excellent or good results; the three with narrowed joint spaces in stage 3 or stage 4 (arthritic) had fair or poor results. Early active mobilisation, as against long-term immobilisation, seemed to have no effect on the outcome of stage-1 or stage-2 disease

We reviewed 29 patients who had developed destructive arthropathy of the spine during long-term haemodialysis. Their mean age when haemodialysis began was 43.8 years; at diagnosis they had been dialysed for an average of 8.6 years. In 26 patients, the lesions were between C4 and C7; in six they were between L4 and S1, three having lesions in both regions. Sixteen patients had had previous surgery for carpal tunnel syndrome. Spinal surgery was performed in nine patients with satisfactory results in only five. We demonstrated beta-2 microglobulin amyloid deposits in the discs and surrounding ligaments in all biopsied cases. The natural history and management of this condition are not yet clear

Tissue engineering is an increasingly popular method of addressing pathological disorders of cartilage. Recent studies have demonstrated its clinical efficacy, but there is little information on the structural organisation and biochemical composition of the repair tissue and its relation to the adjacent normal tissue. We therefore analysed by polarised light microscopy and immunohistochemistry biopsies of repair tissue which had been taken 12 months after implantation of autologous chondrocytes in two patients with defects of articular cartilage. Our findings showed zonal heterogeneity throughout the repair tissue. The deeper zone resembled hyaline-like articular cartilage whereas the upper zone was more fibrocartilaginous. The results indicate that within 12 months autologous chondrocyte implantation successfully produces replacement cartilage tissue, a major part of which resembles normal hyaline cartilage

We examined soft tissue biopsies from 26 patients with symptomatic nerve root fibrosis and arachnoiditis after a previous laminectomy. Dense fibrous connective tissue was found about the nerve roots and in 14 cases (55%) fibrillar foreign material was seen within it. This material had the histochemical characteristics of cotton fibres from swabs and neurosurgical patties. In two other cases nerve root fibrosis was associated with residual radiopaque lipid thought to derive from earlier myelography. Our findings suggest that risks may be associated with the introduction of foreign material into the vertebral canal, and that microscopic fragments of surgical swabs and patties may have a role in the pathogenesis of postoperative periradicular fibrosis

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

We have studied core biopsy specimens from 16 femoral heads affected by idiopathic avascular necrosis at the silent stage, when there were no clinical or radiographic manifestations but scintigraphy was positive. All the specimens showed necrosis of trabeculae and of bone marrow, but the most common and characteristic feature was evidence of old and new haemorrhage in the marrow. In the areas of intramedullary haemorrhages, trabeculae and bone marrow were completely necrotic, with a transitional area of incomplete necrosis between these areas and those without haemorrhagic lesions, where the trabeculae and bone marrow were normal. There was good correlation between necrosis and haemorrhagic episodes, and it was concluded that repeated intramedullary haemorrhage at the silent stage is probably related to the pathogenesis of idiopathic avascular necrosis of the femoral head

Multiple tumours of peripheral nerves are often seen in patients with neurofibromatosis of type 1 or 2. Multiple schwannomas may occur without other manifestations of neurofibromatosis. We have reviewed 12 patients with multiple schwannomas arising from peripheral lesions who did not fulfil the criteria for either type of neurofibromatosis. Four had spinal and one an intracranial lesion in addition to the peripheral tumours. Two patients had one and three café-au-lait spots, respectively, and another had a probable family history. The largest tumours were 45 to 250 mm in size. Three patients had been referred as having von Recklinghausen’s disease. The large size of tumours, the difficulties of histological diagnosis on biopsy, and the confusion with neurofibromatosis can lead to overtreatment. Malignant change seldom, if ever, occurs in patients with multiple schwannomas

We examined biopsy specimens obtained during surgery on 115 patients with complete rotator cuff rupture. The vascularised connective tissue covering the area of rupture and the proliferating cells in the fragmented tendons reflected more of the features of repair than of degeneration and necrosis. The main source of this fibrovascular tissue was the wall of the subacromial bursa. These features clearly indicated a vigorous reparative response which might play an important role in tendon reconstitution and remodelling. We therefore suggest that extensive debridement along with subtotal bursectomy, commonly practised during surgical repair of rotator cuff rupture, should be avoided. Although strong suture margins are essential for good operative results, debridement should be judicious and preserve as much as possible of the bursa and the associated fibrovascular tissue