Giant-cell tumour of bone (GCT) is a locally benign aggressive tumour. The use of adjuvant agents, such as phenol or liquid nitrogen has been recommended to destroy the remaining tumour cells after curettage, and filling of the defect with methylmethacrylate cement has been advocated. Between 1957 and 1992 we treated 92 patients with a GCT with 50% aqueous zinc chloride solution and bone grafting. Their mean age at the time of surgery was 31 years (15 to 59) and the mean follow-up was 11 years (5 to 31). Twelve (13%) had a local recurrence and one had a wound infection. Two developed degenerative changes around the knee. Eighty-six (93%) achieved good or excellent function. Three had moderate function, and three needed amputation. Our findings indicate that treatment with an aqueous solution of zinc chloride and reconstructive bone grafting after curettage gives good results

We reviewed 38 patients who had been treated for anosteochondral defect of the talus by arthroscopic curettage and drilling. The indication for surgical treatment was persistent symptoms after conservative treatment for at least six months. A total of 22 patients had received primary surgical treatment (primary group) and 16 had had failed previous surgery (revision group). The mean follow-up was 4.8 years (2 to 11). Good or excellent results, as assessed by the Ogilvie-Harris score, were found in 86% in the primary group and in 75% in the revision group. Two further procedures were required, one in each group. Radiological degenerative changes were seen in one ankle in the revision group after ten years. Arthroscopic curettage and drilling are recommended for both primary and revision treatment of an osteochondral defect of the talus

We report the technique and results of a new method of debridement arthroplasty for advanced primary osteoarthritis of the elbow. Triceps and the periosteum of the olecranon are reflected towards the ulnar side and the joint is opened by dividing the radial collateral ligament. Osteophytes are removed, the olecranon and coronoid fossae are deepened and the fibrosed anterior joint capsule is excised. The degenerative changes are always more advanced on the radial side, with erosion of the capitellum, and it is usually necessary to remodel the head of the radius. In 29 elbows reviewed at a mean of 64 months, the average gain of range of motion was 34 degrees, with good pain relief and improved grip in most patients. Two elbows required reoperation but there were no other serious complications

In a longitudinal case-control study, we followed 81 subjects with dysplasia of the hip and 136 control subjects without dysplasia for ten years assessing radiological evidence of degeneration of the hip at admission and follow-up. There were no cases of subluxation in the group with dysplasia. Neither subjects with dysplasia nor controls had radiological signs of ongoing degenerative disease at admission. The primary radiological discriminator of degeneration of the hip was a change in the minimum joint space width over time. There were no significant differences between these with dysplasia and controls in regard to age, body mass index or occupational exposure to daily repeated lifting at admission. We found no significant differences in the reduction of the joint space width at follow-up between subjects with dysplasia and the control subjects nor in self-reported pain in the hip. The association of subluxation and/or associated acetabular labral tears with dysplasia of the hip may be a conditional factor for the development of premature osteoarthritis in mildly to moderately dysplastic hips

We report a long-term follow-up of abduction-extension osteotomy of the first metacarpal, performed for painful trapeziometacarpal osteoarthritis. Of a consecutive series of 50 operations, 41 thumbs (82%) were reviewed at a mean follow-up of 6.8 years. Good or excellent pain relief was achieved in 80%, and 93% considered that surgery had improved hand function, while 82% had normal grip and pinch strength, with restoration of thumb abduction. Metacarpal osteotomy was equally successful in relieving symptoms of those with early (grade 2) and moderate (grade 3) degenerative changes. This simple procedure provides lasting pain relief, corrects adduction contracture and restores grip and pinch strength, giving good results with few complications

Hemiarthroplasty of the hip and some other joints has been used for many years with satisfactory results, but the fate of articular cartilage when weight-bearing against metal has not been reported. Replacement of the head of the femur was carried out in one hip of each of 26 dogs, and the changes in acetabular cartilage studied at intervals of up to 24 weeks. There was early loss of proteoglycan, followed by surface damage to the cartilage, progressive degenerative changes, and growth of pannus from the articular margins. At 24 weeks after operation there was little remaining articular cartilage, while intense subchondral activity suggested that the bony skeleton was being remodelled to conform to the shape of the prosthesis. This study is not intended to suggest that hemiarthroplasty does not help patients

Aims

Early cases of cauda equina syndrome (CES) often present with nonspecific symptoms and signs, and it is recommended that patients undergo emergency MRI regardless of the time since presentation. This creates substantial pressure on resources, with many scans performed to rule out cauda equina rather than confirm it. We propose that compression of the cauda equina should be apparent with a limited sequence (LS) scan that takes significantly less time to perform.

In the Trillat procedure for recurrent anterior instability of the shoulder the coracoid process is osteotomised and tilted downward to act as a bone block, and a screw is used to fix it and the Bankart lesion to the anterior scapular neck. We reviewed 52 cases after a mean follow-up of 69 months. Results in 73% of shoulders were excellent, 10% were good, 7% fair and 10% poor. Dislocation recurred in 4%, but a positive apprehension sign was present in 10 other shoulders. Some degenerative changes were seen in 62% of shoulders, a complication known to be associated with bone-block procedures. The most important reason for loss of lateral rotation was iatrogenic impingement of the coracoid. This frequent and potentially serious complication can also cause posterior subluxation of the humeral head and osteoarthritis

We report the clinical and radiographic results of the Chiari pelvic osteotomy in 49 hips (45 patients) at an average of 14 years after operation. Of these hips, over half had minimal or no pain, had good or excellent results as assessed by the Harris hip score, and could walk at least three miles; three-quarters, however, had a positive Trendelenburg sign. A younger age at operation and a painless hip with no radiographic evidence of degeneration before operation were associated with a higher hip score at review. The percentage of hips without degenerative changes fell from 68% before operation to 15% at final review. There were no major complications and it was found that a Chiari osteotomy need not interfere with normal childbirth

A prospective trial is reported which compares distal osteotomy of the first metatarsal with Keller's arthroplasty in the treatment of adult hallux valgus. A total of 33 patients attended for review at least three years after operation. Symptomatic improvement, as assessed by patient satisfaction, pain relief, cosmetic improvement and restoration of function, was similar in the two groups. Objective measurement showed that the range of movement of the metatarsophalangeal joint was better maintained after osteotomy, as was the relationship of the sesamoid bones to the head of the first metatarsal. Correction of the valgus deformity also was significantly better in the patients who underwent osteotomy and in these patients the first intermetatarsal angle was reduced to within normal limits. There was no evidence that initial degenerative changes or subluxation at the metatarsophalangeal joint compromised a successful result from osteotomy

A study of the natural history and aetiology of deep vein thrombosis in 499 patients after total hip replacement is presented. Deep vein thrombosis was diagnosed by scanning the leg for 125Iodine-labelled fibrinogen for a period of 14 to 18 days and by ascending phlebography. It has been shown that deep vein thrombosis occurs ater than in patients who have undergone abdominal operations, and the risk period is longer. The peak of onset of thrombosis is on the fourth day after the hip replacement. Attempts at prophylaxis using subcutaneous heparin or intermittent pneumatic compression of the calves delay the appearance of thrombosis. Analysis of possible aetiology factors shows that the age of the patient, the degenerative disease of the hip, the surgical approach, and under-transfusion of blood, all have a significant effect on the incidence of thrombosis

Fifty-four hips converted to low friction arthroplasty between 1965 and 1975 have been reviewed one to eleven years after operation. In many cases malposition had led to degenerative changes in the opposite hip, the lumbar spine or the knee, often with severe loss of function due to pain. It was found that total replacement could give useful relief of pain and improved function, though the range of movement obtained was not as good as in primary replacement. An outstanding feature was the correction of inequality of leg length. In general, the results were much better in cases of ankylosis acquired in adult life than in cases of spontaneous fusion after sepsis in childhood. The most important complication was a single case of sciatic palsy

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. Correction of hallux valgus by spike osteotomy of the neck of the first metatarsal is described, and the results in eighty-two feet are presented. 2. A high proportion of satisfactory results can be obtained, but great care is needed in both selection and technique. 3. The ideal case is one of moderate deformity, without degenerative arthritis, and with symptoms referable to increased width of the forefoot; the operation should not be performed in cases with obvious degenerative change, nor when metatarsalgia is a prominent symptom. 4. It is important to displace the metatarsal head as far laterally as possible, and vital to avoid dorsal angulation or displacement. 5. It is suggested that enough is now known about the natural evolution of hallux valgus and the results of some operations for prophylactic surgery to be undertaken in carefully selected cases

1. Tennis elbow is largely an affliction of middle age, and it is believed that degenerative changes in the orbicular ligament may underlie its pathology. 2. It has been shown that most patients may be relieved by either extra-articular or intra-articular injection of hydrocortisone, and operative intervention is required only in a minority of cases. 3. Contraction of the extensor carpi radialis brevis is considered to be the principal pain-producing factor, and Z-lengthening of the tendon of this muscle has been found to relieve the symptoms when conservative measures have failed. 4. The late results in fifty patients have shown that this operation causes diminution neither of the power of wrist dorsiflexion nor in the efficiency of the grip. The operation may therefore be undertaken with every prospect of relieving the discomfort of tennis elbow without inviting alternative disability

We have reviewed 20 patients stage-IIIB and stage-IV Kienböck’s disease in order to examine the efficacy of two forms of radial osteotomy, namely radial wedge osteotomy and radial shortening. Lateral closing wedge osteotomies and radial shortenings were carried out on 11 and nine patients, respectively. There were no preoperative differences with respect to age, gender, and radiological stage. After a mean follow-up of 29 months, all patients, in both groups, had either a good or an excellent outcome. After the lateral closing wedge osteotomy, the radioscaphoid angle significantly increased and the St̊hl index significantly decreased. Progression of the degenerative changes at the radioscaphoid joint was found in two patients in this group. By contrast, there were no significant changes in any radiological parameters after radial shortening. Both procedures gave acceptable clinical results in stage-IIIB and stage-IV Kienböck’s disease

We have measured the dynamic movement of the lumbar spine in 57 patients with degenerative lumbar disc disease. Each completed a questionnaire which recorded pain and subjective signs and symptoms. From plain lateral radiographs, the subjects were graded using the criteria of Kellgren and Lawrence and those of Lane et al, which are both based on the severity of degenerative changes. Measurements of the height of the disc space and the vertebral height were obtained and expressed as a ratio. We found no relationship between the characteristics of spinal movement and the overall grading of degenerative disc disease with either system. Both were influenced (p < 0.01) by age, walking distance, severity of symptoms, drug intake and frequency of pain. The present systems for grading degenerative disc disease from plain lateral radiographs have limited application

We report a retrospective study of 54 acetabular fractures treated by open reduction and internal fixation, with an average follow-up of 9.6 years (3 to 17). Reduction leaving displacement of less than or equal to 2 mm was achieved in 36 hips (67%); good or excellent functional results were obtained in 33 patients (61%). Early complications requiring re-operation included postoperative loss of reduction in one case and an intra-articular screw in another. Arthrodesis or total hip arthroplasty had been performed in 10 patients (19%) who had late symptomatic degenerative changes. Failure to obtain accurate reduction was the most important factor leading to a poor result, but heterotopic calcification caused poor results in seven patients, five of whom had had an anatomical reduction

We evaluated the outcome of partial lateral meniscectomy of 31 knees in 29 patients whose knees were otherwise normal. The mean follow-up was 10.3 years. According to the Lysholm score, 14 knees were rated as excellent, four as good, five as fair and eight as poor, with a mean score of 80.5 points. Radiologically, only one lateral compartment was classified as grade 0, eight as grade 1, nine as grade 2, 11 as grade 3, and two as grade 4 according to Tapper and Hoover. No significant (p < 0.05) correlation was found between the amount of tissue resected and the subjective, clinical and radiological outcome. Although early results of lateral meniscectomy may be satisfactory, we have demonstrated that in the long term there was a high incidence of degenerative changes, a high rate of reoperation (29%) and a relatively low functional outcome score

Five patients severely affected by haemophilia, in whom six knees showed advanced haemophilic arthropathy, have been studied. The patients presented with painful limitation of movement and increasingly frequent episodes of spontaneous bleeding in the affected knees. These all showed secondary degenerative changes and varus deformity. A Corrective osteotomy of the proximal tibia was performed under full haematological cover without complications. Follow-up ranged from 6 to 36 months, with a mean of 18 months. At follow-up all patients were free of pain and had retained their range of movement. In the three patients with a longer follow-up there was radiological improvement. The most significant feature was that there was almost complete cessation of bleeding episodes into the knee in all patients and no progression of the arthropathy. The cost benefit implications of this corrective procedure are discussed