Seven patients with chronic insufficiency of the triceps were treated by either a rotation flap using anconeus (4) or an allograft of tendo Achillis (3). The latter procedure was selected for patients with a large defect in whom the anconeus muscle had been devitalised. Five disruptions were in patients who had previously undergone an elbow replacement. The patients were assessed for subjective satisfaction, pain, range of movement and strength, and the results were graded using the Mayo Elbow Performance Score (MEPS). The mean follow-up was for 33 months (9 to 63). One rotation flap failed six months after operation. At the most recent follow-up, the remaining six patients had no or slight pain, restoration of a functional arc of movement and normal or slightly decreased power of extension. All six were satisfied with the outcome and were able to resume their daily activities with no limitations other than those imposed by the previous elbow replacement. The final MEPS was 100 points in five patients and 75 in one

Forty-four patients who had undergone 50 capsular arthroplasties for congenital dislocation of the hip were reviewed after a mean follow-up of 20 years. Their average age at operation was 5.9 years; 31 of the operations were undertaken because of late presentation, the remainder because of the failure of previous surgery. In all, 70% of the hips showed good function despite a reduced range of movement, but patients with bilateral arthroplasties fared poorly. Excellent containment within the acetabulum was found in 80%, but the femoral head was always abnormally high though not unduly lateral or medial. This configuration had remained unchanged during follow-up. The accuracy of reduction along the mediolateral axis was the only variable found to influence the outcome significantly. Functional deterioration, associated with pain, was noted to be more common after 20 years than before, and was associated with radiographic evidence of joint degeneration

Ninety-five patients with steroid-induced avascular necrosis of bone have been personally treated by the author. Of these, eighteen had a lesion of the head of the humerus, on one or both sides. The conditions for which the steroids were given included post-transplantation, lupus erythematosus, glomerulonephritis and asthma. The characteristic lesion began as a subchondral osteolytic area which frequently progressed to collapse. The articular cartilage divided from the subchondral bone, either becoming detached as a free cap or at a later stage reattaching. In some cases the lesion was minimal and the symptoms were slight. Conservative treatment has consisted of pendulum exercises and avoidance of abduction, particularly against resistance. In fourteen patients this led to satisfactory function with only intermittent symptoms. Four patients required replacement of five humeral heads with Neer's prostheses. After one to seven years the results of all five were classified as excellent in terms of absence of symptoms and a free range of movement

1. Two hundred and seventeen low-friction arthroplasties performed between November 1962 and April 1969 in 203 patients with failed previous operations have been analysed. 2. The technical details of operation in relation to these conversion problems have been outlined. 3. The quality of the results in relation to pain, mobility and ability to walk has been assessed before operation and one year afterwards, with small numbers at three and five years. 4. Pain was completely relieved or was minimal in 96·3 per cent of the patients, and in no case was the pain worse. 5. The total range of movement was 100 degrees or more in 98·5 per cent. No hip lost movement after conversion. 6. The failures were principally due to infection and to technical difficulties. There were no mechanical failures without a technical or radiological explanation. 7. Low-friction arthroplasty is an excellent salvage procedure, especially for failed cup arthroplasty

1. Stainless steel mould arthroplasty of the knee is described and a ten-year follow-up study of sixty-two operations is reported. Fifty-four were for rheumatoid arthritis and eight for osteoarthritis. 2. Forty-nine of the sixty-two joints retained mobility, six had become ankylosed and five were later arthrodesed ; two limbs were amputated. The forty-nine mobile knees included twenty-seven which were painless at all times, and fourteen in which only an occasional twinge was felt. 3. The range of movement was increased in twenty-two joints as compared with the state before operation, diminished in twelve and unaltered in five. In ten knees measurements before operation were not available. 4. Flexion deformity, swelling, stability and function were improved in a significant number of joints. 5. Patients suffering from active rheumatoid arthritis often found that the joint operated upon no longer took part in generalised flares of the disease

To study the effect of ligament injuries and surgical repair we investigated the three-dimensional kinematics of the ankle joint complex and the talocrural and the subtalar joints in seven fresh-frozen lower legs before and after sectioning and reconstruction of the ligaments. A foot movement simulator produced controlled torque in one plane of movement while allowing unconstrained movement in the remainder. After testing the intact joint the measurements were repeated after simulation of ligament injuries by cutting the anterior talofibular and calcaneofibular ligaments. The tests were repeated after the Evans, Watson-Jones and Chrisman-Snook tenodeses. The range of movement (ROM) was measured using two goniometer systems which determined the relative movement between the tibia and talus (talocrural ROM) and between the talus and calcaneus (subtalar ROM). Ligament lesions led to increased inversion and internal rotation, predominantly in the talocrural joint. The reconstruction procedures reduced the movement in the ankle joint complex by reducing subtalar movement to a non-physiological level but did not correct the instability of the talocrural joint

We review the results of a modified quadricepsplasty in five children who developed stiffness of the knee after femoral lengthening for congenital short femur using an Ilizarov external fixator which spanned the knee. All had a full range of movement of the knee before lengthening was undertaken. Unifocal lengthening was carried out in the distal metaphysiodiaphyseal region of the distal femur with a mean gain of 6.5 cm. The mean percentage lengthening was 24%. At the end of one year after removal of the Ilizarov frame and despite intensive physiotherapy all patients had stiffness. Physiotherapy was continued after the quadricepsplasty and, at the latest follow-up (mean 27 months), the mean active flexion was 102° (80 to 130). The gain in movement ranged from 50° to 100°. One patient had a superficial wound infection which settled after a course of oral antibiotics. None developed an increased extension lag after surgery and all were very satisfied with the results. Quadricepsplasty is a useful procedure for stiffness of the knee after femoral lengthening which has not responded to physiotherapy

A vascular necrosis of the lunate, first described by Kienböck, can be treated either conservatively or by various surgical procedures. We compared the results of 18 conservatively treated patients, all of whom had stage-2 or stage-3 disease, with those of 15 who underwent a radial shortening procedure. We evaluated pain, range of movement, grip strength and functional disability, and determined the progression of the disease by assessing radiologically carpal height, the width and flattening of the lunate, the radioscaphoid angle, the pattern of the fracture and sclerosis and cysts. The mean follow-up was for 3.6 years (1.5 to 9). Patients treated by radial shortening had less pain and better grip strength than those managed conservatively. In some patients with stage-3 disease treated conservatively there was rapid deterioration to carpal collapse. Although radial shortening did not reverse or prevent carpal collapse, it slowed down the process in patients with stage-3 disease. We recommend a radial shortening procedure for patients with severe pain and radiological signs of progressive carpal collapse

Since 1986, we have treated displaced intra-articular fractures of the calcaneum by open reduction through a lateral approach, stable internal fixation and bone grafting. We assessed the results at a mean follow-up of 2.92 years in 44 patients, comparing them with those for 19 patients treated non-operatively. Clinical assessment used the scoring system of Crosby and Fitzgibbons (1990) and radiological measurements were made from lateral, axial and internal oblique views. The articular congruity of the subtalar joint and any arthritic changes were also assessed. We found significantly better results in the operated group with respect to pain, activity, range of movement, return to work and swelling of the hind foot. Radiologically, the operated group showed significantly better scores for articular congruity and arthritic changes. We conclude that the operative treatment of displaced intra-articular fractures of the calcaneum gives better medium-term results than conservative management

We randomised prospectively 44 patients with fractures of the shaft of the humerus to open reduction and internal fixation by either an intramedullary nail (IMN) or a dynamic compression plate (DCP). Patients were followed up for a minimum of six months. There were no significant differences in the function of the shoulder and elbow, as determined by the American Shoulder and Elbow Surgeons’ score, the visual analogue pain score, range of movement, or the time taken to return to normal activity. There was a single case of shoulder impingement in the DCP group and six in the IMN group. Of these six, five occurred after antegrade insertion of an IMN. In the DCP group three patients developed complications, compared with 13 in the IMN group. We had to perform secondary surgery on seven patients in the IMN group, but on only one in the DCP group (p = 0.016). Our findings suggest that open reduction and internal fixation with a DCP remains the best treatment for unstable fractures of the shaft of the humerus. Fixation by IMN may be indicated for specific situations, but is technically more demanding and has a higher rate of complications

We undertook a prospective study of 61 children in Malawi with septic arthritis of the shoulder. They were randomised into two groups, treated by aspiration (group 1, 31 patients) or arthrotomy (group 2, 30 patients). Both received antibiotics for six weeks. We studied the results of blood tests, microbiology, and the clinical and radiological outcome one year after diagnosis. Only one patient was sickle-cell positive and three were HIV-positive. Non-typhoidal Salmonella species accounted for 86% (19/22) of the positive joint cultures in group 1 and 73% (16/22) in group 2. Of the 33 radiographs available for review at follow-up at six months, 23 (70%) showed evidence of glenohumeral damage. There was no statistical difference in radiological outcome for the two groups. We devised and validated a scoring system, the Blantyre Septic Joint Score, for the assessment of joints based upon swelling, tenderness, function and range of movement. Despite the radiological changes only one of the 24 joints examined at one year had any deficit in these parameters. There was no statistical difference in the clinical outcome for the two treatment groups at any stage during the period of follow-up

We treated 31 intra-articular fractures of the distal radius by arthroscopically-assisted reduction and percutaneous fixation with Kirschner (K-) wires. Tears of the triangular fibrocartilage (58%), scapholunate (85%) and lunotriquetral (61%) instability and osteochondral lesions (19%) were also treated. A total of 26 patients was independently reviewed at an average of 19 months. The mean pain score was 1.3/10, the range of movement 79% and the grip strength 90% of the contralateral wrist. Using the New York Orthopaedic Hospital score, 88% were graded excellent to good. On follow-up radiographs, 65% had no step and 31% had a step of ≤1 mm. Pain was significantly related to the size of the step. There was a significant difference in the incidence of persistent scapholunate diastasis and the Leibovic and Geissler grade (p < 0.01): I (0%), II (0%), III (42%) and IV (100%). We recommend anatomical reduction and acceptance of a step of < 1 mm since the size of the step is related to the incidence of pain

We have reviewed 81 patients with fractures of the odontoid process treated between May 1983 and July 1997, by anterior screw fixation. There were 29 patients with Anderson and D’Alonzo type-II fractures and 52 with type III. Roy-Camille’s classification identified the direction and instability of the fracture. Operative fixation was carried out on 48 men and 33 women with a mean age of 57 years. Associated injuries of the cervical spine were present in 15 patients, neurological signs in 13, and 18 had an Injury Severity Score of more than 15. Nine patients died and 11 were lost to follow-up. Of 61 patients, 56 (92%) achieved bony union at an average of 14.1 weeks. Two patients required a secondary posterior fusion after failure of the index operation. A full range of movement was restored in 43 patients; only six had a limitation of movement greater than 25%. We conclude that anterior screw fixation is effective and practicable in the treatment of fractures of the dens

Aims

To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes.

Aims

Perthes’ disease is a condition which leads to necrosis of the femoral head. It is most commonly reported in children aged four to nine years, with recent statistics suggesting it affects around five per 100,000 children in the UK. Current treatment for the condition aims to maintain the best possible environment for the disease process to run its natural course. Management typically includes physiotherapy with or without surgical intervention. Physiotherapy intervention often will include strengthening/stretching programmes, exercise/activity advice, and, in some centres, will include intervention, such as hydrotherapy. There is significant variation in care with no consensus on which treatment option is best. The importance of work in this area has been demonstrated by the British Society for Children’s Orthopaedic Surgery through the James Lind Alliance’s prioritization of work to determine/identify surgical versus non-surgical management of Perthes’ disease. It was identified as the fourth-highest priority for paediatric lower limb surgery research in 2018.

Fractures of the scaphoid are most common in young men; immobilisation in a cast usually means a long period away from work and athletic activities. Early rigid fixation has been shown to promote a rapid functional recovery, but open reduction and internal fixation is technically demanding with the dangers of damage to the radiocarpal ligaments, the scaphotrapezial joint, and the blood supply of the scaphoid. For minimally displaced or undisplaced B1 or B2 fractures, these problems can be overcome by percutaneous fixation. We report our technique and the results of a pilot study in 15 patients. There was no immobilisation; patients were allowed movement soon after operation, but union was obtained in all at a mean of 57 days (38 to 71). The range of movement after union was equal to that of the contralateral limb and grip strength was 98% of the contralateral side at three months. Patients were able to return to sedentary work within four days and to manual work within five weeks. Our initial results show that percutaneous scaphoid fixation for acute fractures is satisfactory and gives rapid functional recovery

Thirteen methods of hip scoring were applied in the postoperative assessment of 47 hip arthroplasties. Their results were found to be inconsistent, often giving contrary measures of success in the same patient. Ten variables were measured during the postoperative review of 256 hip arthroplasties and the data were submitted to multivariate factor analysis. This revealed that the ten variables could be reduced to three factors: pain, which correlated poorly with any other variable (Spearman correlation, r < 0.02); functional activity (distance walked, use of walking aids, stair climbing, use of public transport, limp, sitting and tying shoelaces); and deformity and range of movement. The range of hip flexion correlated closely with the sum of the arcs of movement and with Gade's index (Spearman correlation, r > 0.9). We suggest that, for outcome assessment, only three variables need to be recorded: pain, walking distance and range of hip flexion. The combination of these three measures into a single hip score is misleading

Although the outcome of fractures of the distal radius is traditionally assessed using objective clinical variables such as grip strength and range of movement of the wrist, the extent to which they reflect function and outcomes of importance for the patient is uncertain. This may cause considerable inconsistencies in the assessment of outcome using current scoring systems. We prospectively studied 31 patients recovering from unstable fractures of the distal radius in order to investigate the association between objective variables and the level of post-traumatic disability of the wrist as measured by the patient-rated wrist evaluation (PRWE) score. Multiple regression showed considerable differences in the extent to which limitations in specific objective clinical variables reflected the level of disability of the wrist. Grip strength was shown to be a significant predictor of the PRWE score (regression coefficient −1.09, 95% confidence interval −1.76 to −0.42, p < 0.01) and thus appears to be a sensitive indicator of return of function of the wrist. Forearm rotation and flexion and extension of the wrist were not significantly associated with the PRWE score. These observations should be taken into account during the evaluation of methods of treatment and in constructing future clinical outcome scoring systems

We determined the outcome of 56 ‘Oxford’ unicompartmental replacements performed for anteromedial osteoarthritis of the knee between 1982 and 1987. Of these, 24 were in patients who had died without revision, one was lost to follow-up and two had been revised. Of the remaining 29 knees, 26 were examined clinically and radiologically, two were only examined clinically and one patient was contacted by telephone. The mean age of the patients was 80.3 years. At a mean follow-up of 11.4 years (10 to 14) the measurements of the knee score, range of movement and degree of deformity were not significantly different from those made one to two years after operation, except that the range of flexion had improved. Comparison of fluoroscopically-controlled radiographs at a similar interval of time showed no change in the appearance of the lateral compartments. The retained articular cartilage continued to function for ten or more years which suggests that anteromedial osteoarthritis may be considered as a focal disorder of the knee. This justifies continued efforts to develop methods of treatment which preserve intact joint structures

Cadaver knee joints were mounted so that life-like forces of weight-bearing were simulated. The patello-femoral contact areas were defined under load throughout the range of movement by the dye method. During movement from extension to 90 degrees of flexion a band of contact sweeps across the patella from inferior to superior pole, but the odd facet makes no contact. At about 135 degrees of flexion separate medial and lateral contact areas form, the medial one limited to the odd facet. From extension to 90 degrees of flexion the patella holds the quadriceps tendon away from the femur, but in further degrees of flexion an extensive "tendo-femoral" contact area forms. Between 90 degrees and 135 degrees of flexion the patella rotates and the ridge between the medial and odd facets engages the femoral condyle. The odd facet is shown to be a habitual non-contact area and the ridge to be subject to high load, observations which correlate with cartilage lesions described in Part 2 of the paper