Techniques for the selective cutting of ligaments in cadaver knees defined the static contributions of the posterolateral structures to external rotation, varus rotation and posterior tibial translation from 0° to 120° of flexion under defined loading conditions. Sectioning of the popliteofibular ligament (PFL) (group 1) produced no significant changes in the limits of the knee movement studied. Sectioning of the PFL and the popliteus tendon (femoral attachment, group 2) produced an increase of only 5° to 6° in external rotation from flexion of 30° to 120° (p < 0.001). Even when other ligaments were sectioned first (group 3), the maximum effect of the PFL was negligible. Our findings show that the popliteus muscle-tendon-ligament complex, lateral collateral ligament, and posterolateral capsular structures function as a unit. No individual structure alone is the primary restraint for the movements studied. Operative reconstruction should address all of the posterolateral structures, since restoration of only a portion may result in residual instability

We describe the application of a non-invasive extendible endoprosthetic replacement in skeletally-mature patients undergoing revision for failed joint replacement with resultant limb-length inequality after malignant or non-malignant disease. This prosthesis was developed for tumour surgery in skeletally-immature patients but has now been adapted for use in revision procedures to reconstruct the joint or facilitate an arthrodesis, replace bony defects and allow limb length to be restored gradually in the post-operative period. We record the short-term results in nine patients who have had this procedure after multiple previous reconstructive operations. In six, the initial reconstruction had been performed with either allograft or endoprosthetic replacement for neoplastic disease and in three for non-neoplastic disease. The essential components of the prosthesis are a magnetic disc, a gearbox and a drive screw which allows painless lengthening of the prosthesis using the principle of electromagnetic induction. The mean age of the patients was 37 years (18 to 68) with a mean follow-up of 34 months (12 to 62). They had previously undergone a mean of six (2 to 14) open procedures on the affected limb before revision with the non-invasive extendible endoprosthesis. The mean length gained was 56 mm (19 to 107) requiring a mean of nine (3 to 20) lengthening episodes performed in the outpatient department. There was one case of recurrent infection after revision of a previously infected implant and one fracture of the prosthesis after a fall. No amputations were performed. Planned exchange of the prosthesis was required in three patients after attainment of the maximum lengthening capacity of the implant. There was no failure of the lengthening mechanism. The Mean Musculoskeletal Tumour Society rating score was 22 of 30 available points (18 to 28). The use of a non-invasive extendible endoprosthesis in this manner provided patients with good functional results and restoration of leg-length equality, without the need for multiple open lengthening procedures

The classification of intra-articular fractures of the calcaneum described in part I is related to an operative approach which allows accurate reduction and stable fixation of the fracture fragments. An extended lateral incision is used to avoid sural nerve damage and problems of soft-tissue healing. In type 3 fractures, access to the lateral joint fragment requires an osteotomy of the lateral wall, but after this the lateral joint fragment can be rotated out of the subtalar joint to allow transcalcaneal reduction of the medial wall. Reduction of the body fragment and lateral joint fragment on to the sustentacular fragment allows the three fragments to be stabilised by a 3.5 mm Y-shaped reconstruction plate. Our early results have been successful in terms of fracture reduction and the restoration of heel shape and joint congruity, but extended follow-up will be necessary to define the indications for this difficult procedure

The clinical features, management and outcome of bleeding into the muscles of the upper limb of 44 patients are reported. Of 158 episodes of bleeding, 99% were treated within two hours of onset of symptoms and the mean time to complete restoration of function was 2.1 days. The most frequent site of bleeding was the deltoid muscle (24%), followed by the forearm flexors (23.5%), brachioradialis (19.5%), biceps (14%), forearm extensors (11%) and triceps (8%). The majority of bleeds presented with pain, either on movement or at rest, or with tenderness. Bleeds into the biceps required the most transfusions (mean 2.00) and took the longest to resolve (mean 4 days). Bleeding into the flexors and extensors of the forearm resolved most rapidly. The policy of early treatment has been shown to be effective in prompting early and complete recovery

1. Musculoplastic stump correction is a method of physiological preparation of all the elements of the stump–muscles, bone, vessels and nerves–so as to establish the best relations between them. It removes the cause of existing circulatory disorders by creating active muscular movements. 2. In all cases stump pains, even those of causalgic character, have been eliminated. We attribute this to the attainment of normal muscular tension, and we believe that many phantom sensations and pains are caused by cramped and retracted muscles. 3. Active muscular work produces increased arterial inflow, as has been shown by arteriography, and also eliminates venous stasis in the end of the stump by restoration of the muscle pump mechanism. 4. Stumps prepared in the way described become painless and warm and their muscles become strong

1. A method of denervating the elbow joint, based upon observations on the articular branches of the main nerve trunks, is presented. 2. In a small group of cases with post-traumatic arthritis and osteoarthritis, relief of pain and restoration of painless movement has been gained. 3. There was recurrence of pain after six months in one patient with acute rheumatoid arthritis; in such cases denervation is not recommended until further study is completed. 4. Denervation must be as complete as possible and full exposure with stripping of nerve trunks is recommended. There have been no complications. 5. The results in this small series of cases are encouraging, but patients should be warned that there will be no significant increase in the range of movement, and that a normal joint is not to be expected. 6. Articular neurectomy is still on trial. If the limitations are recognised, the procedure may have a useful place in the relief of pain in the elbow joint

We performed a prospective, randomised study on 110 patients more than 50 years old with fractures of the distal radius to compare the outcome of conservative treatment with that using remodellable bone cement (Norian skeletal repair system, SRS) and immobilisation in a cast for two weeks. Patients treated with SRS had less pain and earlier restoration of movement and grip strength. The results at one year were satisfactory in 81.54% of the SRS patients and 55.55% of the control group. The rates of malunion were 18.2% and 41.8%, respectively. There was a significant relationship between the functional and radiological results. Soft-tissue extrusion was present initially in 69.1% of the SRS patients; most deposits disappeared progressively, but persisted in 32.73% at one year. We conclude that the injection of a remodellable bone cement into the trabecular defect of fractures of the distal radius provides a better clinical and radiological result than conventional treatment

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

Unlike hyaline cartilage, mandibular condylar cartilage can respond to injury by complete healing. We have used the reparative potential of mandibular cartilage to promote repair of defects in a hyaline cartilage joint surface. In 12 adult marmosets, articular fibrocartilage from the mandibular condyles was transplanted into full-thickness defects created in the femoral condyles. Additional defects acted as an ungrafted control group. The grafted defects showed good incorporation of the transplant with restoration of the articular surface within six months. Repair was by proliferation of the fibrocartilaginous graft and chondrogenesis of hyaline cartilage. The repopulating cells were distributed in a matrix of maturing collagen and sulphated glycosaminoglycans. Ungrafted control defects were only partly repaired with fibrous tissue, leaving articular deficiencies. We conclude that transplanted mandibular fibrocartilage can promote reconstitution of wounded hyaline cartilage joint surfaces in primates

In an attempt to repair articular cartilage, allograft articular chondrocytes embedded in collagen gel, were transplanted into full-thickness defects in rabbit articular cartilage. Twenty-four weeks after the transplantation, the defects were filled with hyaline cartilage, specifically synthesising Type II collagen. These chondrocytes were autoradiographically proven to have originated from the transplanted grafts. Assessed histologically the success rate was about 80%, a marked improvement over the results reported in previous studies on chondrocyte transplantation without collagen gel. By contrast, the defects without chondrocyte transplantation healed with fibrocartilage. Immunological enhancement induced by transplanted allogenic chondrocytes or collagen was not significant at eight weeks after treatment, so far as shown by both direct and indirect blastformation reactions. Thus, allogenic transplantation of isolated chondrocytes embedded in collagen gel appears to be one of the most promising methods for the restoration of articular cartilage

Seven pectoralis major transfers in children suffering from bilateral paralysis of elbow flexion due to arthrogryposis or to trauma are reported. A technique is described in which the muscle is mobilised from the clavicle to allow the tendon of insertion to be attached to the biceps tendon at the elbow. The biceps tendon was found to be present and could be mobilised forwards in all the arthrogrypotic elbows. Subjectively, the results were considered by patients or parents to be very good in six cases and fair in one. Elbow flexion power against gravity and against some resistance was achieved in all patients except one. The overall function was very good in one elbow, good in two, fair in three and poor in only one. The merits of the various procedures described for the restoration of elbow flexion in arthrogryposis are discussed. It is concluded that total pectoralis major transfer by the method described here has given the best results

A series of 29 patients with fractures of the tibial plateau were treated by means of a cast-brace. There were seven wedge fractures of the lateral tibial condyle, two dicondylar fractures and 20 compression fractures involving the lateral tibial plateau. The seven patients with wedge fractures were treated by skin or skeletal traction, followed as soon as possible by flexion exercises for the knee. Cast-braces were applied to all fractures as soon as possible after injury, and the patients allowed to bear weight freely. Early restoration of function of the injured limb was thereby achieved. The results of our study over a period of two and a half years indicate that cast-bracing is a very satisfactory method of treating fractures of the tibial plateau. All the fractures united, the movements and control of the knee were excellent, and valgus or varus deformity was unchanged before application and after removal of the brace

The thalamus is the part of the calcaneus that supports the posterior articular facet and continues forward, becoming thinner towards the groove of the sinus tarsi. The main displacements after fracture depend on 1) a primary fracture line dividing the bone into anterior and posterior fragments, and 2) a semilunar fragment in the thalamic region. In the operation advised the sinus tarsi is exposed and the semilunar fragment is reduced by rotation in the opposite direction and is fixed to the medial fragment (the sustenaculum tali not being displaced) by a transverse Kirschner wire. The two main fragments are fixed by an antero-posterior wire. Plaster is applied and is retained for twelve weeks. Weight-bearing is not permitted for the first four weeks. There were no major complications in fifty-eight operations. The anatomical results were good: restoration of the tuber-joint angle by reduction of the semilunar fragment was maintained. The functional results were very satisfactory: permanent disability was slight or mild

1. Sixty-eight crush fractures of the articular surface of the lateral tibial condyle have been analysed. 2. Follow-up examination at a minimum of three years after injury was carried out in all cases. 3. The only factors which appeared to influence the results were the extent of the original depression, and if this was severe, the degree of restoration obtained by the treatment. Prolonged plaster fixation was avoided. 4. At review, no patient complained of symptoms which were attributable to damage to ligaments or menisci and no patient had symptoms of late onset. 5. The results suggest that there is nothing to be gained by open reduction if the lateral condyle is depressed by less than 10 millimetres, as conservative treatment gives good results. If the depression is more severe, however, a good result can only be assured if the articular surface is successfully reconstituted, but this is sometimes difficult to achieve. It is not possible to reconstitute the surface by non-operative means

We studied 1061 children with myelomeningocele, reviewing 3184 pelvic radiographs from 802 patients. Hip dislocation had occurred by the age of 11 years in 28% of children with a thoracic neurosegmental level, 30% of those with an L1/2 level, 36% of L3, 22% of L4, 7% of L5 and only 1% of those with sacral levels. Hip dislocation was not inevitable even when there was maximal muscle imbalance about the hip. The average hip flexion contracture in children aged 9 to 11 years was significantly greater in those with thoracic (22 degrees) and L1/2 (33 degrees) levels than in those with L4 (9 degrees), L5 (5 degrees) or sacral (4 degrees) levels. Our findings indicate that muscle imbalance is not a significant factor in the production of flexion deformity or dislocation of the hip; both are commonly seen in the absence of imbalance. The restoration of muscle balance should no longer be considered to be the principal aim of the management of the hip in children with myelomeningocele

The changes in serum adjusted ionised calcium and parathyroid hormone (PTH) were prospectively studied in 32 patients with isolated tibial fractures, treated conservatively. We measured serum albumin, adjusted total calcium, phosphate, pH, adjusted ionised calcium and PTH at intervals until the fractures had healed. The mean ionised calcium adjusted for pH fell within 24 hours of injury, and then rose to a peak at between four and six weeks. These changes cannot be explained by changes in serum pH or PTH. The restoration of normal ionised calcium levels after fracture coincided with the period when the callus was being calcified. Analysis of the changes in ionised calcium, phosphate and PTH suggests that PTH levels alter in response to changes in ionised calcium levels. PTH is highest immediately after fracture and lowest, often not recordable, at six weeks. The cause of the changes in the ionised calcium level has yet to be elucidated

Aims

To compare patients undergoing total knee arthroplasty (TKA) with ≤ 80° range of movement (ROM) operated with a 2 mm increase in the flexion gap with matched non-stiff patients with at least 100° of preoperative ROM and balanced flexion and extension gaps.

The results of 63 operative repairs of chronic tears of the rotator cuff in 61 patients are reviewed retrospectively; the mean follow-up was 32.7 months. Fifty-four patients presented with symptoms of persistent pain and seven patients with gross loss of movement. All the patients had failed to respond to conservative treatment. Results were assessed in terms of relief of pain, restoration of movement, the patients' ability to return to work and whether they were satisfied with the results. Overall, a good result in terms of relief of pain was achieved in 40 shoulders. In 31 shoulders (30 with pain and one without pain) the operation included particular measures to decompress the subacromial space; 26 of the patients achieved relief of pain which was significantly better than in those patients whose operation did not include a decompression. The complications and failures are discussed. It is suggested that operative repair of the chronically torn rotator cuff of the shoulder is a worthwhile operation and that the operation should include an adequate decompression of the subacromial space

Fifty-five patients with severe pain from spinal instability secondary to metastatic cancer were referred to Hope Hospital, none being judged to be in a terminal condition. One patient had too extensive disease for surgery so 54 were treated by 55 spinal stabilisations; 49 obtained complete relief of pain and two had partial relief. There were three failures. Twenty-eight of the patients had clinical evidence of spinal cord or cauda equina compression and were decompressed at the time of stabilisation. Of these, 20 had major recovery of neurological function. Patients with pre-operative evidence of extradural tumour had 'prophylactic' decompression at the time of stabilisation; none of these patients later developed signs of cord or cauda equina compression. The results suggest that alleviation of pain and restoration of mobility are best achieved by segmental spinal stabilisation; a few patients require a combined anterior and posterior stabilisation. Postoperative radiotherapy should be given whenever possible, and the causative tumour should be treated by endocrine or chemotherapy, as indicated

We performed ulnar nerve neurolysis and transposition during reconstructive operations on 20 consecutive patients (21 elbows) with neuropathy after the failure of primary treatment of elbow fractures. There were 11 men and nine women with a mean age of 48.3 years. Preoperatively, four elbows were in McGowan stage I, seven in stage II and ten in stage III and the mean Gabel and Amadio ulnar nerve score was 3.2. At a mean follow-up of 32.1 months (24 to 67) we performed comprehensive neurological, functional, electrophysiological and outcome assessments. Patient satisfaction was high with good pain relief and restoration of hand strength and dexterity. The mean Gabel and Amadio score had improved to 6.5, an improvement of 3.3. There were one excellent, 16 good, 2 fair and 2 poor results; both of the last were due to failure of the underlying elbow reconstruction. Even for advanced stage-II and stage-III lesions we achieved good function, return of intrinsic power, and a high rate of patient satisfaction