1. The literature on pigmented villonodular synovitis has been reviewed and a series of eighty additional cases is reported. 2. The condition usually presents either as a nodule in a finger or knee, or as a diffuse lesion in a knee. The lesions, although benign, sometimes erode or invade the tissue of adjacent bones. 3. Distinction from malignant synovioma can be made on the basis of the macroscopic appearance of the lesion at operation (relationship to joints or tendon sheaths: villonodular appearance: pigmentation), and by histological examination. 4. Treatment of the nodular form by excision is satisfactory but extensive synovectomy for diffuse lesions of the knee gives poor results. 5. The etiology of pigmented villonodular synovitis is unknown, but it appears to be a self-limiting process, possibly inflammatory in nature

1. A series of eighty-one hips with slipped upper femoral epiphysis in sixty-three patients is reviewed. 2. The importance of early diagnosis is emphasised. 3. Conservative treatment is condemned. 4. In attempting reduction violent manipulation and strong traction must be avoided. 5. In cases of slight displacement pinning in the position of displacement gives the best results. 6. Three or four small pins are recommended for fixation. 7. When the amount of slip is 50 per cent or more of the diameter of the head gentle manipulation should be tried and, if successful, followed by fixation with three or four pins. 8. The hip with an irreducible slip of 50 per cent or more should be treated by pertrochanteric or subtrochanteric osteotomy

Ninety-eight fractures of the shaft of the femur were seen in one unit over the two years 1974 and 1975, and the results have been assessed in sixty-nine. Of these, thirty-eight were treated by skeletal traction in a Thomas's splint followed by skin traction, and thirty-one by skeletal traction followed by a cast-brace. The technique of application is described in some detail. The average time for application of the cast-brace was six weeks after the injury, the time in hospital eight weeks and the time till removal fifteen weeks. The patients selected for a cast-brace were in hospital for just over half the time of the others and their fractures on average united more quickly, though with some trouble from angulation of fractures of the uppermost third of the shaft. It is concluded that when used with all the judgment and skill it demands, the cast-brace method is a great advance in conservative treatment

We have investigated the effectiveness of the transplantation of bone-marrow-derived mononuclear cells (BMMNCs) with interconnected porous calcium hydroxyapatite (IP-CHA) on early bone repair for osteonecrosis of the femoral head. We studied 22 patients (30 hips) who had osteonecrosis with a minimum follow-up of one year after implantation of BMMNCs. The mean age at surgery was 41 years (18 to 64) and the mean period of follow-up was 29 months (19 to 48). In a control group, cell-free IP-CHA was implanted into a further eight patients (9 hips) with osteonecrosis of the femoral head and the outcomes were compared. A reduction in the size of the osteonecrotic lesion was observed subsequent to hypertrophy of the bone in the transition zone in the BMMNC group. In three patients in the treatment group progression to extensive collapse was detected. In the control group subtle bone hypertrophy was observed, but severe collapse of the femoral head occurred in six of eight hips. In this limited study the implantation of BMMNCs and IP-CHA appears to confer benefit in the repair of osteonecrosis and in the prevention of collapse

We retrospectively studied local recurrence of giant cell tumour in long bones following treatment with curettage and cementing in 137 patients. The median follow-up time was 60 months (3 to 166). A total of 19 patients (14%) had at least one local recurrence, the first was diagnosed at a median of 17 months (3 to 29) after treatment of the primary tumour. There were 13 patients with a total of 15 local recurrences who were successfully treated by further curettage and cementing. Two patients with a second local recurrence were consequently treated twice. At the last follow-up, at a median of 53 months (3 to 128) after the most recent operation, all patients were free from disease and had good function. We concluded that local recurrence of giant cell tumour after curettage and cementing in long bones can generally be successfully treated with further curettage and cementing, with only a minor risk of increased morbidity. This suggests that more extensive surgery for the primary tumour in an attempt to obtain wide margins is not the method of choice, since it leaves the patient with higher morbidity with no significant gain with respect to cure of the disease

We reviewed 80 shoulders (77 patients) at a mean follow-up of 44 months after insertion of a Grammont inverted shoulder prosthesis. Three implants had failed and had been revised. The mean Constant score had increased from 22.6 points pre-operatively to 65.6 points at review. In 96% of these shoulders there was no or only minimal pain. The mean active forward elevation increased from 73° to 138°. The integrity of teres minor is essential for the recovery of external rotation and significantly influenced the Constant score. Five cases of aseptic loosening of the glenoid and seven of dissociation of the glenoid component were noted. This study confirms the promising early results obtained with the inverted prosthesis in the treatment of a cuff-tear arthropathy. It should be considered in the treatment of osteoarthritis with a massive tear of the cuff but should be reserved for elderly patients

We report the six-year results of a prospective, controlled demographic trial of developmental dysplasia of the hip (DDH) treated in the Pavlik harness using ultrasound supervision. Our aim was to assess the value of ultrasound and its role in monitoring reduction in the harness, in terms of progression or failure of reduction at an early state. From 1988 to 1994, a total of 221 patients with 370 ultrasonographically abnormal hips was treated in the Pavlik harness. This represents a treatment rate for the Southampton district of 5.1 per 1000 live births. Sixteen hips in 12 patients were not reduced in the harness and required surgical treatment; 95.7% were successfully reduced. One case of mild avascular necrosis (0.3%) was identified in those treated by harness alone. Of the 221 patients 87.8% remain under radiological review, with 3.2% of affected hips showing continued, mild acetabular dysplasia. We conclude that ultrasound monitoring has led to an acceptably low level of intervention, a high reduction rate and minimal iatrogenic complications. The trial is continuing

The results obtained with a lightweight dynamic axial fixator in the treatment of fractures are reported. The apparatus comprises a single bar with articulating ends which clamp self-tapping screws and can be locked at an angle appropriate for axial alignment. A telescopic facility allows ready conversion from rigid to dynamic fixation once periosteal callus formation has commenced. Reduction and controlled distraction or compression are achieved by means of a detachable compressor unit. We treated 288 patients with fresh fractures and 50 with ununited fractures. The success rate for fresh fractures was 94%, with average healing times ranging from 3.4 to 6.5 months. In ununited fractures also, the success rate was 94% with average healing times ranging from 4.7 to 6.5 months. Complications were minimal. The device is versatile and can be applied in an average of 15 minutes. It permits ambulatory fracture care without sacrificing a sound anatomical result

We have systematically reviewed the effect of alternative methods of stabilisation of open tibial fractures on the rates of reoperation, and the secondary outcomes of nonunion, deep and superficial infection, failure of the implant and malunion by the analysis of 799 citations on the subject, identified from computerised databases. Although 68 proved to be potentially eligible, only eight met all criteria for inclusion. Three investigators independently graded the quality of each study and extracted the relevant data. One study (n = 56 patients) suggested that the use of external fixators significantly decreased the requirement for reoperation when compared with fixation with plates. The use of unreamed nails, compared with external fixators (five studies, n = 396 patients), reduced the risk of reoperation, malunion and superficial infection. Comparison of reamed with unreamed nails showed a reduced risk of reoperation (two studies, n = 132) with the reamed technique. An indirect comparison between reamed nails and external fixators also showed a reduced risk of reoperation (two studies) when using nails. We have identified compelling evidence that unreamed nails reduced the incidence of reoperations, superficial infections and malunions, when compared with external fixators. The relative merits of reamed versus unreamed nails in the treatment of open tibial fractures remain uncertain

1. A total of 120 Moore's arthroplasties in 111 patients were reviewed one to nine years after operation. 2. There was striking reduction in the severity of pain in 105 out of the 120 hips reviewed. Range of movement was improved in most patients but the degree of independence was improved less often. The reasons for this are discussed. 3. We draw the following conclusions regarding the place of Moore's arthroplasty. Firstly, it was a natural step in the evolution towards total hip replacement, an operation which promises to give more complete relief of symptoms and which seems likely to replace Moore's arthroplasty as the treatment of choice in osteoarthritis of the hip in the elderly. Secondly, Moore's arthroplasty is still a rational procedure for the treatment of degeneration if the acetabulum is not involved—for instance, in idiopathic avascular necrosis of the femoral head. Thirdly, it is certainly a valuable operation for some cases of recent fracture of the femoral neck. Avascular necrosis of the femoral head after trifin nailing can be satisfactorily treated by Moore's arthroplasty, particularly in the early stages before the acetabulum becomes involved. Finally, Moore's arthroplasty gave many fairly elderly patients considerable relief of pain at a time when nothing better was available. Much of the relief afforded has proved to be lasting, but deterioration sometimes occurred with time. In the few patients whose deterioration amounted to failure a definite cause for the failure was found. In the majority the deterioration was slight, and it seems likely that the operation will last most of these elderly patients for the rest of their lives

Aims

Loosening of pedicle screws is a major complication of posterior spinal stabilisation, especially in the osteoporotic spine. Our aim was to evaluate the effect of cement augmentation compared with extended dorsal instrumentation on the stability of posterior spinal fixation.

Aims

We present a case series of five patients who had revision surgery following magnetic controlled growing rods (MGCR) for early onset scoliosis. Metallosis was found during revision in four out of five patients and we postulated a mechanism for rod failure based on retrieval analysis.

Our study describes the mid-term clinical results of the use of transtrochanteric valgus osteotomy (TVO) for the treatment of osteoarthritis of the hip secondary to acetabular dysplasia. The operation included valgus displacement at the level of the lesser trochanter, and lateral displacement of the greater trochanter by inserting a wedge of bone. We reviewed 70 hips. The mean age of the patients at operation was 44 years (14 to 59). Most (90%) had advanced osteoarthritis. The scores for pain and gait had improved significantly at a mean follow-up of 9.4 years. The rate of survival until an endpoint of a further operation during a follow-up of ten years was 82%. The survival rate was 95% in patients with unilateral involvement who were less than 50 years of age at operation. TVO is a useful form of treatment for advanced osteoarthritis of the hip, particularly in young patients with unilateral disease

We describe the mid-term clinical results of the surgical treatment of primary degenerative arthritis of the sternoclavicular joint in eight women. They had not responded to conservative treatment and underwent a limited resection arthroplasty. For pre-and postoperative clinical evaluation we used the Rockwood score for the sternoclavicular joint. Postoperatively, the Constant score was also determined. The mean follow-up was 31 months (10 to 82). The median Rockwood score increased from 6 to 12.5 points. The median postoperative Constant score was 87 (65 to 91). Four patients had an excellent, three a good, and one a poor result. All patients were pleased with the cosmetic result. Resection arthroplasty is an effective and safe treatment for chronic, symptomatic degenerative arthritis of the sternoclavicular joint with a high degree of patient satisfaction

Aims

To present our experience of using a combination of intra-articular osteotomy and external fixation to treat different deformities of the knee.

We have evaluated the clinical outcomes of simple excision, ulnar lengthening and the Sauvé-Kapandji procedure in the treatment of deformities of the forearm in patients with multiple hereditary osteochondromas. The medical records of 29 patients (33 forearms) were reviewed; 22 patients (22 forearms) underwent simple excision (four with ulnar lengthening) and seven the Sauvé-Kapandji procedure. Simple excision increased the mean supination of the forearm from 63.2° to 75.0° (p = 0.049). Ulnar lengthening did not significantly affect the clinical outcome. The Sauvé-Kapandji technique improved the mean pronation from 33.6° to 55.0° (p = 0.047) and supination from 70.0° to 81.4° (p = 0.045). Simple excision may improve the range of movement of the forearm but will not halt the progression of disease, particularly in younger patients. No discernable clinical or radiological improvement was noted with ulnar lengthening. The Sauvé-Kapandji procedure combined with simple excision of osteochondromas can improve stability of the wrist, movement of the forearm and the radiological appearance

1. One hundred and seventy-three hips in 138 patients have been examined and studied in reference to the type of treatment received. 2. Shepherd's method of assessing the results of arthroplasty operations has been adapted to this series. 3. Satisfactory results were found in 77·9 per cent of all patients. 4. The value of straight longitudinal traction is questioned. Medial rotation appears to be an essential step in the reduction of the deformity. 5. Manipulation was found to be a relatively safe and effective method of reducing the deformity in patients seen soon after an acute episode, and should be reserved for them. 6. Complications were common after nailing operations, and included subtrochanteric fracture in three cases. 7. Avascular necrosis was the commonest cause of a poor result. The two types of avascular necrosis are discussed. 8. Avascular necrosis was found in 37 per cent of cases in which a manipulation was followed by a nailing operation. 9. Avascular necrosis was not found in any case in which a manipulation was combined with the use of Moore's pins, but such cases were kept under observation for a shorter time. 10. Avascular necrosis was found in 38·1 per cent of cases of cervical osteotomy

We undertook a prospective, randomised study to compare the analgesic effect of injection of steroid and of extracorporeal shock-wave therapy (ESWT) for the treatment of tennis elbow. Group 1 received a single injection of 20 mg of triamcinolone with lignocaine while group 2 received 2000 shock waves in three sessions at weekly intervals. After six weeks there was a significant difference between the groups with the mean pain score for the injection group falling from 66 to 21 compared with a decrease from 61 to 35 in the shock-wave group (p = 0.05). After three months, 84% of patients in group 1 were considered to have had successful treatment compared with 60% in group 2. In the medium term local injection of steroid is more successful and 100 times less expensive than ESWT in the treatment of tennis elbow

1. Almost all patients with osteoarthritis of the hip who consult the surgeon do so because they wish to be relieved of pain. They all have limitation of movement in varying degrees but most of them will be either unaware of it or will have accepted it. What is more important, they would not have sought medical advice because of stiffness if there had been no pain. The primary objective of operative treatment must therefore be to relieve pain. 2. Displacement osteotomy will give substantial relief from pain in a high proportion of cases and the relief is lasting. Perhaps that explains why this operation, advocated by McMurray and Malkin twenty-five years ago, is being practised more widely than ever to-day while its competitors (neurectomy, capsulectomy, arthroplasty) have steadily diminished in popularity. 3. The disadvantages of the operation are all related to post-operative immobilisation in plaster, which may induce further stiffness of the hip, even to the extent of ankylosis, or stiffness and pain in the knee. These disadvantages may be overcome to a considerable degree by internal fixation followed by sling suspension and early active movement. But when, under anaesthesia, the range of hip flexion is reduced to 45 degrees or less, the operation is always liable to result in ankylosis, and it is wise in these circumstances to take this possibility into account and warn the patient beforehand

Seven children with a post-traumatic cubitus varus deformity were treated using the Ilizarov technique of distraction osteogenesis. The outcome was rated as excellent in each case and all were satisfied with the cosmetic appearance. No complications had been encountered by the latest follow-up at a mean of 66.7 months. This technique seems reliable for the treatment of such deformities, provided that it achieves full correction by gradual distraction. Nerve palsy and unsightly scars are avoided, and the range of movement of adjacent joints is preserved