1. A method of arthrodesis of the ankle is described which combines the compression principle of Charnley with the medial approach to the joint described by Pridie.

2. Fusion occurred promptly in seventeen out of nineteen cases. In one case fusion was delayed, and in one case there was failure of fusion.

1. Sixty-nine patients with degenerative disease of the hip joint were treated by intra-articular arthrodesis using secure internal fixation. External fixation with plaster was not used and the patients were mobilised on crutches after a mean interval of 3·2 weeks. Radiologically evident bony union occurred in 87 per cent of cases. Among the nine patients (13 per cent) who failed to show union only three complained of persistence of severe symptoms.

2. The only significant complication was fracture of the upper femoral shaft in three cases (4·3 per cent). However, this has not occurred since a small plate was used in addition to the nail.

3. The disadvantages of the routine use of plaster fixation are discussed and are contrasted with the advantages of early mobilisation without plaster.

4. Whereas this series does not show a rate of fusion as good as that in the best reported series, it supports the view that arthrodesis of the hip offers the most certain, reliable and efficient means of treatment for severe unilateral degenerative disease of that joint.

It will be seen that the proportion of successful fusions in this series of ninety-five patients treated by ischio-femoral arthrodesis of the hip was over 80 per cent. Similar percentages of successful fusion have been reported by Knight (1945), Freiberg (1946), Langston (1947), and Nisbet, who was resident surgical officer at the Robert Jones and Agnes Hunt Orthopaedic Hospital, and informed me in a personal communication that he had carried out twenty-six operations with an approximate fusion rate of 80 per cent. He stated: "It is the only operation which gives a reasonable chance of a successful arthrodesis in children. Up till now at Oswestry the chances of a fusion by the other methods in children have proved so disappointing that the operation had been abandoned. Dame Agnes Hunt, with her vast experience of the condition, was always very annoyed when she found a surgeon trying to fuse a child's hip. All this has been changed."

A combined anterior and posterior surgical approach is generally recommended in the treatment of severe congenital kyphosis, despite the fact that the anterior vascular supply of the spine and viscera are at risk during exposure. The aim of this study was to determine whether the surgical treatment of severe congenital thoracolumbar kyphosis through a single posterior approach is feasible, safe and effective.

We reviewed the records of ten patients with a mean age of 11.1 years (5.4 to 14.1) who underwent surgery either by pedicle subtraction osteotomy or by vertebral column resection with instrumented fusion through a single posterior approach.

The mean kyphotic deformity improved from 59.9° (45° to 110°) pre-operatively to 17.5° (3° to 40°) at a mean follow-up of 47.0 months (29 to 85). Spinal cord monitoring was used in all patients and there were no complications during surgery. These promising results indicate the possible advantages of the described technique over the established procedures. We believe that surgery should be performed in case of documented progression and before structural secondary curves develop. Our current strategy after documented progression is to recommend surgery at the age of five years and when 90% of the diameter of the spinal canal has already developed.

Cite this article: Bone Joint J 2013;95-B:1527–32.

1. A study is presented of 286 extra-articular subtalar arthrodeses done during the years 1958 to 1965 on 258 patients with pes calcaneo-valgus, pes planovalgus, pes varus or flail foot.

2. Certain changes in the surgical technique originally presented by Grice have been made. We have applied the arthrodesis not only to valgus feet but also to varus feet, and we have described the details of the surgical technique as used on the varus foot.

3. In none of our cases was there failure of fusion or reabsorption of the graft. The unsatisfactory results (239 per cent) were caused by residual varus or valgus deformity of the foot.

1. A modification of the Grice extra-articular subtalar arthrodesis is described.

2. The results of this operation are presented.

1. A series of twenty-three compression arthrodeses of the shoulder are reviewed.

2. The review demonstrates compression arthrodesis to be an excellent method of obtaining bony fusion of the shoulder.

3. The consistent success in achieving arthrodesis, in what is to be considered a difficult joint to fuse, is significant in the theory of compression arthrodesis, because the shoulder offers a more perfect example of compression arthrodesis than the knee in that the element of absolute fixation is less obvious.

One hundred cases of Lambrinudi's arthrodesis are reviewed. The shortest follow-up was one year. and the longest twenty-seven years. Thirty-seven per cent were successful. Nineteen per cent were failures; many of these were associated with faulty technique, and one method of operation which gives good results is described.

Success is likely if there is a balance of power between the dorsiflexors and plantarflexors of the ankle, especially if there is some fixed equinus before operation.

Success is less likely when the operation is done for a flail foot. In such circumstances arthrodesis of the ankle may have to be considered subsequently for instability of the lateral ligament, recurrence of dropfoot, or arthritis which may develop in the more active patients.

Age in itself is no bar to success, but pseudarthrosis is more likely to occur in patients over the age of twenty.

A method of intra-articular arthrodesis of the hip is described in which fixation is obtained with a lag-screw. Two main advantages are claimed: first, that it is a compression arthrodesis and gives early bony fusion; and second, that it gives adequate internal fixation in most cases so that the disadvantages of a plaster hip spica are avoided, and the patient may walk with crutches two or three weeks after the operation.

The results were satisfactory in forty-seven of the first fifty cases in which this method of arthrodesis was employed. There were two post-operative deaths and one failure to secure fusion in a case of massive necrosis of the femoral head.

1. The results of compression arthrodesis of the ankle performed on fifty-five patients (four bilateral) are presented.

2. Fifty per cent of these ankles were immobilised for a total period of no more than eight weeks.

3. Bony fusion occurred in 91 per cent.

4. The subjective result was good or excellent in 88 per cent.

5. The theoretical disadvantages of the transverse incision are not serious in practice.

6. The best position for arthrodesis of the ankle is at, or close to, the right angle.

1. A simple and effective method of wrist arthrodesis is described. Originally designed for the correction of flexion deformity of the wrist, it is useful also as a routine method of wrist fusion.

2. The results in nineteen cases are reviewed.

The technique of the transfibular approach for arthrodesis of the ankle joint is described. The results of this operation in a series of thirty cases shows that the procedure is reliable if the technique is carried out faithfully. The two cases in which a first operation failed can both be explained by errors of technique or after-treatment.

Transarticular screw fixation with autograft is an established procedure for the surgical treatment of atlantoaxial instability. Removal of the posterior arch of C1 may affect the rate of fusion. This study assessed the rate of atlantoaxial fusion using transarticular screws with or without removal of the posterior arch of C1. We reviewed 30 consecutive patients who underwent atlantoaxial fusion with a minimum follow-up of two years. In 25 patients (group A) the posterior arch of C1 was not excised (group A) and in five it was (group B). Fusion was assessed on static and dynamic radiographs. In selected patients CT imaging was also used to assess fusion and the position of the screws. There were 15 men and 15 women with a mean age of 51.2 years (23 to 77) and a mean follow-up of 7.7 years (2 to 11.6). Stable union with a solid fusion or a stable fibrous union was achieved in 29 patients (97%). In Group A, 20 patients (80%) achieved a solid fusion, four (16%) a stable fibrous union and one (4%) a nonunion. In Group B, stable union was achieved in all patients, three having a solid fusion and two a stable fibrous union. There was no statistically significant difference between the status of fusion in the two groups. Complications were noted in 12 patients (40%); these were mainly related to the screws, and included malpositioning and breakage. The presence of an intact or removed posterior arch of C1 did not affect the rate of fusion in patients with atlantoaxial instability undergoing C1/C2 fusion using transarticular screws and autograft.

Cite this article: Bone Joint J 2013;95-B:972–6.

Correction of valgus deformity of the hindfoot using a medial approach for a triple fusion has only recently been described for patients with tight lateral soft tissues which would be compromised using the traditional lateral approach. We present a series of eight patients with fixed valgus deformity of the hindfoot who had correction by hindfoot fusion using this approach.

In addition, we further extended the indications to allow concomitant ankle fusion. The medial approach allowed us to excise medial ulcers caused by the prominent medial bony structures, giving simultaneous correction of the deformity and successful internal fixation.

We had no problems with primary wound healing and experienced no subsequent infection or wound breakdown. From a mean fixed valgus deformity of 58.8° (45° to 66°) pre-operatively, we achieved a mean post-operative valgus angulation of 13.6° (7° to 23°). All the feet were subsequently accommodated in shoes. The mean time to arthrodesis was 5.25 months (3 to 9).

We therefore recommend the medial approach for the correction of severe fixed valgus hindfoot deformities.

We analysed the long-term results of arthrodesis of the shoulder after infection in 15 patients. At the time of operation, 14 cultures were positive for Staphylococcus aureus. The mean follow-up was 8.3 years (3 to 14) and 90% of the patients were satisfied with the outcome. There were complications in five patients (33%); in three there was nonunion with loosening of the implant. One patient had a sound bony union but with a persistent sinus six years after arthrodesis and another had a sinus which healed after the metal was removed. Four of these five patients (80%) were heavy smokers (> 20 cigarettes/day). Cancellous bone grafting did not affect the incidence of complications. The mean age of the patients with complications was 58.6 v 48.6 years for those without (p = 0.2808 ; not significant). Those with complications had had more previous operations (6.4 v 2.5, p < 0.05). Antibiotics, as determined by the bacteriological cultures, were administered for six weeks.

The complication rate was higher in patients with active sepsis but the younger the patient and the fewer number of previous operations (< 50 years, < four previous operations), the better was the outcome. Considering the rate of complications, we recommend early surgery in these patients.

The use of autograft bone is the best option when undertaking a procedure that requires bone graft because it is osteogenic, osteoconductive and osseo-inductive. Pain, morbidity and complications associated with harvesting iliac or non-iliac sites occur in between 6% and 30% of cases. An alternative source of graft with possibly a lower morbidity is the intramedullary canal. In this study, 28 patients undergoing 30 arthrodesis procedures on the hindfoot had a mean of 48 cm³ (43 to 50) of bone harvested locally from the hindfoot or the tibial shaft by antegrade or retrograde reaming. No patient sustained a fracture of the calcaneum, talus or tibia. There was no morbidity except for one complication when the reamer breached the medial tibial cortex. This healed uneventfully.

This method of using the reamer–irrigator–aspirator system is an extension of the standard technique of intramedullary reaming of the lower limb: it produces good-quality bone graft with viable growth factors consistent with that of the iliac crest, and donor site morbidity is low. This is an efficient method of obtaining autologous bone for use in arthrodesis of the ankle or hindfoot.