1. Sixty-five cases of medial fracture of the femoral neck treated by substitution of the head by an acrylic prosthesis have been studied. 2. In general, the long-term clinical results of prosthetic arthroplasty after fresh fractures have been disappointing. The method has given slightly better results in the treatment of old fractures. 3. In view of the almost perfect results obtained after successful Smith-Petersen nailing in the presence of an adequate blood supply to the femoral head, it seems unjustifiable to abandon this principle for immediate substitution with an acrylic femoral head. Nevertheless it is believed that an arthroplasty of this type is justified in fractures seen late, and in fresh subcapital fractures when the fracture is irreducible. If a prosthesis is to be used, more protection for the stump of the neck against the strain of weight bearing is essential; a simple head prosthesis is inadequate, and a head with either a neck extension or an intramedullary prolongation may give better results

1. The rate of non-union of 100 intertrochanteric osteotomies of the McMurray type, with internal fixation, is reported. One in five was not united one year after operation. The criteria of union are discussed. 2. The patient's disability in twelve ununited osteotomies has been assessed, and related to the mobility of the osteotomy. 3. The factors which prejudice union have been analysed. The principal cause of non-union appeared to be the varus angulation strain on a varus osteotomy displaced medially more than half the diameter of the bone. Obliquity inwards and upwards of the osteotomy was a contributory factor. The types of internal fixation used, the use of external splintage and the period of protected weight bearing with crutches did not appear to be related to the rate of union. 4. It is concluded that marked inward displacement of the osteotomy, combined with either obliquity of the osteotomy or a varus position, prejudices union; that the use of this technique is unfounded in principle and not supported empirically; and that displacement should be eschewed to avoid this complication of intertrochanteric osteotomy in the treatment of osteoarthritis of the hip

1. A family is described of which several members in four generations suffered epiphysial growth disturbances of an unusual kind in the capital epiphyses of the femur, with shortness of stature. 2. This disorder forms one of a group of epiphysial growth disturbances which embraces several recognised disorders, whose effects on the epiphyses vary in severity. They may occur sporadically or they may be inherited as recessive or dominant characters. 3. Differentiation depends on the behaviour of the joint line–in other words, whether the epiphysis starts to show defects through inability to sustain the stress of weight bearing. In the most serious cases the picture is that of Morquio-Brailsford's disease; when the changes are less severe the appearance may be that of bilateral Perthes' disease. Differential diagnosis is no longer possible in later life, because the ultimate condition of the defective femoral heads is the same. Only in the hereditary cases is one able, by studying the capital epiphyses of the hip in childhood, to differentiate between the changes like those of Perthes' disease on the one hand, and micro-epiphysial dysplasia without necrosis on the other

1. Bones consist essentially of bundles of collagenous fibres united by a cementing substance in which the inorganic material lies in the form of minute plate-like crystals. 2. During weight bearing and muscle action bones as a whole are deformed to a variable extent. Periods of deformation are followed by periods of relaxed pressure during which the bones tend to return to their normal form. 3. These variations in deformation and elastic recoil set up alternating pressures and tensions within the bones along the bone cyrstal encrusted fibres which make up the trabeculae, lamellae and Haversian systems, and these alternating phases of compression and tension stimulate the activity of osteoblasts so that bone formation predominates over bone resorption. 4. These alterations of pressure and tension are intermittent and reciprocal in nature and do not, as postulated by the trajectorial theory, involve different trabeculae, nor is it necessary to consider whether tension or pressure is the more important phase in determining bone deposition. 5. The pressure exerted by cysts, tumours, erupting teeth, etc., is of a quite different nature, as is the response to trauma or callus formation in the healing of fractures. These processes are essentially vascular phenomena involving localised areas of bony tissue and not bones as mechanical units

1. Posterior fusion of the spine in scoliosis cannot be relied upon to maintain correction of the curve or to prevent progression of a vicious resistant curve. It can, however, hold to some extent the correction of a mobile curve and the compensation of a fixed curve. 2. Despite generally poor results as assessed radiographically, the clinical improvement is often gratifying. Most patients claim to be greatly improved: the spine feels stronger, there is less fatigue, and balance is better controlled. Moreover, visible deformity may be improved markedly even though the anatomical correction as observed radiographically is slight (Figs. l0 and 11). 3. It is believed that the true cause of relapse is that the bone formed from sliver grafts remains immature for a long time. Even when incorporated with the immature bone of the child's spine or the mature bone of the adult spine, it remains soft and resilient. When subjected to the stresses and strains of weight bearing and gravity, and then to the unnatural forces which initiated or perpetuated the scoliosis, this immature bone undergoes remodelling to Wolff's Law—like the neck of the femur after slipping of the upper femoral epiphysis. The forces that alter the grafted bone are not only lateral forces but also—perhaps more important—rotational forces. There seems to be a definite link between the degree of rotation and the amount of relapse, correction being maintained best when rotation is least

What is the present position? There is no doubt that the meaning of Kleinberg and Lieberman has been misconceived. With the passing of years their cautious conclusion concerning the acetabular index has been transformed into a firm conviction. Even so, it is apparent from the literature that the use of the acetabular index is a matter of controversy, and that, to a lesser degree, the normal values of the index are a matter of debate. It is concluded that the measurement is not an absolute index of a predisposition to congenital dislocation of the hip and cannot be divorced from other radiological signs. Nevertheless, so long as there is a feeling of uncertainty about the most reliable early signs of congenital dislocation of the hip, it would be folly to ignore a high acetabular index, especially in an infant over six months of age. It seems that to radiograph every infant at birth is not justified. The radiological signs at birth are not only unreliable because of problems of technique, but also equivocal because of the small size of the structures and the fact that they consist largely of cartilage. Until the radiographic technique is standardised it would be advisable to continue to regard 30 degrees as the upper limit of normal for the acetabular index in the newborn. To make recommendations concerning treatment is beyond the scope of this paper. Nevertheless it is worth stating that the presence of a high index alone is not necessarily regarded as an indication for immediate treatment. But an infant found to have a high acetabular index should be kept under close observation and should be thoroughly examined at regular intervals before the beginning of full weight bearing

1. The synovial membrane and capsule in osteoarthritis of the hip have been studied in twenty-five cases. Dissections have been made on fresh cadavers to establish the normal structure and function of these tissues at different ages. 2. Fragments of bone and cartilage were found beneath the synovial surface in twenty-three cases of the twenty-five cases of osteoarthritis. 3. The source of these fragments is the degenerate articular surfaces. 4. The fibrosis of the synovial membrane and capsule follows the synovial hyperplasia which accompanies the phagocytosis of these fragments. 5. A similar histological picture has been produced by injecting fragmented cartilage into the knee joints of rabbits. The injected fragments are found beneath the surface, and synovial hyperplasia is followed by subsynovial fibrosis. 6. The greatest amount of this joint debris is found in the lowest part of the joint cavity. 7. The joint capsule is particularly sensitive to traction. 8. All parts of the capsule are tight in extension, which is the weight-bearing position. 9. Fibrotic shortening of the capsule in the lowest part of the joint cavity explains many of the symptoms and signs of the disease: pain is caused by an attempt to stretch the capsule; muscle spasm occurs in the muscles supplied by the sensory nerves of this part of the capsule; extension, medial rotation and abduction, which tighten this area, are lost first; progressive shortening causes deformity in the opposite direction, namely flexion, lateral rotation and adduction; the loss of extension causes a more rapid wearing of articular cartilage on weight bearing; subperiosteal new bone is formed on the under-surface of the neck of the femur. 10. The symptomatology is discussed

Aims

The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome.

1 . The results of compression arthrodesis of the hip have been studied in fifty-six patients. There was one post-operative death from pulmonary embolism on the tenth day. 2. Bony union for the whole series (fifty-five patients) was achieved in 76·4 per cent. Sound fibrous ankylosis, indistinguishable from bony union clinically and functionally, was achieved in 10·9 per cent. Residual movement occurred in 12·7 per cent. 3. Thirty-five patients were treated by the standard technique of eight weeks in plaster, followed by full weight bearing, irrespective of whether any movement was detected on clinical testing. 82·8 per cent achieved sound bony union; 5·7 per cent achieved sound fibrous ankylosis, and residual movement occurred in 11·4 per cent. 4. Ten patients were treated without plaster protection; six achieved bony union; three had sound fibrous ankylosis and one had residual movement. Healing was delayed in this group and there was more residual deformity. 5. 67·5 per cent of all patients recovered full knee range. Only one patient with reduced range had knee flexion of less than 90 degrees. Twenty-four of the thirty-five patients treated by the standard technique of eight weeks in plaster were examined. Fifteen had full knee movement; in only four was knee flexion less than 120 degrees and in no case was it less than 90 degrees. 6. Return to full activity was rapid. Sixty per cent of patients returned to work within six months and 80 per cent within nine months of surgery. Five of the six patients examined with residual movement in the hip joint were back at work within six months of surgery. 7. This study lends support to the view that arthrodesis of the hip, in the presence of normal function in the opposite hip, is compatible with vigorous and full activity

Dr J. Robert Close has been good enough to point out a misquotation from his article, "Some Applications of the Functional Anatomy of the Ankle Joint"(Journal of Bone and Joint Surgery, 1956, 38-A, 761) in a later contribution by Mr M. G. H. Smith entitled "Inferior Tibio-fibular Diastasis Treated by Cross-screwing (Journal of Bone and Joint Surgery, 1963, 45-B, 737). Dr Close, in referring to tibio-fibular diastasis and deltoid ligament rupture with low fractures of the fibula, wrote (p. 780), "Treating diastasis therefore frequently means treatment for the deltoid lesion. When one realises that a certain amount of spreading apart of the malleoli and a certain amount of rotation of the fibula about the tibia are anatomical requirements for normal ankle motion the necessity for later removal of such internal fixation becomes obvious. Screws thus placed have been known to break during normal walking after the fractures have healed." In his paper Mr M. G. H. Smith, making mention of tibio-fibular movement, wrote, "This small range of movement of the fibula at the inferior tibio-fibular joint caused Close (1956) to recommend that screws placed across the joint to maintain reduction of diastasis be removed before weight bearing and movement were commenced. He stated that screws had broken when left in position." Further abbreviation by editorial staff led to the statement actually printed p. (737): "Close (1956) recommended the removal of screws that had been placed across the joint to maintain reduction of diastasis before movement was allowed, because the screws broke when left in position." The inadvertent change in sense unfortunately escaped attention, and we very much regret that Mr Close was thus misquoted

Aims

This study aims to enhance understanding of clinical and radiological consequences and involved mechanisms that led to corrosion of the Precice Stryde (Stryde) intramedullary lengthening nail in the post market surveillance era of the device. Between 2018 and 2021 more than 2,000 Stryde nails have been implanted worldwide. However, the outcome of treatment with the Stryde system is insufficiently reported.

1. Idiopathic necrosis of the femoral head is generally considered to be a rare disease but it appears to be rather frequent in France in view of the fact that 139 cases were recorded in the orthopaedic clinic of Hôpital Cochin between 1959 and 1963. Ninety cases treated by operation have been analysed in this paper. Men are nearly exclusively affected between the ages of eighteen and seventy, with the highest incidence between thirty and fifty years of age. Both hips are affected in 52 per cent of cases. 2. The etiology is unknown, but steroid therapy was noted in 36 per cent of the cases and some history of slight injury in 30 per cent. The sudden onset of pain in half the cases suggests the obliteration of one of the blood vessels supplying the femoral head. 3. Radiographs are often normal at the time of onset of the symptoms but later they show increased density of the head localised to the antero-superior aspect, and later still collapse of this weight-bearing region. The extent of the lesion appears to be determined from the very beginning rather than to be progressive. The superior joint space is never reduced and may in fact be widened. 4. Pathological examination of the head and neck confirms necrosis of the cancellous bone and the integrity of the overlying cartilage, but shows deep to the necrotic region a highly reactive zone characterised by hypervascularity and raised metabolism. These features have been demonstrated by injection of the blood vessels and also by the uptake of phosphorus 32 and by the succino-deshydrogenase test. 5. In six cases microscopic vascular lesions were found in the antero-lateral pedicle of the femoral head. 6. The high degree of activity of the tissue deep to the necrotic zone gives some hope for revascularisation of the necrotic segment. For this reason protection from pressure may be the way to prevent dramatic collapse of the head. Rest, medical treatment and freedom from weight bearing, however, do not achieve adequate protection. Varus or rotation osteotomy of the femoral neck not only gives relief from pain but appears to prevent collapse of the femoral head. 7. When destruction of the head has already taken place good results may be expected from the insertion of a metallic prosthesis, provided the acetabulum is sound. The results are less favourable when the acetabulum has been altered by secondary arthritic change, and arthrodesis may have to be considered if the disease is unilateral or when a prosthesis has been successfully inserted on the other side

1. The results of treatment of 134 patients with congenital dislocation of 167 hips are reviewed. 2. Late diagnosis is still a major problem. 3. Subluxations rarely give rise to poor results, but in dislocations first treated over the age of five years there is a one-in-three risk of failure. 4. Manipulative reduction is successful less often than reduction on a frame and carries a higher risk of avascular necrosis. 5. Closed reduction on a frame was satisfactory in 58 per cent of patients under the age of three years, and can succeed up to the age of five. 6. Open reduction was required in 20 per cent of cases under the age of three, and can be used successfully up to the age of six. 7. Seven anatomical barriers to closed reduction have been recognised and two or more are commonly found in one hip when open reduction is performed. 8. The acetabular roof may fail to develop after reduction, especially if this is delayed. A C.E. angle of under 20 degrees does not necessarily forebode this, unless measured on an arthrograph. Sclerosis of a sloping acetabular roof is an indication for operation. Acetabuloplasty is the proper operation for a sloping acetabulum and can be done successfully up to the age of twelve. Over this age, a shelf operation should be performed; this is appropriate also in younger patients in whom the curvature of the acetabulum is normal but does not extend far enough laterally. These operations were required in 38 per cent of hips treated in patients under the age of three, and in 64 per cent over this age. There is a one-in-three risk of avascular necrosis when acetabular reconstruction is done in patients under three. 9. Anteversion, if excessive, should be corrected by subtrochanteric osteotomy, and any valgus of the femoral neck should be corrected simultaneously. 10. Unilateral dislocations in patients over the age of six are best treated by Colonna's operation. In our few bilateral cases over this age our results have been disappointing. 11. Avascular necrosis is less common but more serious when it occurs over the age of three. Manipulative reduction and the use of frog-leg plasters are two avoidable factors which appear to increase its incidence. The more serious degrees are accompanied by stiffness of the hip, and when this sign is present weight bearing should be avoided. 12. Prolonged, though rarely permanent, limitation of movement occurs in some 10 per cent of cases. In a few, operative correction was required

Aims

We compared the clinical outcomes of curved intertrochanteric varus osteotomy (CVO) with bone impaction grafting (BIG) with CVO alone for the treatment of osteonecrosis of the femoral head (ONFH).

Aims

There is an increased risk of dislocation of the hip after the resection of a periacetabular tumour and endoprosthetic reconstruction of the defect in the hemipelvis. The aim of this study was to determine the rate and timing of dislocation and to identify its risk factors.

Aims

This exploratory randomized controlled trial (RCT) aimed to determine the splint-related outcomes when using the novel biodegradable wood-composite splint (Woodcast) compared to standard synthetic fibreglass (Dynacast) for the immobilization of undisplaced upper limb fractures in children.

Aims

The aim of this prospective multicentre study was to describe trends in length of stay and early complications and readmissions following unicompartmental knee arthroplasty (UKA) performed at eight different centres in Denmark using a fast-track protocol and to compare the length of stay between centres with high and low utilization of UKA.

Aims

Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP.