Clinical examinations and radiographic skeletal surveys have been carried out in 15 patients with foetal alcohol syndrome. Fusion of the capitate and hamate bones in the carpus was bilateral in one patient and unilateral in two. All three had accessory ossification centres at the proximal ends of both second metacarpals. Two of these patients also had radio-ulnar synostosis. Digital shortening, which was demonstrated by pattern profile analysis, was very variable in degree and anatomical distribution. Other skeletal changes of uncertain significance were a "beaten copper" appearance of the calvarium in four patients, and coxa valga in one other. Diagnosis of the foetal alcohol syndrome warrants consideration in any individual presenting with carpal fusion or with radio-ulnar synostosis

1. Grafts of joint cartilage from immature lambs were used to repair articular cartilage defects in other lambs and in adult sheep. 2. Stability of these grafts in a functional state was found in most for periods up to fourteen months. Although a limited homograft reaction occurred this did not lead to destruction of the cartilage, even though parts of it were well vascularised. 3. The results suggest that the process of endochondral ossification is associated with the liberation of antigenic material leading to sensitisation of the host. Destruction ofthe cartilage is prevented by an inhibitory action which the matrix appears to exert on the destructive elements themselves and which is itself dependent on the vitality of the chondrocytes. 4. The avascularity of cartilage is not a sufficient explanation for its privileged position in relation to the homograft reaction

Aims

Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort.

We describe the histology of a specimen taken from an amputated leg seven months after a 15 cm bone gap in the tibia had been closed by bone transport. Lengthening appeared to have occurred by repeated minor trauma to the bone, with the fractured trabeculae in sufficiently close contact for the repair process to proceed. Osteogenesis did not occur through a cartilage phase, but the fracture gaps were bridged by collagen fibres, around which new bone formed. Microfractures had repaired by primary healing with woven bone and with no microcallus. Small regions of bone were necrotic. Resorption of the necrotic bone and remodelling of the immature bundle and woven bone were still at an early stage, suggesting that complete remodelling in man may take years rather than months

A prospective randomised clinical trial was undertaken to compare biodegradable polyglycolic acid pins with standard Kirschner wires used to fix displaced elbow fractures in children. Twenty-four children were enrolled in the trial; 14 had fractures of the lateral condyle of the humerus, eight of the medial epicondyle and two had olecranon fractures. Eleven fractures were fixed with Kirschner wires and 13 with polyglycolic acid pins. Fracture union with full function occurred in all cases within six months. Kirschner wires caused problems including infection in three cases, soft-tissue ossification in one and they required removal under general anaesthesia in nine cases. No such complications occurred with polyglycolic acid pins but one patient in this group developed avascular necrosis and premature fusion of the medial epicondyle

We made a prospective longitudinal clinical and radiological study of 18 children diagnosed as having dysplasia epiphysealis capitis femoris. Half the cases were bilateral. Boys were affected five times more often than girls. There were no symptoms or clinical signs in most but some of the bilateral cases had an inconsistent waddling gait. The imaging studies suggest that the cartilaginous proximal femoral epiphysis is hypoplastic, with delayed appearance of single or multiple ossification centres. Progressive improvement occurred and at an average age of five years and six months, there was complete fusion of all the ossific nuclei and normal density and texture of the epiphyseal bone. The end result was a round epiphysis with a slightly diminished height. The dysplasia is attributed to focal hypoplasia of the proximal femoral epiphysis

In fifty-six patients with ankylosing spondylitis three types of arthroplasty had been performed in ninety-nine hips. Forty-one of the patients were men and fifteen were women, their average age at operation being forty-two years. Primary pseudarthrosis produced well-satisfied patients, but only a fair result in five hips, whereas cup arthroplasty resulted in a poor outcome for eight hips, all of which needed revision. Total replacement of eighty-six hips, however, led to 73 per cent being graded as good or excellent up to ten years later. The main complications were deep infection of five hips, para-articular ossification around nine hips (six leading to bony ankylosis), and fibrous ankylosis of six hips

1. Thirteen cases of congenital pseudarthrosis of the clavicle conforming to the classical picture are presented, together with five cases of pseudarthrosis occurring for various other reasons, and nine cases of congenital pseudarthrosis that form a special group because there was a strong family history. 2. Treatment, if desired by the patient, is easy, but should be deferred until the age of four or five years. 3. The etiology remains obscure. Our embryological study does not support the theory that the clavicle normally develops from two ossification centres that may fail to coalesce. Although in thirteen of our patients there was no family history of pseudarthrosis, there was another group of nine patients who presented a strong family history, and it seems certain that in some instances congenital pseudarthrosis of the clavicle can be transmitted genetically

The variability in measurement of angles in congenital scoliosis is not known, but it is postulated that it is larger than that in adolescent idiopathic scoliosis due to skeletal immaturity, incomplete ossification, and anomalous development of the end-vertebrae. To determine this variability, we selected 54 radiographs of adequate quality showing 67 scoliotic curves from children with congenital scoliosis. The end-vertebrae were preselected. Each curve was measured by the Cobb method on two separate occasions by six different observers, using the same goniometer and marker. The intraobserver variability was +/- 9.6 degrees and the interobserver variability +/- 11.8 degrees. If 'significant progression' is to be used as a criterion for surgical fusion in congenital scoliosis, there should be at least a 23 degrees increase, the entire range of the interobserver variability, in the curvature to ensure that the perceived increase is not due to variability in measurement

Aims

Kashin-Beck disease (KBD) is a kind of chronic osteochondropathy, thought to be caused by environmental risk factors such as T-2 toxin. However, the exact aetiology of KBD remains unclear. In this study, we explored the functional relevance and biological mechanism of cartilage oligosaccharide matrix protein (COMP) in the articular cartilage damage of KBD.

Cleidocranial dysplasia (CCD) is inherited as an autosomal dominant disorder characterised by failure of membranous ossification. The condition is due to a mutation of the cbfa1 gene on chromosome 6 which has a role in the development of osteoblasts from the mesenchymal cells. In their growing years, these patients have an unusual shape of the femoral head reminiscent of a ‘chef’s hat’. In order to confirm the consistency of this sign, we have reviewed the radiographs of 28 patients with CCD. All except three had this appearance. The sign was also seen in patients with coxa vara associated with a variety of other conditions. The chef’s hat sign may occur secondary to the particular mechanical environment created by coxa vara as well as abnormal cellular function in patients with CCD. Although coxa vara has some influence on the shape of the femoral head, it is not entirely responsible for its morphology since it was present in only six of the 28 patients with CCD

We have compared, in rabbits, two techniques of limb lengthening by distraction of the epiphyseal plate using a unilateral external fixation frame. In all cases, 14 mm of symmetrical lengthening without deviation was achieved. With rapid distraction at rates of 1 mm per day (distractional epiphyseolysis) separation of the epiphysis from the metaphysis occurred by day 7, and by day 70 almost complete ossification of the cartilage and the elongated segment was evident. In contrast, slow distraction at 0.25 mm every 12 hours (chondrodiatasis) produced hyperplasia of growth cartilage without any evidence of detachment at 28 days, the end of the distraction period. By day 70 the epiphyseal plate had returned to normal thickness with normal cellular morphology, while the lengthened segment was occupied by ossified tissue. The significance of these findings is discussed

1. The results of posterior spinal fusion for paralytic scoliosis in 118 patients have been reviewed after growth had finished. The criteria for skeletal maturity were both clinical and radiological, with emphasis on ossification of the iliac apophyses. 2. The age of onset of anterior poliomyelitis and the age at which scoliosis was first noticed, as well as the extent of the muscle weakness and the curve patterns, all have a bearing on the severity of the deformity and the indication for operative treatment. 3. The method of treatment including operation is described and the complications detailed. The use of a tibial strut has now been abandoned and Harrington instrumentation has become routine. 4. There were five deaths in the series, three early and two late. 5. The difference in height, changes in respiratory function and eventual functional capacity have been analysed

1. The process of repair after fracture of the humerus of the growing rat has been studied by histological, histochemical and biochemical methods. 2. Both periosteal and surrounding mesenchymal cells take part in the process of repair. 3. The primary framework of collagen bridging the gap is mainly formed by the mesenchymal cells, while calcification and ossification of the framework is largely a function of the periosteum. 4. The mucopolysaccharide content rises rapidly in the first week after injury, and is followed by a rise in the collagen content during the second week. The deposition of calcium phosphate during the third and fourth weeks causes an apparent fall in the collagen content during that period. The collagen content tends to return to normal during the phase of remodelling in the fifth and sixth weeks. 5. The tensile strength of the healing bone bears a close relation to its collagen content

We reviewed 24 displaced fractures through the physis of the medial epicondyle of the distal humerus. One was a Salter-Harris type-II fracture-separation of the whole distal humeral epiphysis; the others involved only the medial epicondylar centre of ossification. Two cases had presented as pseudarthroses. One fracture had been treated closed in a plaster slab and 21 had had open reduction and internal fixation with sutures, Kirschner wires or Palmer nails. At 2 to 13 years later we found five types of deformity of the epicondyle: pseudarthrosis, an ulnar sulcus, a double-contoured epicondyle, hypoplasia or hyperplasia. Pseudarthrosis had developed after either no treatment, closed reduction and plaster, or open reduction and suturing. Hypoplasia followed nailing, as did a trend to varus tilting of the joint surface. One very young patient, with fracture-separation of the whole distal epiphysis treated by nailing, developed marked cubitus varus

We reviewed the serial radiographs of 54 hips in 47 children treated by closed reduction for congenital dislocation of the hip and followed to at least 14 years of age, to determine the causes of acetabular dysplasia. We excluded hips with femoral head deformity or residual subluxation and compared the results with those from a control series of unaffected hips of patients with unilateral CDH. Acetabular development after the age of 11 or 12 years was significantly worse in Severin group III than in Severin group I hips on the affected side or Severin group III in unaffected control hips. One of the causes of acetabular dysplasia at maturity was found to be impairment of acetabular development after 11 or 12 years of age. This may be attributable to impaired secondary ossification in the acetabular rim. Our findings emphasise the importance of continuing the follow-up of patients treated for congenital dislocation of the hip until full skeletal maturity

Thirty-four patients wtih fibrodysplasia (syn., myositis) ossificans progressiva are described. Marked delay in diagnosis was usual, but all had characteristic skeletal malformations and ectopic ossification. The clinical features included: four types of malformation of the big toe, reduction defects of all digits, deafness, baldness of the scalp, and mental retardation. Progression of disability was erratic in all, but severe restriction of movement of the shoulder and spine was usual by the age of 10 years; the hips were usually involved by the age of 20 years; and most patients were confined to a chair by the age of 30 years. Exacerbating factors included trauma to the muscles, biopsy of the lumps, operations to excise ectopic bone, intramuscular injections, careless venepuncture and dental therapy. Progression of disability did not appear to be influenced by any form of medical treatment and therefore management of the patients must concentrate on the avoidance of exacerbating factors

A quantitative study of the vascularity and a qualitative study of the remodelling of the calcified cartilage and subchondral bone end-plate of adult human femoral and humeral heads were performed with respect to age. In the femoral head the number of vessels per unit area was found to fall 20% from adolescence until the seventh decade and in the humeral head 15% until the sixth decade. Thereafter an increase was noted in the femur but none in the humerus. More vessels were present at all ages in the more loaded areas of the articular surfaces: 25% more for the femur and 15% more for the humerus. The degree of active remodelling by endochondral ossification declined 50% from adolescence until the seventh decade in the femoral head, and 30% until the sixth decade in the humeral head, rising thereafter to levels comparable to those found at young ages. More remodeling was noted in the more loaded areas at all ages

1. The normal anatomy of the intervertebral disc of immature rabbits is described. 2. An account is given of the changes that occur after an operative incision in the ventral part of the intervertebral discs of rabbits which allowed the escape of the nucleus pulposus. The account is based on observations made on fifty-five young animals killed at intervals during the twenty-five months after operation. 3. The superficial part of the wound in the annulus heals rapidly by active fibrosis. Thereafter there is a chondrification of the ventral region of the disc, followed by ossification. A prominent bony ridge ultimately ankyloses the vertebrae adjoining the disc. 4. The site of the nucleus pulposus is eventually occupied by a dense pad of fibrocartilage. A tongue of this tissue projects into the deep median part of the wound which remains unhealed. 5. A hypothesis is submitted regarding the mechanism of rupture of the annulus fibrosus and prolapse of the nucleus pulposus in man; this hypothesis is based in part on the observations of lesions in discs not subjected to operation

We report three cases of spontaneous healing of aneurysmal bone cysts (ABC). In one case histological material was obtained after resection of the already ossified expansile mass discovered as a lytic lesion seven months previously. In the two other patients, spontaneous ossification of a radiologically presumed ABC in the lytic and expansile phase was observed after nine and seven months respectively. The healed lesions have remained stable at 12, 32, and 36 months respectively. These findings suggest that when the diagnosis can be made with confidence, and the lesion is in a location and at a stage that does not entail any risk of fracture or compression, expectant management should be considered. Our three patients were aged 22, 19 and 18 years, older than usual for developing ABC. This is also true for many of the few other reported cases of spontaneous or almost spontaneous healing and suggests that ABC has a greater tendency to stabilise in older patients