We treated 90 patients with an isolated injury to the anterior cruciate ligament (ACL) by reconstruction using a patellar tendon autograft and interference screw fixation. Of these, 82 (91%) were available for review at 24 months. Two grafts and two contralateral ACLs had ruptured during sport and there was one case of atraumatic graft resorption. Using the assessment of the International Knee Documentation Committee (IKDC), 86% of the remaining patients were normal or nearly normal. The median Lysholm knee score was 95/100 and 84% of patients were participating in moderate to strenuous activity. All had grade-0 or grade-1 Lachman, pivot-shift and anterior-drawer tests. Measurement with the KT1000 arthrometer gave a side-to-side difference of < 3 mm of anterior tibial displacement in 90%. Sixty-six radiographs were IKDC grade A and one was grade B. Pain on kneeling was present in 31% and graft site pain in 44%. At 24 months after operation all patients had excellent knee stability, a high rate of return to sport and minimal radiological evidence of degenerative change. Our series therefore represents a basis for comparison of results using other techniques and after more severe injuries

The anatomy of 1000 symptomatic meniscus lesions is described and related to the age of the patients. All symptomatic lesions found during the study period were treated by arthroscopic surgery. Meniscal lesions were commoner in the right knee (56.5%) and 81% of the patients were men. Of the medial meniscus tears, 75% were vertical and 23% horizontal. Vertical tears of the medial meniscus occurred most often in the fourth decade and horizontal tears in the fifth. There were 22% type I, 37% type II and 31% type III vertical tears; 62% of type I tears and 23% of type II tears had locked fragments. Superior flaps were six times more common than inferior flaps. Of all medial meniscus fragments, 6% were inverted; 51% of these were flaps and the rest ruptured bucket-handle fragments. Of the lateral meniscus lesions 54% were vertical tears, 15% oblique, 15% myxoid, 4% were inverted and 5% were lesions of discoid menisci. The commonest pattern of tear in the lateral compartment (27%) was a vertical tear involving half the length and half the width of the meniscus

1. The radiological features of skeletal hydatid disease are discussed. Osseous lesions occur in about 1 to 2 per cent of cases, bone being involved only after the embryos have passed the filters provided firstly by the liver and secondly by the lungs. At first, ill defined areas of translucency appear which are not diagnostic. In developed lesions, clear-cut destructive areas, with a surrounding sclerotic reaction, become visible. The cysts thin and expand the cortex and tend to spread throughout an affected bone. In advanced stages the cortex is ruptured, and exuberant hydatid cyst growth takes place in the adjacent soft tissue. Around this an ectocyst forms, which may later calcify, indicating death of the parasite. The progress of the disease is very slow. 2. Three cases of affection of the thoracic spine are described, and the differential diagnosis is considered, particularly from plasmacytoma and neurofibroma. Each case presented with cord pressure symptoms. Operative decompression relieved these totally in one case, incompletely in another, and not at all in the third and most advanced case. 3. With rapid and easy travel in the modern world hydatid disease is liable to be seen in areas where it is not endemic

We made a prospective arthroscopic study of 106 skeletally mature male sportsmen with an average age of 28.35 years (16.8 to 44) who presented with an acute haemarthrosis of the knee due to sporting activities. We excluded those with patellar dislocations, radiographic bone injuries, extra-articular ligamentous lesions or a previous injury to the same joint. The anterior cruciate ligament (ACL) was intact in 35 patients, partially disrupted in 28 and completely ruptured in 43. In the patients with an ACL lesion, associated injuries included meniscal tears (17 patients), cartilaginous loose bodies (6), and minimal osteochondral fractures of the patella (2), the tibial plateau (3) or the femoral condyle (9). We found no age-related trend in the pattern of ACL injuries. Isolated injuries included one small osteochondral fracture of the patella, and one partial and one total disruption of the posterior cruciate ligament. Three patients had cartilaginous loose bodies, and no injury was detected in five. Acute traumatic haemarthrosis indicates a serious ligament injury until proved otherwise, and arthroscopy is needed to complement careful history and clinical examination. All cases with a tense effusion developing within 12 hours of injury should have an aspiration. If haemarthrosis is confirmed, urgent admission and arthroscopy are indicated

We treated 43 acute tears of the calcaneofibular ligament by operation in 43 patients after subtalar arthrography. There were 22 men and 21 women with a mean age of 22.3 years (14 to 61). Anteroposterior (AP), lateral and oblique views were obtained with the foot in 45° of internal rotation and the ankle in the neutral position. Any communication or leakage to the ankle, tendon sheaths, subcutaneous tissue and sinus tarsi was recorded. We examined an oblique view of the microrecess along the interosseous ligament and an AP view of the lateral recess just under the distal end of the fibula. We also studied a control group of 27 patients with isolated injuries of the anterior talofibular ligament without rupture of the calcaneofibular ligament. The findings in the two groups were significantly different when examined for leakage to the ankle (p = 0.0002), to the peroneal tendon sheaths (p = 0.0347) and to the subcutaneous tissue (p = 0.0222), absence of the microrecess (p = 0.0055) and presence of the lateral recess (p = 0.0012). Many ankle sprains which involve tearing of the calcaneofibular ligament are accompanied by injuries of the subtalar joint. Combined injuries of the anterior talofibular ligament and calcaneofibular ligament, and isolated injury of the anterior talofibular ligament should be differentiated

We reviewed the results of reconstruction of 97 upper limbs in a consecutive series of 57 tetraplegic patients, treated from 1982 to 1990. Of these, 49 had functional and eight had cosmetic reconstructions. The principal functional objectives were to provide active elbow extension, hook grip, and key pinch. Elbow extension was provided in 34 limbs, using deltoid-to-triceps transfer. Hook grip was provided in 58 limbs, mostly using extensor carpi radialis longus to flexor pollicis longus transfer, and key pinch in 68, mostly using brachioradialis to flexor pollicis longus transfer. Many other procedures were employed. At an average follow-up of 37 months, 70% had good or excellent subjective results, and objective measurements of function compared favourably with other series. Revisions were required for 11 active transfers and three tenodeses, while complications included rupture of anastomoses and problems with thumb interphalangeal joint stabilisation and wound healing. We report a reliable clinical method for differentiating between the activity of extensor carpi radialis longus and brevis and describe a successful new split flexor pollicis longus tenodesis for stabilising the thumb interphalangeal joint. Bilateral simultaneous surgery gave generally better results than did unilateral surgery

Operative release for entrapment of the suprascapular nerve was carried out in 35 patients. They were assessed at an average of 30 months (12 to 98) after operation using the functional shoulder score devised by Constant and Murley. The average age at the time of surgery was 40 years (17 to 67). Entrapment was due to injury in ten patients and no cause was found in three; 34 had diffuse posterolateral shoulder pain. The strength of abduction was reduced in all the patients. The average Constant score, unadjusted for age or gender, before operative release was 47% (28 to 53). In 25 of the patients both the supraspinatus and infraspinatus muscles were atrophied and seven had isolated atrophy of the infraspinatus muscle. The average conduction time from Erb’s point to the supraspinatus muscle and to the infraspinatus muscle was 5.7 ms (2.8 to 12.8) and 7.4 ms (3.4 to 13.4), respectively. In two patients MRI revealed a ganglion in the infraspinatus fossa and, in another, a complete rupture of the rotator cuff. The average time from the onset of symptoms to operation was ten months (3 to 36). A posterior approach was advocated. The average Constant score, after operative release, unadjusted for age or gender was 77% (35 to 91). The overall result was excellent in ten of the patients, very good in seven, good in 14, fair in two, and poor in two. The symptomatic and functional outcome in our series confirmed the usefulness and safety of operative decompression for entrapment of the suprascapular nerve

Abstract

Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for axillary nerve palsy, intrinsic re-innervation following proximal ulnar nerve repair, and critical sensory recovery despite non-reconstructable median nerve lesions.

We studied the vascular pattern of human posterior tibial tendons by injection techniques and immunohistochemically using antibodies against laminin. The intravascular volume of the posterior tibial tendon was determined using a new method of injection of a solution of . 99m. Tc and gelatin ink into the lower legs of cadavers. Three segments of 1 cm length from different regions of the human posterior tibial tendon were measured using a gamma well counter. The main blood supply arises from the posterior tibial artery. Blood vessels enter the paratenon of the posterior tibial tendon via a mesotenon from the posterior aspect. From the paratenon, the blood vessels penetrate the posterior tibial tendon and anastomose with a longitudinally orientated intratendinous network. The number of vessels in the substance of the tendon is consistently less than that in the surrounding paratenon. The distribution of blood vessels within the posterior tibial tendon is not homogeneous. In the retromalleolar region the intravascular volume was significantly reduced with a mean value of 15 μl/g of tendon tissue. There was no significant difference between the mean intravascular volumes of the proximal and distal areas (distal, 27.7 μl/g tendon tissue; proximal, 30 μl/g tendon tissue). The immunohistochemical investigation showed that there was no immunostaining for laminin in the anterior part of the tendon in the region where it passes behind the medial malleolus. This region is avascular. The most frequent site of rupture of the posterior tibial tendon is in the region behind the medial malleolus. A potential endogenous risk factor may be the limited healing potential of avascular tissue

1. Three groups of one month old rats were fed for a period of four to five weeks on a rachitogenic diet (group R), the same rachitogenic diet with vitamin D (group N), and a complete diet (group S). 2. Young's modulus of elasticity E for bone can be derived from measurements of the deflexion of the centre of a femur loaded at the centre and supported at its ends. 3. The three different diets produced significant differences in breaking stress S. B. , Young's modulus E, and percentage ash in the bones. It has not been shown conclusively that higher ash content alone is responsible for the greater S. B. and E values of bones produced on the better diets. 4. The value of E in group R was 0·6 x 10. 6. lb./in. 2. ; in group N 1·0 x 10. 6. lb./in. 2. ; and in group S (which can be taken as normal) 1·6 x 10. 6. lb./in. 2. . 5. There is a high correlation between S. B. and E even when the effect of diet is eliminated. 6. Although the bones produced on the good diet (group S) were much stronger than those of groups N or R, the strain at the elastic limit was the same (about 1·5 per cent.). The strain at rupture tended to be higher in groups N and R than in group S. 7. The properties of bone as a structural material are discussed

Objectives

The long head of the biceps (LHB) is often resected in shoulder surgery and could therefore serve as a cell source for tissue engineering approaches in the shoulder. However, whether it represents a suitable cell source for regenerative approaches, both in the inflamed and non-inflamed states, remains unclear. In the present study, inflamed and native human LHBs were comparatively characterized for features of regeneration.

Cadaveric knees replaced with the Geomedic, ICLH, Marmor and Total Condylar prostheses were tested in axial compression, in rotation and in hyperextension in order to observe the strength of fixation of the tibial components. In axial compression the strengths at failure varied widely, both with any one prosthesis and between prostheses. This is attributed largely to the strength of the cancellous bone of the tibia, which was measured in each case and also varied widely. Three natural knees failed at loads of 7300, 7600 and 8300 newtons respectively, whereas the strengths of replaced knees ranged from 3000 to 15750 newtons. At least one example of each design failed at less than 7300 newtons, suggesting little or no reserve of strength. The strength of fixation was greater when the tibial prosthesis was large enough to rest on the whole cross-section of the tibia. In rotation the three prostheses embodying rollers in troughs were stiffer than the Marmor which had a nearly flat tibial-bearing surface. The presence or absence of the cruciate ligaments had a negligible effect on torsional stiffness. In hyperextension, knees replaced with the ICLH, Marmor and Total Condylar prostheses failed by rupture of the posterior capsule at moments of about 60 newton-metres, compared with about 100 for natural knees. With the Marmor prosthesis the anterior cruciate ligament was avulsed at about 20 newton-metres compared with about 75 in natural knees, suggesting that in this respect the retention of the cruciate ligaments contributes little. None of the four knees tested after inserting a Geomedic prosthesis showed strengths as high as those replaced with the other three designs

Objectives

The Attune total knee arthroplasty (TKA) has been used in over 600 000 patients worldwide. Registry data show good clinical outcome; however, concerns over the cement-tibial interface have been reported. We used retrieval analysis to give further insight into this controversial topic.

Between June 1993 and December 1994, we performed total knee arthroplasty (TKA) on 27 knees in 24 patients with spontaneous bony ankylosis in severe flexion. The mean age at operation was 43.5 years (30 to 60). No patient had preoperative pain. Three were unable to walk and 21 could manage less than five blocks. The mean duration of the ankylosis was 18.7 years (13 to 25) and its mean position was 105° flexion (75 to 135). The preoperative Hospital for Special Surgery Knee Score of 60 points was improved to 87 at the final follow-up three to five years later. All knees were free from pain. The mean range of active flexion in 24 knees was 97° (78 to 115) and the mean arc of movement 91° (78 to 98). The mean fixed flexion deformity was 6° (0 to 25) and the extension lag 8° (0 to 25). Angular deformity was corrected to between 0° and 10° of valgus. Four patients were able to walk one block and 20 five to seven blocks. Thirteen knees (48%) showed some necrosis at the skin edge; one knee required arthrodesis and another resection arthroplasty. One had a recurrence of tuberculous infection requiring arthrodesis. One patient had a rupture of the quadriceps tendon. To date no prosthesis has required revision for loosening. Radiolucency of 1 mm or less about the tibial prosthesis was observed at follow-up in four of the 24 knees. Our results have shown that one-stage TKA and skeletal traction after operation can achieve correction of severe flexion deformity of the knee with marked improvement in the function and quality of life

Displaced extension supracondylar fractures of the elbow 1. One hundred and ten children were treated by reduction and stabilisation by two pins inserted laterally at an angle of 30 degrees to one another. 2. The complications before and after treatment included fifteen nerve lesions in thirteen patients. The ulnar nerve was involved on one occasion only. Solitary radial nerve injuries occurred with postero-medial displacement of the distal fragment, while median nerve and brachial artery injuries were associated with postero-lateral displacement. All the lesions recovered spontaneously. 3. There were no ischaemic complications after treatment, despite the ligation of one ruptured brachial artery. 4. The average stay in hospital was four days, compared with twenty days for thirty-two other patients treated in traction because of gross oedema. 5. Of eighty patients seen six months to five years after the fracture, seventy (or 87·5 per cent) had excellent or good results, seven patients with marked varus deformities had fair results, and two patients had poor results with very stiff elbows. Displaced flexion fractures 1. The clinical features, complications and treatment of seventeen cases are described. 2. There were no complications involving the median or radial nerves or the brachial artery, but three patients had a lesion of the ulnar nerve. 3. Nine children had closed reduction and fixation by two lateral percutaneous pins. 4. Reduction was difficult and the results poor compared with extension fractures. Closed reduction failed in one-third of the children, and the functional and cosmetic results were unsatisfactory in over half the patients reviewed

Aims

Improvements in the evaluation of outcomes following peripheral nerve injury are needed. Recent studies have identified muscle fatigue as an inevitable consequence of muscle reinnervation. This study aimed to quantify and characterize muscle fatigue within a standardized surgical model of muscle reinnervation.