We have studied the natural history of spontaneous dislocation of the hip in cerebral palsy, with particular reference to the pattern of neurological involvement. In patients with bilateral hemiplegia and severe involvement of the upper limbs the incidence of dislocation was very high (59%), while in those with diplegia and little involvement of the upper limbs, only 6.5% were affected. There was no evidence of dysplasia or instability of the hip in any of the patients with unilateral hemiplegia. A strong correlation was found between the stability of the hip and the patients' ability to walk. These findings have a bearing on clinical surveillance and also on the indications for prophylactic surgery

1. One hundred patients with osteochondritis dissecans of the knee have been reviewed. Sixty-eight were male. Unilateral lesions were found in seventy-four. The average age at onset of symptoms was eighteen years. 2. The outstanding etiological feature was found to be direct injury to the joint surface (46 percent), repeated injuries sustained in first class athletics and field sports, and mechanical abnormalities of the knee. 3. Osteochondral fracture was found in seven cases. 4. The results of various types of treatment are described and a plan of management outlined

Aims

The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common elective orthopaedic procedures

Congenital or acquired shortness of a metatarsal may cause pain in adjacent metatarsals. From 1983 to 1990, we performed nine metatarsal lengthenings in seven adolescent patients by metaphyseal osteotomy followed by gradual distraction of callus (callotasis). Two patients required bone grafts after the lengthening. We used a rigid, unilateral external fixator designed for use in the hand and foot. At follow-up, from three to ten years later, healing had been achieved in all with an average healing index of 50 days/cm, and metatarsalgia had been relieved by the restoration of correct metatarsal length

After total hip (THR) or knee replacement (TKR), there is still an appreciable risk of developing deep-vein thrombosis despite prophylaxis with low-molecular-weight heparin (LMWH). In a prospective, randomised study we examined the efficacy of LMWH in combination with intermittent pneumatic compression in patients undergoing primary unilateral THR or TKR. We administered 40 mg of enoxaparin daily to 131 patients combined with either the use of intermittent pneumatic compression or the wearing of graduated compression stockings. Compression ultrasonography showed no evidence of thrombosis after LMWH and intermittent pneumatic compression. In the group with LMWH and compression stockings the prevalence of thrombosis was 28.6% (40% after TKR, 14% after THR). This difference was significant (p < 0.0001). In the early post-operative phase after THR and TKR, combined prophylaxis with LMWH and intermittent pneumatic compression is more effective than LMWH used with graduated compression stockings

Between 1992 and 1994 we performed a prospective study of the effect of total knee replacement (TKR) on the health status of 119 patients over the age of 80 years who had had a primary unilateral TKR. The Nottingham Health Profile was used to assess this before and at three and 12 months after operation. We found a significant improvement in the scores for pain, emotional reaction, sleep and physical mobility at three months. After 12 months, the scores for pain and sleep were well maintained. The other factors had deteriorated slightly but remained better than before operation. Our findings show that TKR leads to a significant improvement in the general health status of the very elderly

The long-term results following the correction of coxa vara by Pauwels' Y-shaped intertrochanteric osteotomy have been evaluated in 14 children. Ten of the children had unilateral hip disease and were otherwise normal while four had bilateral hip disease due to generalised skeletal dysplasias. In each case, the growth plate was vertical, the femoral head was displaced inferiorly and there were abnormalities in the metaphysis of the femoral neck. The results indicate that this osteotomy provides lasting correction of the deformity, regardless of the cause, as long as the inclination of the growth plate is corrected to 40 degrees or less and adequate support is provided for the metaphyseal defect and the displaced femoral head

The results of excision arthroplasty on forty hips in thirty-two patients have been studied by personal review. The mean follow-up was ten years and the results were graded in the Lazansky system. The outcome was fairly predictable, most patients achieving a fair to good result. The patients were satisfied with the operation in unilateral cases as a secondary operation, but it was generally unsatisfactory as a primary procedure or when performed bilaterally. Pain relief was satisfactory, and previously infected hips achieved sound wound and bone healing. Half could walk with no aid or one stick. No correlation could be found between the radiological appearances and the quality of the result

Aims

The aim of this study was to review the value of accepting referrals for children with ‘clicky hips’ in a selective screening programme for hip dysplasia.

We studied the detection of joint replacements at airport security checks in relation to their weight, using two types of detector arch. A single-source, unilateral detector showed different sensitivities for implants on different sides of a test subject. All implants weighing more than 145 g were detected by one of the arches. The degree of detection was directly related to the logarithm of the weight of the prosthesis in patients, with a linear correlation (r. 2. = 0.61). A bilateral arch detected all prostheses weighing over 195 g. With their usual sensitivity settings many joint replacements were detectable; an identification pass containing the site and weight of such prostheses would help to avoid the need for body-search procedures

A technique for epiphysiodesis using a cannulated tubesaw has been developed to combine the precision of the original Phemister method with newer percutaneous methods. The approach is unilateral, and requires minimal access. Reinsertion of the removed core of bone reduces haemorrhage from the defect and augments arrest of the growth plate. In 35 patients treated by this method predicted discrepancies of 2 to 4.5 cm were reliably reduced to 0.7 ± 0.6 cm, with no serious complications. The timing of surgery is critical, and relies upon careful monitoring of the pattern of discrepancy over several years, using clinical and radiographic measurements. Undercorrection of the disparity in three patients was the direct result of late referral

Substance P is readily detected in the synovial fluid of the knee in which it acts as a powerful inflammatory agent in response to injury and disease. It may be an objective predictor of pain after knee replacement surgery. The level of substance P was measured in the synovial fluid in both knees of 114 patients having unilateral and in 86 patients having bilateral total knee replacement for osteoarthritis. All had severe pain in the knee to be replaced and joint destruction. Substance P was elevated in 73% of replaced knees but not in normal or asymptomatic knees. Good or excellent pain relief was achieved in 97% of patients with an elevated preoperative level of substance P and in 61% of those with a normal preoperative level (p < 0.05 compared with preoperative values)

We studied 12 consecutive patients with facet joint dislocation in the cervical spine to assess the incidence, site and clinical sequelae of occlusion of the extracranial vertebral artery. Intra-arterial digital subtraction angiography was performed after the orthopaedic management of the dislocations. This demonstrated vertebral artery occlusion (one bilateral) in five of the seven patients with bilateral dislocations and in four of the five patients with unilateral dislocations. Two of the nine patients with vertebral artery occlusion had neurological deficits above the level of the injury, all of which resolved spontaneously within two months. In our experience, a distraction-flexion injury appears to be the most common cause of closed traumatic vertebral artery occlusion

Reports of spondylolysis in vertebrae other than those of the lower lumbar spine are rare. We report 32 patients with upper lumbar spondylolysis who have been studied clinically, radiologically and scintigraphically. Twenty patients had bilateral lesions, and seven of those with unilateral lesions had structural changes or anomalies in the opposite posterior arch. Positive scans were found to be associated with a short clinical history, and indicated stress-related lesions. Our findings suggest that mechanical factors may play a role in the aetiology of spondylolysis in the upper lumbar spine similar to that which they play in the lower lumbar spine, and that local structural anomalies may contribute to abnormal loading of these vertebrae

Unilateral Colles' fractures in 187 patients over the age of 55 years were studied in a randomised prospective trial: 97 fractures were minimally displaced and were treated either conventionally or in a crepe bandage; 90 displaced Colles' fractures were reduced and of these 47 were treated conventionally while 43 were encouraged to mobilise the wrist in a cast which restricted extension. Early wrist movement hastened functional recovery and led to earlier resolution of wrist swelling. Discomfort was no greater than in patients who were treated conventionally. The bony deformity, which recurred irrespective of the method of treatment, was not adversely affected by early mobilisation

Fifty-four adults with eighty hips affected by congenital disease which had not been treated have been reviewed. Fifty-nine per cent of forty-two dislocated hips had fair or poor grading scores. The incidence of osteoarthritis was markedly increased in the presence of a well-developed false acetabulum. Unilateral dislocation led to valgus deformity and degenerative changes in the ipsilateral knee in seven of twenty-two patients. Dislocation did not increase the incidence of symptomatic lumbar spondylosis. The height of the dislocated head on the ilium was not found to be related to the prognosis for the hip, the knee or the lumbar spine and did not correlate with the development of the false acetabulum. Frank congenital subluxation eventually led to osteoarthritis of the hip

1. A method has been described whereby the disability of hip disease, bilateral or unilateral, can be graded, and the quality of result following arthroplasty assessed, on a scale of numerical values. 2. The grade expresses the condition of the entire patient, rather than that of the hip joint alone. 3. Certain clinical criteria and physical tests have been adopted as the bases for scoring. The calculation of the patient's total score has been weighted to emphasise mobility, and to provide a more critical measure of the success of arthroplasty. Subjective tests (aside from the patient's estimate of his pain) are avoided, to provide as objective and accurate a method of assessment as possible

Reimplantation is a well-established procedure in reconstructive surgery. This is especially so after amputation of the upper limb since prostheses provide limited function. In unilateral amputation of the lower leg orthotopic reimplantation is the treatment of choice. With bilateral amputation, in which orthotopic reimplantation is not possible because of the complexity of the trauma, heterotopic reimplantation is an option. We report five patients who received orthotopic and two who received heterotopic reimplantations of the lower leg. We assessed the functional outcome with reference to cutaneous sensation, mobility, pain, and the cosmetic result. The functional outcome was good, as was the patients’ satisfaction. Their mobility, stability, and psychological state were satisfactory. Patients with heterotopic reimplantations preferred the reimplanted leg to a prosthesis. Although reimplantation of the lower leg requires prolonged hospitalisation, delayed mobilisation and secondary operations, we conclude that there is an indication for this operation in order to improve the patient’s quality of life

Fixation by a single screw is considered the current treatment of choice for a slipped capital femoral epiphysis. This approach promotes premature physeal closure. The use of a modified, standard, single, cannulated screw designed to maintain epiphyseal fixation without causing premature closure of the physis was reviewed in ten patients. The nine boys and one girl aged between 10.6 and 12.6 years with unilateral slipped capital femoral epiphysis (SCFE), were markedly skeletally immature (Tanner stage I, bone age 10 to 12.6 years). Clinical and radiological review at a mean follow-up of 44.3 months (36 to 76) showed no difference in the time to physeal closure between the involved and uninvolved side. Measurement of epiphyseal and physeal development showed continued growth and remodelling in all patients. Use of this device provided epiphyseal stability and maintained the capacity for physeal recovery and growth following treatment for both unstable and stable slipped capital femoral epiphysis