Recent clinical studies have suggested that a neurological lesion may be a cause of adolescent idiopathic scoliosis and animal experiments have implicated the posterior column pathway. We have tried to determine if differences in neurological response could be detected and measured clinically, and have compared the threshold of detection of vibratory sensation in 20 girls with adolescent idiopathic scoliosis with that in 20 clinically normal age-matched controls. A highly significant reduction of the threshold of detection of vibration was seen in the scoliotic group compared to the controls (p less than 0.001). Curve magnitude did not correlate with this threshold for either the upper (r = 0.172) or lower extremity (r = 0.126). Significant asymmetry between right- and left-sided thresholds to vibration was demonstrated in the scoliotic group. Our study supports the concept that an aberration in the function of the posterior column pathway of the cord may be of primary importance in the aetiology of idiopathic scoliosis. A clinically practical test to measure this function is presented

A subjective, objective and radiographic study of 21 patients with comminuted calcaneal fractures showing severe involvement of the subtalar joint is reported. The average follow-up was 14.6 years (range 8 to 29 years). Only patients with unilateral closed fractures and no associated injuries to either lower limb were admitted to the study. All were treated by early active mobilisation of the ankle, and the subtalar and the midtarsal joints. Seventy-six per cent of the patients achieved a good result with minor symptoms which did not interfere with their occupation or leisure requirements. Although two-thirds of the patients reached a point of maximal recovery at two to three years, 24% continued to improve for six years. None of the patients experienced any deterioration after this time. Neither the degree of clinical stiffness nor the degeneration of the subtalar joint, assessed radiographically, correlated with the severity of symptoms or functional disability. The role of the soft tissues in the aetiology of residual symptoms is discussed

Coxa valga may sometimes occur as a complication of varus osteotomy for congenital dislocation of the hip. Six such cases are described with a minimum follow-up of nine years. In three cases the varus osteotomy had been performed on only one side; in one case it was done on both sides and coxa valga developed bilaterally; and in two further bilateral cases coxa valga developed on one side only. In each case the coxa valga was sub-capital. Detailed radiographic analysis included measurements of neck-shaft angle, acetabular angle and C.E. angle. The epiphysis-shaft angle is described; it is an index of the constant tendency of the capital epiphysis to assume a horizontal position. The cause remains unknown, but damage to the trochanteric growth plate or to the lateral part of the capital growth plate could not be identified as aetiological factors. Poor acetabular cover was considered a possible factor. All the patients in this series had functionally excellent hips, but the long-term prognosis of the hips with partly uncovered femoral heads is doubtful

A series of 246 patients with scoliosis and attempted fusion had exploration performed six months later in order to detect and treat any pseudarthrosis at an early stage and so prevent subsequent loss of correction. Bilateral or unilateral pseudarthroses occurred in 25 per cent and were of three types--definite, hairline and doubtful. Single unilateral pseudarthroses accounted for 6 per cent and were of little if any clinical significance. The hairline pseudarthroses could not be seen radiologically and were easily missed at exploration. In general the pseudarthroses were least common in the more rigid parts of the spine and in curves which by nature of their aetiology or long duration had become most rigid. Neither the initial severity of the curve nor the degree of correction obtained before the initial attempted fusion had any apparent effect on the incidence. Follow-up for an average of four years has shown that a pseudarthrosis is of little significance with regard to the ultimate result provided it is recognised early and repaired

1. A survey has been made of 518 operations for hallux valgus and hallux rigidus. 2. The methods of critical examination used in this survey are described. 3. The results obtained have led to the formulation of certain views on etiology and modes of treatment. 4. In hallux valgus in the adolescent, operations aimed at correcting the primary deformity are justifiable when correctly performed, though the exact form such operations should take still requires further study. 5. In hallux valgus in the adult, arthroplasty offers a reasonably good solution in the well chosen case, though no one should consider that the results are so good as to make unnecessary any further research in this field. Metatarsal osteotomy has in the adult only a limited sphere of application. 6. In hallux rigidus arthroplasty alone has no place in the treatment of the adult cases showing metatarsus primus elevatus, nor in the adolescent case. The possibilities of other methods of operative treatment, notably osteotomy, are discussed

Aims

To assess the effect of age on clinical outcome and revision rates in patients who underwent total ankle arthroplasty (TAA) for end-stage ankle osteoarthritis (OA).

Recent reports have suggested an association between Perthes’ disease and an underlying thrombophilic or hypofibrinolytic tendency. In Northern Ireland there is a high incidence of Perthes’ disease (11.7 per 100 000 or 1 in 607 children) in a stable paediatric population. We reviewed 139 children with Perthes’ disease and compared them with a control group of 220 aged- and gender-matched healthy primary schoolchildren with similar racial and ethnic backgrounds. There were no significant deficiencies of antithrombotic factors protein C, protein S, antithrombin III or resistance to activated protein C. A total of 53 (38.1%) of the children with Perthes’ disease had a prolonged activated partial thromboplastin time (> 38) compared with 13 (5.9%) of the control group (p < 0.001). Our findings have shown that using standard assays, thrombophilia secondary to antithrombotic factor deficiency or resistance to activated protein does not appear to be an aetiological factor for Perthes’ disease. The cause of the prolonged activated partial thromboplastin time, usually associated with a clotting factor deficiency, is under further investigation

We report a prospective study of gait and tibial component migration in 45 patients with osteoarthritis treated by total knee arthroplasty (TKA). Migration was measured over two years using roentgen stereophotogrammetry. We used the previously established threshold of 200 μm migration in the second postoperative year to distinguish two groups: a risk group of 15 patients and a stable group of 28 patients. We performed gait analysis before operation and at six months and at two years after TKA. On all three occasions we found significant differences between the two groups in the mean sagittal plane moments of the knee joint. The risk group walked with higher peak flexion moments than the stable group. The two groups were not discriminated by any clinical or radiological criteria or other gait characteristics. The relationship which we have found between gait with increased flexion moments and risk of tibial component loosening warrants further study as regards the aetiology of prosthetic loosening and possible methods of influencing its incidence

We operated on 111 patients with 159 congenital club feet with the aim of correcting the deformity and achieving dynamic muscle balance. Clinical and biomechanical assessment was undertaken at least six years after operation when the patient was more than 13 years of age. The mean follow-up was for 11 years 10 months (6 to 36 years). Good and excellent results were obtained in 91.8%. Patients with normal function of the calf had a better outcome than those with weak calf muscles. The radiological changes were assessed in relation to the clinical outcome. The distribution of pressure under the foot was measured for biomechanical assessment. Our results support the view that muscle imbalance is an aetiological factor in club foot. Early surgery seems to be preferable. It is suggested that operation should be undertaken as soon as possible after the age of six months, although it may be carried out up to the age of five years. The establishment of dynamic muscle balance appears to be an effective method of maintaining correction. Satisfactory long-term results can be achieved with adequate appearance and function

Aims

To report the mid-term results of a modified self-growing rod (SGR) technique for the treatment of idiopathic and neuromuscular early-onset scoliosis (EOS).

Aims

The aims of this study were to validate the outcome of total elbow arthroplasty (TEA) in patients with rheumatoid arthritis (RA), and to identify factors that affect the outcome.

The clinical features of nine new patients with dysplasia epiphysialis hemimelica are reported, with a long-term follow-up on a further seven patients who were described in the earliest case reports of this disease. Each of these 16 patients had only one leg involved, but 12 had multiple epiphyses affected. The distal femur, distal tibia and talus were the commonest sites and most patients presented with painless swelling or deformity. Wasting of the muscles of the affected leg was a common finding, and was occasionally disproportionate to the degree of disuse. One patient had the unique combination of involvement of the lateral and medial halves of different epiphyses in the same limb and another had unusual metaphysial changes. Diagnosis was often delayed despite typical radiographic appearances. There was no evidence for a genetic component in the aetiology nor was any common environmental factor identified. Treatment by local excision was generally effective for lesions in the vicinity of the knee, but some patients with involvement of the talus required arthrodesis around the ankle. The long-term prognosis appears to be good and so far only two of these patients have developed premature osteoarthritis

1. Using the incidence of hip fracture as an indication of senile osteoporosis, the occurrence of this disease is found to vary greatly in different racial groups. The highest reported incidence is in Sweden, followed by Britain, Hong Kong Chinese, Singapore Chinese and South African Bantu, in that order. Likewise, the sex incidence varies, women outnumbering men in Sweden and Britain, men exceeding women in Singapore; an equal sex incidence is found in Hong Kong. 2. In all races and in both sexes the incidence is more closely related to age than any other factor, a progressive increase being noted after forty-five. Ageing is clearly the dominant etiological factor, but this does not explain the different racial incidence. These differences cannot be attributed to hormonal state or to the dietary intake of calcium, but do accord in general with the living standards of the different countries and the degree of physical activity undertaken by the different populations and sexes. 3. Hereditary factors may play a part, but further geographical study of the incidence of senile osteoporosis is necessary before the relative importance of inheritance and environment can be assessed

1. The term "observation hip" refers to a form of hip disease affecting children and adolescents, the most significant features being the transient nature of the symptoms and the absence of a bony or cartilaginous lesion on radiographic examination. 2. With a view to determining the possible sequelae of the disorder, twenty-three patients aged between two and fifteen years at the onset of the condition were studied fifteen to thirty years later. 3. Varying degrees of coxa magna, osteoarthritis or simple broadening of the femoral neck in the "observed" hip joint were found in the radiographs of twelve of the twenty-three patients studied. 4. This analysis suggests that the " observation hip" syndrome is the result ofan inflammatory process ofthejoint due to varied etiology, whether from injury or infection. The developmental and degenerative changes which may occur are a consequence of hypervascularisation of the bone. Thus changes may develop without necessarily producing the epiphysial necrosis characteristic of the first stage of ischaemia in Legg-Calvé-Perthes' disease. 5. The persistence of this stage of hypervascularity, and therefore the possible outcome of the transient synovitis, may be conditioned by the age at onset of the pathological process, the severity of the condition, and the duration of the symptoms and signs

Aims

To explore the clinical relevance of joint space width (JSW) narrowing on standardized-flexion (SF) radiographs in the assessment of cartilage degeneration in specific subregions seen on MRI sequences in knee osteoarthritis (OA) with neutral, valgus, and varus alignments, and potential planning of partial knee arthroplasty.

Aims

Our purpose was to describe an unusual series of 21 patients with fungal osteomyelitis after an anterior cruciate ligament reconstruction (ACL-R).

The division of osteoarthritis into primary and secondary varieties implies that these are aetiologically distinct entities, the former being due to some intrinsic defect of cartilage and the latter resulting from previous articular damage. This traditional concept is questioned and the hypothesis is advanced that osteoarthritis is always secondary to some underlying abnormality of the joint. A detailed clinical, radiographic and morbid anatomical study of 327 cases of osteoarthritis of the hip is presented. In all but twenty-seven some predisposing abnormality of the joint was diagnosed: 107 (33%) were associated with major pathology such as Perthes' disease or epiphysiolysis; minor acetabular dysplasia was present in sixty-seven (20%), with a male: female ratio of 1:10; minimal femoral head tilt was demonstrated in fifty-nine (18%), the male: female ratio being 14:1; and in forty-three (13%) there were features suggesting an underlying inflammatory arthritis. On the basis of this study a new classification is proposed and osteoarthritis of the hip is divided into three pathogenetic groups: 1) failure of essentially normal cartilage subjected to abnormal or incongruous loading for long periods; 2) damaged or defective cartilage failing under normal conditions of loading; 3) break-up of articular cartilage due to defective subchondral bone

1. Clinically, hallux rigidus is a painful condition of the joints of the great toe associated with loss of dorsiflexion of the first phalanx. 2. Pathologically, the morbid changes are those of a traumatic synovitis followed by an early development of osteoarthritis, the initial lesions of which are erosions of the cartilage at the centre and near the dorsal margin of the base of the proximal phalanx. There is no fundamental pathological difference between the adult and adolescent varieties of hallux ngidus. Both represent stages in the developmental cycle of osteoarthritis in the proximal joint of the great toe. 3. The radiographic density and apparent fragmentation of the phalangeal epiphysis do not represent an abnormality of the bone and have no significance in the etiology of hallux rigidus. 4. The cause of hallux rigidus is an abnormal gait developed either to protect an injured or inflamed metatarso-phalangeal joint from the pressure of weight-bearing, or to stabilise a hypermobile first metatarsal. The effects of this gait are to transfer most of the pressure from the flexor brevis tendon and the two sesamoids to the base of the first phalanx. Excessive pressure on this joint predisposes to osteoarthritis. 5. Evidence of this abnormal gait is found in the peculiarities of wear seen in old shoes. 6. There is a high correlation between unilateral hallux rigidus and the patient's footedness

We made a clinical study of polyethylene wear in 240 hips of 187 patients having primary total hip arthroplasties from 1989 to 1990, using uncemented Osteonics components, with a head size of 26 mm. We excluded cups with anteversion of over 20° and measured linear wear by a new method using a digitiser and special software of our design. Follow-up was from two to five years (mean 4.3). The mean age at operation was 50.3 years, with more men than women (1.4:1). The mean linear wear per year was 0.15 mm; this did not increase with the longevity of the prosthesis (p = 0.54). In 59 hips showing evidence of osteolysis, the mean linear wear rate was significantly higher at 0.23 mm/year (p < 0.001). The mean linear wear rate also correlated significantly with age at the time of operation (p = 0.008), but we found no significant correlations with body-weight, gender, aetiology of the disease, thickness of polyethylene, or cup position. Our new method of measurement is time-saving and reproducible. The results confirm the greater rate of linear wear of polyethylene in patients showing osteolysis and in those who are younger

Aims

The diagnosis of periprosthetic joint infection (PJI) can be difficult. All current diagnostic tests have problems with accuracy and interpretation of results. Many new tests have been proposed, but there is no consensus on the place of many of these in the diagnostic pathway. Previous attempts to develop a definition of PJI have not been universally accepted and there remains no reference standard definition.