1. Three new cases of injury to main arteries at orthopaedic operations are described, and a follow-up of two previously described cases is given. The rarity of these accidents is a credit to those engaged in orthopaedic surgery, for many orthopaedic operations are done very close to great vessels, and often under the bloodless conditions of a tourniquet. Nevertheless, it is well to have the risk of great vessel injury in mind because such an accident, although rare, may be a serious threat to life or limb. 2. It is important to repair the damaged artery rather than ligate it because the risk to the growth or viability of the limb is lessened. 3. The aim should be a return to full function with as near normal a vascular anatomy as possible

1. Thirty cases of stiff knee treated by the operation of quadricepsplasty are reviewed. 2. The causes and morbid anatomy are analysed. The operative technique is based on an appreciation of the latter. 3. The after-care must be meticulous and prolonged. Manipulation under anaesthesia was used after operation in over half the cases. 4. The results were most gratifying. There were two technical failures but in the remaining twenty-eight cases the average gain of fiexion was 68 degrees. In twenty-one of these active extension was full and it was only 5 degrees short in another three. Permanent loss of active extension occurred when the rectus femoris tendon had to be divided or lengthened

The anatomy and development of the growing acetabulum are not clearly understood. We dissected and studied histologically two acetabula from the pelvis of a three-month-old infant. Relative rates of growth at the different growth plates were assessed by comparing the height of the proliferative layer with that of the hypertrophic layer. The three bones which form the acetabulum are surrounded by growth plates on all sides except medially. These face towards the centre of the triradiate cartilage, the limbs of the triradiate cartilage and the articular surface and each may be divided into four distinct areas according to the orientation of its cell columns which reflect the direction of growth. Growth was particularly rapid at the ischial growth plates directed towards the centre and the articular cartilage, and on both sides of the anterior limb of the triradiate cartilage. These findings may explain the mechanism by which the acetabulum changes orientation and inclination with growth

Superior labral tears of the shoulder involve the biceps tendon and labrum complex which may be detached, displaced inferiorly, and interposed between the glenoid and the humeral head. We have treated ten young athletes with painful shoulders due to this lesion by arthroscopic stapling. Arthroscopy at the time of staple removal, after three to six months, showed that all the lesions had been stabilised. Clinical review at over 24 months showed an excellent or good result in 80%. The two relative failures were due in one to residual subacromial bursitis, and the other to multidirectional shoulder instability. Arthroscopic stapling can restore the shoulder anatomy, and it is recommended for active adolescent athletes with this lesion

The shallow lateral recesses of the trefoil shape of the lumbar spinal canal have been implicated in the production of the spinal stenosis syndrome. In the present study, 485 skeletons of South African Blacks and Whites were examined in order to establish the incidence and possible genesis of the trefoil configuration. The overall incidence was 14 per cent, with little variation between the sexes or races. The incidence was not related to increasing age, measured stenosis of the spinal canal or osteophytosis. Of 74 trefoil-shaped vertebrae, 68 (92 per cent) were found at the fifth lumbar level. It is suggested that the trefoil configuration is a common non-pathological condition, usually of the fifth lumbar vertebral canal, and is probably a developmental variation of normal anatomy

Comparisons were made between 54 children with resolving congenital talipes equinovarus deformity and 81 children whose feet required surgical correction. There was a significant difference in the incidence of bilateral deformity, sex ratio and family history of congenital talipes in the two groups. The children with resolving deformity had feet which were indistinguishable from the normal side of unilaterally affected children in their calf muscle measurements at six weeks of age, and in the range of movement and radiographs at four years of age. Those requiring surgery had varying degrees of muscle reduction, and although often well corrected, had a reduced range of movement and altered joint anatomy at four years of age. This suggests that they are two distinct populations

We used ultrasound to investigate the anatomy and stability of the hip during the phase of joint stabilisation after closed reduction of unilateral late CDH in 15 infants aged from two to 15 months. Conservative treatment by splintage in abduction led to complete stability in all hips in from three to 13 weeks. Immediately after reduction, interposed soft tissue caused lateralisation of the femoral head, but this progressively disappeared, and the initially smaller femoral head on the dislocated side regained normal size. Ultrasonic evaluation of the hip in late CDH is a valuable and safe tool; it reduces the need for radiographic examination and improves treatment by visualising the actual pathology. The more frequent use of ultrasound can reduce the need for open reduction in the age group that we studied

Many authors recommend surgery to remove retropulsed bone fragments from the canal in burst fractures to 'decompress' the spinal canal. We believe, however, that neurological damage occurs at the moment of injury when the anatomy is most distorted, and is not due to impingement in the resting positions observed afterwards. We studied 20 consecutive patients admitted to our spinal injuries unit over a two-year period with a T12 or L1 burst fracture. There was no correlation between bony or canal disruption and the degree of neurological compromise sustained but there was a significant correlation between the energy of the injury (as gauged by the Injury Severity Score) and the neurological status (p < 0.001). This suggests that neurological injury occurs at the time of trauma rather than being a result of pressure from fragments in the canal afterwards and questions the need to operate simply to remove these fragments

Objectives

The aim of this study was to investigate the biomechanical effect of the anterolateral ligament (ALL), anterior cruciate ligament (ACL), or both ALL and ACL on kinematics under dynamic loading conditions using dynamic simulation subject-specific knee models.

We studied the arterial anatomy and the effect of four-part fractures on the vascularity of the humeral head, using barium sulphate perfusion of 16 cadaver shoulders. The main arterial supply to the humeral head was via the ascending branch of the anterior humeral circumflex artery and its intraosseous continuation, the arcuate artery. There were significant intraosseous anastomoses between the arcuate artery and: 1) the posterior humeral circumflex artery through vessels entering the posteromedial aspect of the proximal humerus; 2) metaphyseal vessels; and 3) the vessels of the greater and lesser tuberosities. Simulated four-part fractures prevented the perfusion of the humeral head in most cases. If, however, the head fragment extends distally below the articular surface medially, some perfusion of the head persists by the posteromedial vessels. These vessels are important in the management of comminuted fractures of the proximal humerus

Biological fixation of cementless femoral implants requires primary stability by optimal fit in the proximal femur. The anatomy of the bone must then be known precisely. We analysed in vitro the accuracy of bone measurements of 32 femurs and compared the dimensions obtained from radiographs and CT scans with the true anatomical dimensions. Standard radiographs gave only a rough approximation of femoral geometry (mean difference: 2.4 +/- 1.4 mm) insufficiently accurate to allow selection of the best fitting prosthesis from a range of sizes and altogether inadequate to design a custom-made prosthesis. CT scans give greater accuracy (mean difference: 0.8 +/- 0.7 mm) in our experimental conditions, but in clinical practice additional sources of error exist

To study the anatomy of subarticular bone and cartilage, fresh specimens of cartilage on bone from the human shoulder, hip and knee were treated with bleach or papain, or were fixed and decalcified. All were compared using scanning electron microscopy. Papain digestion selectively removed cartilage to the tidemark. The tidemark contour was highly variable; irregularities were indirectly related to degenerative lesions and were most prominent in peripheral non-weight-bearing areas of joints with central fibrillation. Decalcification exposed the interface between the bone and calcified cartilage. Collagen fibrils in articular cartilage did not interdigitate with those of bone. The subchondral bone was appositional, avascular, smooth and very thin in most areas of human joints. Perforations through subchondral bone or calcified cartilage were rare. Bleach maceration destroyed important details

The anatomy of the autonomic sympathetic vasomotor nerve supply of bone was studied in rabbits by methods of histochemistry, and fluorescent and electron microscopy. Our observations show that the intraosseous vessels are richly supplied by adrenergic nerves. The large primary nerves are located on or about the surface of the vessel; the medium sized secondary nerves spiral around the long axis of vessels lying more deeply in the tunica adventitia; and the fine tertiary nerves form a rich plexus at the outer area of the tunica media. The tertiary nerves have various structures which probably contain neurotransmitter substance--that is, noradrenaline--and function as neuro-vasomuscular synapses. The sympathetic nerve supply of bone originates from the appropriate ganglion, and in the case of the tibial diaphysis it descends through the sciatic nerve and thereafter mainly through the medial popliteal nerve and enters the bone alongside the nutrient artery

Two distinct lesions affect the articular cartilage of the patella. Surface degeneration occurs particularly on the odd facet; it is age dependent, often present in youth and it becomes more frequent with increasing age. It probably does not occasion patello-femoral pain in youth, but may predispose to degenerative arthritis in that joint in later years and is regarded as a consequence of habitual disuse. The term "basal degeneration" is used to describe a lesion in which there is a fasciculation of collagen in the middle and deep zones of cartilage without, at first, affecting the surface. It was found astride the ridge separating the medial from the odd facet in twenty-three adolescents who had complained of prolonged patello-femoral pain. They were treated by excision of the disc of affected cartilage, with relief of pain in most cases. The pathogenesis of basal degeneration is related to the functional anatomy of the patella

1. Congenital defects of the extremities are described. Although the detailed anatomy is infinitely variable, a broad classification in relation to prosthetic management has been suggested. 2. Most patients with these deformities can be fitted with a prosthesis without major surgical intervention. With this they will have at least as good function as they would have after amputation. A plea is made for a conservative attitude in this respect. It is suggested that recourse to amputation should be confined to cases in which prosthetic equipment falls short of functional and cosmetic requirements, and that, when possible, it should be deferred until the child is old enough to share in the decision. 3. The prostheses applicable to the various types of deformity are briefly described. 4. The application of similar techniques to cases of acquired shortening is mentioned. 5. The incorporation of certain features of artificial arms in flail arm splints is discussed

Posterior cervical wiring is commonly performed for patients with spinal instability, but has inherent risks. We report eight patients who had neurological deterioration after sublaminar or spinous process wiring of the cervical spine; four had complete injuries of the spinal cord, one had residual leg spasticity and three recovered after transient injuries. We found no relation between the degree of spinal canal encroachment and the severity of the spinal-cord injury, but in all cases neurological worsening appeared to have been caused by either sublaminar wiring or spinous process wiring which had been placed too far anteriorly. Sublaminar wiring has substantial risks and should be used only at atlantoaxial level, and then only after adequate reduction. Fluoroscopic guidance should be used when placing spinous process wires especially when the posterior spinal anatomy is abnormal

Transarticular screws at the C1 to C2 level of the cervical spine provide rigid fixation, but there is a danger of injury to a vertebral artery. The risk is related to the technical skill of the surgeon and to variations in local anatomy. We studied the grooves for the vertebral artery in 50 dry specimens of the second cervical vertebra (C2). They were often asymmetrical, and in 11 specimens one of the grooves was deep enough to reduce the internal height of the lateral mass at the point of fixation to ≤2.1 mm, and the width of the pedicle on the inferior surface of C2 to ≤2 mm. In such specimens, the placement of a transarticular screw would put the vertebral artery at extreme risk, and there is not enough bone to allow adequate fixation. Before any decision is made concerning the type of fixation to be used at C2 we recommend that a thin CT section be made at the appropriate angle to show both the depth and any asymmetry of the grooves for the vertebral artery

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.

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