The intermetatarsophalangeal bursa was investigated by dissection, radiography and injection. In the web spaces between the second and third and the third and fourth digits the bursa lies superior to the transverse metatarsal ligament but projects distally to it, closely applied to the neurovascular bundle. Tissue from the web spaces of patients with classical Morton's metatarsalgia often shows lymphocytic infiltration, with additional fibrinoid necrosis of the bursal wall. It is suggested that inflammatory changes in this bursa could account for the pathological and histological findings in this condition. The bursa in the most lateral web space does not extend beyond the ligament and is not in contact with the neurovascular bundle, which may explain the rarity of symptoms in this space

Aims

Options for the treatment of intra-articular ligament injuries are limited, and insufficient ligament reconstruction can cause painful joint instability, loss of function, and progressive development of degenerative arthritis. This study aimed to assess the capability of a biologically enhanced matrix material for ligament reconstruction to withstand tensile forces within the joint and enhance ligament regeneration needed to regain joint function.

Objectives

Re-rupture is common after primary flexor tendon repair. Characterization of the biological changes in the ruptured tendon stumps would be helpful, not only to understand the biological responses to the failed tendon repair, but also to investigate if the tendon stumps could be used as a recycling biomaterial for tendon regeneration in the secondary grafting surgery.

The passage of technetium-labelled methylene diphosphonate (99mTc-MDP) across rat bone was examined by autoradiography. The autoradiographs showed that shortly after an injection of the bone-seeking agent there was activity outside the bone, within the bone marrow and also adjacent to the highly vascular epiphysial plate; the distribution of the isotope in the incubated bone appeared to be non-uniform, a high concentration being seen adjacent to the epiphysial plate and also on the surfaces of the bone. The evidence suggested that a two-fold mechanism resulted in the uneven distribution of 99mTc-MDP. The first factor probably represented the regional distribution of blood flow with a transcapillary movement of the tracer from the capillary bed to the extravascular space; the subsequent incorporation of the tracer into bone appeared to depend on the nature of the bone matrix

Isolated neuropathy of the cutaneous branch of the radial nerve is a rarely recognised condition. Five cases were described in 1932 by Wartenberg, who suggested the name cheiralgia paraesthetica. The condition has also been described as Wartenberg's disease. Twelve cases of isolated neuropathy of the cutaneous branch of the radial nerve are described, the literature is reviewed and the clinical picture outlined. In six of the cases the condition subsided without treatment, in two there was a good response to local injection of hydrocortisone, and in four cases a satisfactory result followed resection of the nerve. The course and distribution of the superficial branch of the radial nerve are described. The need to avoid the nerve during operations around the wrist is stressed

We evaluated 67 shoulders in 65 patients who had pain and dysfunction for more than two years after an initial acromioplasty for impingement syndrome without a rotator cuff tear. In addition to a thorough history, physical examination, local anaesthesia injection and any other necessary investigations all patients had arthroscopic evaluation of the shoulder. In 27 shoulders there had been diagnostic errors, and in 28 operative errors; only in 12 had the diagnosis and the operative procedure both been correct. Subsequent operative intervention in patients not receiving worker's compensation benefit had a 75% success rate, whereas in those receiving such benefits the success rate was only 46%

Cadaveric lumbar discs were injected with chymopapain and subjected to a series of mechanical tests over a period of up to 19 hours. Discs from the same spine injected with saline were used as controls. The results showed that chymopapain had no measurable effect on the mechanical properties of the disc apart from the increased height and stiffening caused by fluid injection. Another series of tests on isolated pieces of disc material showed that chymopapain could reduce the size of prolapsed nuclear material by 24% in one hour and by 80% in 48 hours. It is concluded that, in the short-term, chymopapain has a negligible effect on the mechanics of a disc but it can reduce the size of any prolapsed nuclear material with which it comes in contact

In order to study the effect of pure torsional forces upon the rotational development of the growing tibia, 35 immature rabbits underwent torsional loading of one tibia in vivo with a spring-loaded cylinder while the other tibia was a control. The radiographic results showed rotation occurring only at the epiphysial plate. Histologically this was assocaited with angulation of the hypertrophic cartilage columns occurring as little as 24 hours after loading which with longer periods of loading produced angled primary and secondary trabeculae. Radiographic and histological analyses of the diaphysis using tetracycline labelling and Spalteholtz injection techniques failed to show any evidence of cortical remodelling or reorientation of the cortical vessels of a rotational nature, suggesting that rotational modelling occurs solely at the epiphysial plate

1. Degenerative arthritis has been produced consistently in adult rabbits by the injection of the proteolytic plant enzyme papain into the hip joint. Arthritic changes were recognisable radiographically after six weeks. 2. A progression of changes occurred, from loss of acid mucopolysaccharide staining in the matrix, fibrillation, fissuring and erosion of articular cartilage with death of chondrocytes in the weight-bearing areas, to secondary bony changes of subchondral sclerosis, occasional cysts and osteophyte formation. 3. Synovial inflammation occurred with accumulation of cartilage and bone debris in the inferior capsule and later capsular thickening. 4. It is suggested that this arthritis is sufficiently similar to human osteoarthritis to be useful as a model for further studies of the pathogenesis of the disease and the effects of different methods of treatment

1. Tennis elbow is largely an affliction of middle age, and it is believed that degenerative changes in the orbicular ligament may underlie its pathology. 2. It has been shown that most patients may be relieved by either extra-articular or intra-articular injection of hydrocortisone, and operative intervention is required only in a minority of cases. 3. Contraction of the extensor carpi radialis brevis is considered to be the principal pain-producing factor, and Z-lengthening of the tendon of this muscle has been found to relieve the symptoms when conservative measures have failed. 4. The late results in fifty patients have shown that this operation causes diminution neither of the power of wrist dorsiflexion nor in the efficiency of the grip. The operation may therefore be undertaken with every prospect of relieving the discomfort of tennis elbow without inviting alternative disability

1. Based on studies in seventy-five patients, a technique is described for body surface activity measurements over localised skeletal lesions up to one month after injection of the λ-emitting isotopes Ca. 47. and Sr. 85. . 2. The activity was high over skeletal lesions like fracture, metastatic cancer, eosinophilic granuloma, chondroma, osteomyelitis and Paget's disease. 3. The high isotope uptake is interpreted as evidence of an increased rate of bone tissue turnover. 4. These findings suggest that external counting of Ca. 47. and Sr. 85. may be used for quantitation of the rate of formation of normal and pathological bone tissue. A special application would be localisation and delineation of metastatic cancer in cases where radiographic evidence is uncertain or non-existent

We analysed the CT scans and radiographs of 76 vertebrae in 49 patients who underwent vertebroplasty for painful osteoporotic compression fractures. Leaks of cement were classified into three types: those via the basivertebral vein (type B), via the segmental vein (type S), and through a cortical defect (type C). More leaks were identified on CT scans than on radiographs by a factor of 1.5 (74/49). Most type-B (93%) and type-S (86%) leaks were missed or underestimated on a lateral radiograph which is usually the only view used during the injection of cement. Of the leaks into the spinal canal, only 7% (2/28) were correctly identified on radiographs. The areas on lateral radiographs where this type of leak may be observed were divided into four zones, and their diagnostic value in predicting a leak into the spinal canal was evaluated. The results showed that cement in the neural foramina had the highest positive predictive value (86%)

The effect of zoledronic acid on bone ingrowth was examined in an animal model in which porous tantalum implants were placed bilaterally within the ulnae of seven dogs. Zoledronic acid in saline was administered via a single post-operative intravenous injection at a dose of 0.1 mg/kg. The ulnae were harvested six weeks after surgery. Undecalcified transverse histological sections of the implant-bone interfaces were imaged with backscattered scanning electron microscopy and the percentage of available pore space that was filled with new bone was calculated. The mean extent of bone ingrowth was 6.6% for the control implants and 12.2% for the zoledronic acid-treated implants, an absolute difference of 5.6% (95% confidence interval, 1.2 to 10.1) and a relative difference of 85% which was statistically significant. Individual islands of new bone formation within the implant pores were similar in number in both groups but were 69% larger in the zoledronic acid-treated group. The bisphosphonate zoledronic acid should be further investigated for use in accelerating or enhancing the biological fixation of implants to bone

1. The distribution of isotope following a single injection of either Ca. 45. or C. 14. -proline has been studied in young rats in which one tibia had previously been removed, killed and reimplanted. 2. The dead tibia took up about 25 per cent as much Ca. 45. or C. 14. as did the living tibia and the possible processes by which this occurred are discussed. 3. Determination of the "accretion rate " by kinetic analysis of the Ca. 45. data showed that this was much too high unless the physico-chemical process of uptake of isotope by bone was taken into account. 4. Under the conditions of the experiment it was not possible to estimate the rate of bone matrix formation using C. 14. -proline as a tracer

Using a scintigraphic technique based on anautologous injection of . 99m. Tc-labelled erythrocytes, we have evaluated the efficiency of different exsanguination procedures in the upper limb of ten healthy male volunteers. The methods were elevation alone, the use of the Esmarch bandage or a gauze bandage, the Pomidor roll-cuff, the squeeze method and the Urias bag. The various procedures gave the following median percentage reductions of blood volumes: elevation for 5 seconds 44%, 15 seconds 45%, 30 seconds 46%, 60 seconds 46% and 4 minutes 42%, the Esmarch bandage 69%, a gauze bandage 63%, the Pomidor roll-cuff 66%, the squeeze method 53%, and the Urias bag 57%. With regard to elevation alone no significant differences were found. All the external methods were significantly more effective than elevation alone. Overall, the squeeze method was found to be the best method of exsanguination before inflation of a tourniquet, because it is effective, fast, practical and inexpensive

In order to investigate the difficulty of quadriceps training in the presence of an effusion into the knee we examined 13 patients with chronic effusions by recording isometric muscle strength. Maximal strength was markedly lower in the presence of an effusion, and aspiration of the effusion produced a 13.6% increase in strength (p less than 0.01). A further, small increase of 8% was recorded after intra-articular lignocaine injection. Isometric strength and surface integrated EMG correlated well in six patients. Two reflex mechanisms seem to inhibit quadriceps innervation in the presence of a persistent knee effusion, one mediated by pressure sensitive receptors, the other still unknown. Joint aspiration and systemic or intra-articular anti-inflammatory drug treatments are advised before any programme of quadriceps training to allow maximum effects to be achieved

The acute childhood diseases haematogenous staphylococcal osteomyelitis and septic arthritis were studied concurrently using avian models which closely resemble the human diseases. Ultrastructural studies during the initial stages of bone and joint infection showed that adherence of bacteria to cartilage, bacterial proliferation, cartilage destruction and subsequent bacterial spread along the vascular channels within cartilage were common to both disease processes. Histological studies revealed that transphyseal blood vessels were present in the growing chickens and were a likely explanation for the frequency of the concurrence of acute osteomyelitis and adjacent joint infection following intravenous injection of bacteria. Transphyseal vessels provide a direct connection between the growth plate (physis) and epiphyseal cartilage supplying a route for bacteria to spread from an osteomyelitic focus in the metaphysis to the epiphysis and subsequently to the joint lumen

Major ruptures of the rotator cuff were repaired in 89 patients over a six-year period, using an approach through the split deltoid muscle and the bed of the excised outer centimetre of the clavicle. Review of these patients showed that poor results were associated with larger cuff defects, with more pre-operative steroid injections and with pre-operative weakness of the deltoid muscle. A randomised prospective study showed that repair followed by splinting in abduction gave no better results than repair followed by resting the arm at the side. Excision of the coraco-acromial ligament was associated with worse results than leaving its divided halves in situ. Follow-up showed that the results continued to improve for two years after operation; their quality was maintained in patients less than 60 years old, but in those over 60 there was deterioration with time

Ninety-seven patients suffering from painful arc syndrome of the shoulder were studied. Local anaesthetic and radiographic contrast investigations were carried out. One-third of the patients had lesions in the posterior part of the rotator cuff which resolved after injections of local anaesthetic and steroid. One-third had anterior lesions in the subscapularis tendon: almost all resolved under the same regime but two required division of the coraco-acromial ligament. The remaining third had lesions of the supraspinatus tendon, usually associated with degeneration of the acromio-clavicular joint: most of these failed to gain relief from the local anaesthetic and steroid. Twenty-two operations were performed either by a transcromial or by a deltoid splitting approach. Excision of the outer end of the clavicle and division of the coraco-acromial ligament abolished the pain in most cases

1. Chronic tuberculous osseous lesions were induced consistently in eight- to ten-week-old unvaccinated guinea-pigs by the insertion of Gelfoam impregnated with mycobacterium tuberculosis into the metaphysial region through a drill hole in the distal part of the femur. Typical tuberculous lesions developed by three weeks and many of them were followed for twelve weeks or more. 2. This experimental model establishes a reliable method of producing a localised lesion at a predetermined site without early death of the animal. The model is sufficiently similar to the human lesion, and may offer a reliable system for further investigations. 3. It was observed that streptomycin penetrates readily into tuberculous osseous lesions. The concentration of streptomycin found in the tuberculous lesion after a single intramuscular injection was much higher than the concentration considered sufficient to have an inhibitory effect on the human type of mycobacterium tuberculosis