The type II Monteggia (posterior) lesion is a rare injury which is sometimes associated with ulnohumeral instability. We have reviewed 23 of 28 patients with this injury. A clinical and radiographic assessment was undertaken at follow-up. Functional outcome scores, including the Broberg and Morrey Index and the Disabilities of the Arm, Shoulder or Hand (DASH), were used. The results from the six patients with associated posterior ulnohumeral dislocation were compared with 17 without ulnohumeral injury. Those with dislocation had reduced movement of the elbow and had outcome scores indicative of greater disability compared to those without associated dislocation

Osteonecrosis of the femoral head can be caused by a variety of disorders and affects the relatively young patient. Most studies have concentrated on the femoral changes; the sites of early lesions of the labrum and acetabular cartilage have not been recorded. We studied 17 hips with osteonecrosis and a wide congruent joint space on radiographs and by direct inspection of the femoral head, labrum and acetabular cartilage during surgery. All of the femoral heads had some anterosuperior flattening which reduced the head-neck ratio in this area. A consistent pattern of damage to the labrum and the acetabular cartilage was seen in all hips. Intraoperatively, impingement and the cam-effect with its spatial correlation with lesions of the labrum and acetabular cartilage were observed. These findings could be helpful when undertaking conservative surgery for osteonecrosis, since the recognition of early radiologically undetectable acetabular lesions may require modification of the surgical technique

Matrix-induced autologous chondrocyte implantation (MACI) is an established technique used to treat osteochondral lesions in the knee. For larger osteochondral lesions (> 5 cm. 2. ) deeper than approximately 8 mm we have combined the use of two MACI membranes with impaction grafting of the subchondral bone. We report our results of 14 patients who underwent the ‘bilayer collagen membrane’ technique (BCMT) with a mean follow-up of 5.2 years (2 to 8). There were 12 men and two women with a mean age of 23.6 years (16 to 40). The mean size of the defect was 7.2 cm. 2. (5.2 to 12 cm. 2. ) and were located on the medial (ten) or lateral (four) femoral condyles. The mean modified Cincinnati knee score improved from 45.1 (22 to 70) pre-operatively to 82.8 (34 to 98) at the most recent review (p < 0.05). The visual analogue pain score improved from 7.3 (4 to 10) to 1.7 (0 to 6) (p < 0.05). Twelve patients were considered to have a good or excellent clinical outcome. One graft failed at six years. The BCMT resulted in excellent functional results and durable repair of large and deep osteochondral lesions without a high incidence of graft-related complications

We have treated osteochondral lesions of the talus using cortical bone pegs. We examined 27 ankles (27 patients) after a mean follow-up of 7.0 years (2 to 18.8). The mean age of the patients was 27.8 years (12 to 62). An unstable osteochondral fragment or osteosclerotic changes in the bed of the talus were regarded as indications for the procedure. The clinical results were good in 24 ankles (89%) and fair in three (11%); none had a poor result. There was also radiological improvement in 24 ankles. Repair of the articular surface and stability of the lesion can be achieved even in unstable chronic lesions

In this study a combination of autologous chondrocyte implantation (ACI) and the osteochondral autograft transfer system (OATS) was used and evaluated as a treatment option for the repair of large areas of degenerative articular cartilage. We present the results at three years post-operatively. Osteochondral cores were used to restore the contour of articular cartilage in 13 patients with large lesions of the lateral femoral condyle (n = 5), medial femoral condyle (n = 7) and patella (n = 1). Autologous cultured chondrocytes were injected underneath a periosteal patch covering the cores. After one year, the patients had a significant improvement in their symptoms and after three years this level of improvement was maintained in ten of the 13 patients. Arthroscopic examination revealed that the osteochondral cores became well integrated with the surrounding cartilage. We conclude that the hybrid ACI/OATS technique provides a promising surgical approach for the treatment of patients with large degenerative osteochondral defects

We compared the quality of debridement of chondral lesions performed by four arthroscopic (SH, shaver; CU, curette; SHCU, shaver and curette; BP, bipolar electrodes) and one open technique (OPEN, scalpel and curette) which are used prior to autologous chondrocyte implantation (ACI). The ex vivo simulation of all five techniques was carried out on six juvenile equine stifle joints. The OPEN, SH and SHCU techniques were tested on knees harvested from six adult human cadavers. The most vertical walls with the least adjacent damage to cartilage were obtained with the OPEN technique. The CU and SHCU methods gave inferior, but still acceptable results whereas the SH technique alone resulted in a crater-like defect and the BP method undermined the cartilage wall. The subchondral bone was severely violated in all the equine samples which might have been peculiar to this model. The predominant depth of the debridement in the adult human samples was at the level of the calcified cartilage. Some minor penetrations of the subchondral end-plate were induced regardless of the instrumentation used. Our study suggests that not all routine arthroscopic instruments are suitable for the preparation of a defect for ACI. We have shown that the preferred debridement technique is either open or arthroscopically-assisted manual curettage. The use of juvenile equine stifles was not appropriate for the study of the cartilage-subchondral bone interface

We investigated 29 cases, diagnosed clinically as having Morton’s neuroma, who had undergone MRI and ultrasound before a neurectomy. The accuracy with which pre-operative clinical assessment, ultrasound and MRI had correctly diagnosed the presence of a neuroma were compared with one another based on the histology and the clinical outcome. Clinical assessment was the most sensitive and specific modality. The accuracy of the ultrasound and MRI was similar and dependent on size. Ultrasound was especially inaccurate for small lesions. There was no correlation between the size of the lesion and either the pre-operative pain score or the change in pain score following surgery. Reliance on single modality imaging would have led to inaccurate diagnosis in 18 cases and would have only benefited one patient. Even imaging with both modalities failed to meet the predictive values attained by clinical assessment. There is no requirement for ultrasound or MRI in patients who are thought to have a Morton’s neuroma. Small lesions, < 6 mm in size, are equally able to cause symptoms as larger lesions. Neurectomy provides an excellent clinical outcome in most cases

A group of patients were studied 10 years after stopping work in a high-pressure environment. Radiographs of their long bones showed little change during the period, but only two of 12 scintigrams were normal. The 10 abnormal scintigrams contained 18 "hot-spots" which were not always associated with an abnormal radiographic appearance; the findings suggest that some lesions may never become visible on a radiograph. A reactive or repair process associated with these lesions may be prolonged and may not be beneficial, as structural failure of the joint may subsequently occur. Prognosis should therefore be guarded

In order to clarify how intra-articular lesions influence the survival of a periacetabular osteotomy in patients with dysplasia of the hip, we performed an observational study of 121 patients (121 hips) who underwent a transposition osteotomy of the acetabulum combined with an arthroscopy. Their mean age was 40.2 years (13 to 64) and the mean follow-up was 9.9 years (2 to 18). Labral and cartilage degeneration tended to originate from the anterosuperior part of the acetabulum, followed by the femoral side. In all, eight hips (6.6%) had post-operative progression to Kellgren–Lawrence grade 4 changes, and these hips were associated with the following factors: moderate osteoarthritis, decreased width of the joint space, joint incongruity, and advanced intra-articular lesions (subchondral bone exposure in the cartilage and a full-thickness labral tear). Multivariate analysis indicated subchondral bone exposure on the femoral head as an independent risk factor for progression of osteoarthritis (p = 0.003). In hips with early stage osteoarthritis, femoral subchondral bone exposure was a risk factor for progression of the grade of osteoarthritis. . Although the outcome of transposition osteotomy of the acetabulum was satisfactory, post-operative progression of osteoarthritis occurred at a high rate in hips with advanced intra-articular lesions, particularly in those where the degenerative process had reached the point of femoral subchondral bone exposure

We report a hitherto undescribed type of peripheral nerve lesion in which pressure results in mechanical demyelinisation of a length of nerve with interruption of conduction. On release of the pressure, early recovery may follow the return of the myelin insulation

Two patients presented with pain in the arm and a radiographic lesion of the upper humerus which warranted surgical exploration and excision biopsy. In both cases the pathology was inflammatory and involved the insertion of pectoralis major. Tendinitis of the pectoralis major with an associated lesion of the humerus has not previously been described

We examined the relationship between the size of the femoral cam in femoroacetabular impingement (FAI) and acetabular pathomorphology to establish if pincer impingement exists in patients with a femoral cam. CT scans of 37 symptomatic impinging hips with a femoral cam were analysed in a three-dimensional study and were compared with 34 normal hips. The inclination and version of the acetabulum as well as the acetabular rim angle and the bony acetabular coverage were calculated. These measurements were correlated with the size and shape of the femoral cams. While the size of the femoral cam varied characteristically, the acetabular morphology of the two groups was similar in terms of version (normal mean 23° (. sd. 7°); cam mean 22° (. sd.  9°)), inclination (normal mean 57° (. sd. 5°); cam mean 56° (. sd. 5°)), acetabular coverage (normal mean 41% (. sd. 5%); cam mean 42% (. sd. 4%)) and the mean acetabular rim angle (normal mean 82° (. sd. 5°); cam mean 83° (. sd. 4°)). We found no correlation between acetabular morphology and the severity of cam lesion and no evidence of either global or focal over-coverage to support the diagnosis of ‘mixed’ FAI. The femoral cam may provoke edge loading but removal of any acetabular bearing surface when treating cam FAI might induce accelerated wear. Cite this article: Bone Joint J 2013;95-B:314–19

Twenty-five patients with 30 chondral lesions of the knee were treated with an autogenous strip of costal perichondrium. The graft was fixed to the subchondral bone with Tissucol (Immuno, Vienna), a human fibrin glue. The leg was then immobilised for two weeks followed by two weeks of continuous passive motion. Weight-bearing was permitted after three months. The mean knee score (Ranawat, Insall and Shine 1976) changed from 73 before operation to 90 one year after; in 14 patients evaluated after two years there was no decrease. In 28 cases the defect was completely filled with tissue resembling articular cartilage. We conclude that in most cases perichondral arthroplasty of cartilage defects of the knee gives excellent results

We investigated the changes seen on serial metal artefact reduction magnetic resonance imaging scans (MARS-MRI) of metal-on-metal total hip arthroplasties (MoM THAs). In total 155 THAs, in 35 male and 100 female patients (mean age 70.4 years, 42 to 91), underwent at least two MRI scans at a mean interval of 14.6 months (2.6 to 57.1), at a mean of 48.2 months (3.5 to 93.3) after primary hip surgery. Scans were graded using a modification of the Oxford classification. Progression of disease was defined as an increase in grade or a minimum 10% increase in fluid lesion volume at second scan. A total of 16 hips (30%) initially classified as ‘normal’ developed an abnormality on the second scan. Of those with ‘isolated trochanteric fluid’ 9 (47%) underwent disease progression, as did 7 (58%) of ‘effusions’. A total of 54 (77%) of hips initially classified as showing adverse reactions to metal debris (ARMD) progressed, with higher rates of progression in higher grades. Disease progression was associated with high blood cobalt levels or an irregular pseudocapsule lining at the initial scan. There was no association with changes in functional scores. Adverse reactions to metal debris in MoM THAs may not be as benign as previous reports have suggested. Close radiological follow-up is recommended, particularly in high-risk groups. Cite this article: Bone Joint J 2015;97-B:1328–37

The effects of gamma irradiation on the growth plate have been studied in nineteen rabbits with a 1,000 rads/skin dose. The rabbits were killed after one to ninety days. The growth plates were studied by microscopic examination, thymidine-H3 autoradiography, and fluorescence with radiographic measurement. Changes were already detected after twenty-four hours at the cell mitosis level, which showed the sensitiveness of the chondrocyte itself. The lesions were clearly seen with the optical microscope after seven days, and they were most advanced between the fourteenth and twenty-first day after irradiation. Regeneration of the cartilage began in the fourth week and the histological appearance became normal after seventy days. Fluorescence with tetracycline showed a temporary retardation of growth, with consequent shortening of the affected limb

We reviewed 42 consecutive children with a supination deformity of the forearm complicating severe birth lesions of the brachial plexus. The overall incidence over the study period was 6.9% (48 of 696). It was absent in those in Narakas group I (27.6) and occurred in 5.7% of group II (13 of 229), 9.6% of group III (11 of 114) and 23.4% of group IV (18 of 77). Concurrent deformities at the shoulder, elbow, wrist and hand were always present because of muscular imbalance from poor recovery of C5 and C7, inconsistent recovery of C8 and T1 and good recovery of C6. Early surgical correction improved the function of the upper limb and hand, but there was a tendency to recurrence. Pronation osteotomy placed the hand in a functional position, and increased the arc of rotation of the forearm. The supination deformity recurred in 40% (17 of 42) of those treated by pronation osteotomy alone, probably because of remodelling of the growing bone. Children should be followed up until skeletal maturity, and the parents counselled on the likelihood of multiple operations

1. Two cases of fracture-dislocation of the spine at the lumbo-sacral level are reported. 2. One patient was treated conservatively and survived, with a cauda equina lesion which is now recovering. One patient was treated by operative decompression and died offat embolism. 3. The lumbo-sacral joint is locked in the dislocated position

Autologous chondrocyte implantation (ACI) and mosaicplasty are methods of treating symptomatic articular cartilage defects in the knee. This study represents the first long-term randomised comparison of the two techniques in 100 patients at a minimum follow-up of ten years. The mean age of the patients at the time of surgery was 31.3 years (16 to 49); the mean duration of symptoms pre-operatively was 7.2 years (9 months to 20 years). The lesions were large with the mean size for the ACI group being 440.9 mm. 2 . (100 to 1050) and the mosaicplasty group being 399.6 mm. 2. (100 to 2000). Patients had a mean of 1.5 previous operations (0 to 4) to the articular cartilage defect. Patients were assessed using the modified Cincinnati knee score and the Stanmore-Bentley Functional Rating system. The number of patients whose repair had failed at ten years was ten of 58 (17%) in the ACI group and 23 of 42 (55%) in the mosaicplasty group (p < 0.001). The functional outcome of those patients with a surviving graft was significantly better in patients who underwent ACI compared with mosaicplasty (p = 0.02)

In 16 patients we used uncemented Lord prostheses at revision operations for aggressive granulomatosis after cemented hip arthroplasties; in 12 bone grafts also were used. In 13 hips the granulomatous lesions were multifocal, and in one the acetabular component was involved. There was no evidence of infection in any case: all the patients had normal ESR and CRP levels. The revision operation was performed on average 9.4 years after the primary replacement; the mean age at revision was 64 years. On radiographs, the bone around the prosthesis had consolidated by an average of 16 months. At follow-up, two to six years later (mean 3.5 years) there had been no recurrences, nine patients had an excellent Mayo hip score, five were good and two fair

We have reviewed 41 patients with pustulotic arthro-osteopathy (PAO), all having both the typical skin rash of pustulosis palmaris et plantaris and bone lesions. The most common bones affected were the clavicle, sternum and ribs. Changes in the clavicle started, not as an enthesopathy, but with periosteal bone formation, indicative of a bone marrow disorder. About 30% of the patients also had lesions in the spine, sacroiliac region or the peripheral joints. Bone and joint lesions followed a variable and intermittent clinical course over a long period of time. Biopsies in eight cases showed similar inflammatory changes in skin, bone and synovium, with infiltration of lymphocytes and polymorphonuclear leucocytes. This suggests that there is a common pathogenesis in the three tissues