We have reviewed 31 consecutive patients, aged 65 years or more, after surgical decompression for degenerative lumbar spinal stenosis. The average follow-up was 42 months. Assessment included a standard questionnaire, a pain diagram which was completed by the patient, and clinical and radiological examination. Patients were considered in three groups; degenerative spondylolisthesis (19), lateral recess stenosis (5), and central-mixed stenosis (7). The indication for surgery was leg pain: no patient had an operation for back pain alone. Fusion was never performed. Overall, 64% of the patients had an excellent result, 17% a good result and 19% a poor result. We conclude that the long-term outcome of decompressive surgery in the elderly is good; it does not differ from that reported for younger patients

Over a seven-year period we treated a consecutive series of 58 patients, 20 men and 38 women with a mean age of 66 years (21 to 87) who had an acute complex anterior fracture-dislocation of the proximal humerus. Two patterns of injury are proposed for study based upon a prospective assessment of the pattern of soft-tissue and bony injury and the degree of devascularisation of the humeral head. In 23 patients, the head had retained capsular attachments and arterial back-bleeding (type-I injury), whereas in 35 patients the head was devoid of significant soft-tissue attachments with no active arterial bleeding (type-II injury). Following treatment by open reduction and internal fixation, only two of 23 patients with type-I injuries developed radiological evidence of osteonecrosis of the humeral head, compared with four of seven patients with type-II injuries. A policy of primary treatment by open reduction and internal fixation of type-I injuries is justified, whereas most elderly patients (aged 60 years or over) with type-II injuries are best treated by hemiarthroplasty. The best treatment for younger patients (aged under 60 years) who sustain type-II injuries is controversial and an individualised approach to their management is advocated

The results of 140 total hip revision procedures for "non-septic" loosening, dislocation, and fracture of the femoral stem or shaft have been personally reviewed and rated by the Harris method. The minimum follow-up period was six months: thirty-three (24 per cent) showed excellent or good results, seventy-two (51 per cent) showed fair or poor results. Subsequent excision arthroplasty was performed in thirty-one patients. The infection rate for these revision procedures was very high, suggesting that many were already infected at the time of revision, and that every "loose" hip must be assumed to be infected until proved otherwise. The mortality rate of 3 per cent was surprisingly low after more than one major surgical procedure in these elderly patients

Four cases of extra-osseous osteosarcoma were found among 242 cases recorded as osteosarcoma in the Swedish Cancer Registry during the years 1958 to 1968. The tumours occurred in middle-aged and elderly patients. Three of the tumours were situated in the proximal part of the thigh and one in the scapular region. Histopathologically, all tumours were subclassified as osteoblastic osteosarcomas. The patients were treated by primary local excision which in one case was followed by a radical en bloc excision of the entire tumour bed. All cases subjected to simple excision died of metastatic disease five to twenty-four months after diagnosis. The patient treated by en bloc excision is alive and apparently free from disease fourteen years after diagnosis

We have endeavoured to make known the results of a simple type of arthroplasty of the hip which is well tolerated even by elderly patients. It has not been the purpose of this article to compare former operations with our own, a newcomer in the field of surgery of the hip. In particular we do not wish to compare our comparatively recent results with Smith-Petersen's well-established method of cup arthroplasty—a magnificent contribution to the surgery of the region. The results we have already obtained, however, appear sufficiently favourable to merit further study and development of the method. If the future confirms the value of our early results, we shall perhaps be able to suggest operation to patients who suffer more from loss of function than from pain

Aims

The primary aim of the study was to perform an analysis to identify the cost per quality-adjusted life-year (QALY) of robot-assisted unicompartmental knee arthroplasty (rUKA) relative to manual total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) for patients with isolated medial compartment osteoarthritis (OA) of the knee. Secondary aims were to assess how case volume and length of hospital stay influenced the relative cost per QALY.

A total of 63 women who had an operation for a fracture of the hip was randomly allocated to one year of treatment either with anabolic steroids, vitamin D and calcium (anabolic group) or with calcium only (control group). The thigh muscle volume was measured by quantitative CT. The bone mineral density of the hip, femur and tibia was assessed by quantitative CT and dual-energy x-ray absorptiometry and of the heel by quantitative ultrasound. Quantitative CT showed that the anabolic group did not lose muscle volume during the first 12 months whereas the control group did (p< 0.01). There was less bone loss in the proximal tibia in the anabolic group than in the control group. The speed of gait and the Harris hip score were significantly better in the anabolic group after six and 12 months. Anabolic steroids, even in this moderate dose, given in combination with vitamin D and calcium had a beneficial effect on muscle volume, bone mineral density and clinical function in this group of elderly women

Between December 1982 and June 1986, 98 displaced subcapital femoral neck fractures were treated using the Charnley-Hastings bipolar hemiarthroplasty. Although the patients were elderly, often with associated medical problems, the operation was well tolerated and the mortality at one and six months was 14.4% and 24.5% respectively. Fifty-four hips were reviewed after an average follow-up of 33 months; 64.8% of patients had a good or excellent result. The fair or poor results were seen mainly in patients with poor pre-operative mobility and multiple medical problems. A significant cause of morbidity was dislocation (two interprosthetic) which occurred in six hips. There were two cases of deep sepsis but neither patient was fit for further surgery. There were no cases of acetabular erosion requiring revision surgery

Five cases are presented of bilateral simultaneous rupture of the quadriceps tendon and the English literature of six isolated case reports is reviewed. All the patients were men, and most were over 50 years old. The injury often happens in elderly people and there is diagnostic confusion with other causes of inability to use the legs, notably with mild strokes. In three of our five cases there was a delay in diagnosis. The cardinal features are diffuse swelling around the knee, a visible or palpable suprapatellar defect and the inability to lift the straight leg despite a functioning quadriceps and normal activity in all other muscle groups in the leg. In all our patients operative repair was undertaken, followed by six weeks immobilisation in plaster and subsequent physiotherapy. Even late repair was associated with successful rehabilitation of the patient and a return to useful function

In 30 elderly women awaiting hip arthroplasty on account of unilateral osteoarthritis of the hip, walking speed and oxygen consumption were measured during a 12-minute test and the power output was calculated from the stair climbing rate. The results were compared with those for a group of 30 normal women of similar age. An age-related decline in maximal walking speed was observed in both groups. After arthroplasty there was a significant increase in maximal walking speed, particularly among the more disabled patients, with the major gain occurring by three months and a further slight increase by six months. Oxygen consumption returned towards normal values, and both stride length and cadence increased by a comparable degree. Mean power output during stair climbing doubled, and both before and after arthroplasty bore a linear relationship to the maximal walking speed

Aims

The aim of this study was to describe implant and patient-reported outcome in patients with a unilateral transfemoral amputation (TFA) treated with a bone-anchored, transcutaneous prosthesis.

The Roger Anderson external fixator was used in the treatment of unstable fractures of the distal radius in 52 patients, and the results evaluated after a follow-up averaging 58 months. The indications for its use were failure to maintain adequate closed reduction using plaster, and instability of the fracture as determined by the initial radiographs. Our radiological criteria for instability included dorsal angulation of more than 20 degrees, fractures involving the joint, radial shortening of more than 10 mm, and severe dorsal comminution. Using the Lucas modification of the Sarmiento demerit point-rating system, we found that 46 patients (89%) had good or excellent results and six (11%) were classified as fair. There were no poor results. Seven patients (14%) developed complications. None of these affected the long-term results except in one elderly woman where the pins loosened and had to be removed

We report a randomised prospective trial of the early results of three types of treatment for displaced intracapsular hip fractures. We used a questionnaire sent to patients at about six months (Nottingham Health Profile, NHP) in addition to clinical assessments. There was a 67.4% usable response to the questionnaire, similar to that in other studies using the NHP. There were more responders from younger patients, those walking independently before injury and those with higher mental test scores on admission. In the younger group (65 to 79 years) we found a trend for better scores in most NHP indices after the use of a bipolar prosthesis rather than a unipolar prosthesis or internal fixation, particularly for social function, pain and physical mobility. Postal assessment using the NHP gave a satisfactory response rate even in the elderly, and can provide an extra assessment to complement or replace hospital follow-up in some circumstances

Three elderly sibling dwarfs are reported from a large and otherwise normal family. Their condition is an unusual and irregular form of cartilaginous defect, combined with club-feet, and bearing some resemblance to the Morquio type. A brief consideration of the literature of the generahised developmental bony syndromes shows confusion of thought and nomenclature. A plea is therefore made for simplification and a rational and simple grouping of these conditions is attempted. It seems particularly desirable that many confusing names for particular syndromes should be scrapped (for example, dyschondroplasia, chondro-osteodystrophy), although quite evidently the terms achondroplasia and osteogenesis imperfecta must remain because of their long-standing and general usage. Incidentally I have suggested elsewhere (Jackson 1951) that the name cleido-cranial dysostosis should be dropped, because it tends to lead the investigator away from the clinically more important lesions in the teeth and the cartilage bones of the pelvis and legs. It seems reasonable to confine the nomenclature of these various syndromes to the names used in the above classification, or something on those lines

Nineteen chondrosarcomas are reported arising in proximal phalanges or metacarpal bones of the hand mainly in elderly patients, predominantly women. The usual clinical presentation was of a progressively painful large tumour, often arising in a dormant lesion near the metacarpo-phalangeal joint. Radiologically most showed some bone expansion with a poorly defined area of destruction and a considerable soft-tissue swelling. Histologically, malignancy was usually obvious, but confusion might arise from the inclusion of bland areas of chondromatous tissue that probably represented the original lesion. Four tumours, initially curetted and grafted, recurred locally and necessitated amputation of the digit or ray. Amputation was the primary treatment for fourteen other tumours and was curative except in one patient who eventually needed amputation through the forearm for a large second recurrence. One tumour was satisfactorily controlled by excision of the affected phalanx. None of these nineteen tumours is known to have metastasised. Correct treatment implies a carefully considered balance between conservation of function and complete removal of all tumour tissue

1. A systematic collection of the clinical findings in fifty patients with pyrophosphate synovitis,among some 300 patients with obscure disorder of the knee, has been made over a period of eighteen months. The numbers of men and women were equal, the mean age being seventy years (range thirty-seven to ninety), and the mean age at the onset of symptoms fifty-nine years. 2. A difference in the clinical picture between the sexes was found. In men an acute synovitis predominated, in women chronic joint complaints. 3. A high incidence of accompanying disease was found, but none had a significant relationship to the arthropathy, although the high frequency (20 per cent) of synovitis following an acute severe illness of some other kind was striking. 4. No specific radiological sign except for calcifications in articular cartilage and menisci was found in these patients, and no relationship to osteoarthrosis could be established. 5. The great variability of symptoms and the surprisingly high incidence attracts attention to pyrophosphate synovitis as a cause of joint symptoms, especially in elderly patients

We investigated the effect of calcitonin in the prevention of acute bone loss after a pertrochanteric fracture and its ability to reduce the incidence of further fractures in the same patient. Fifty women aged between 70 and 80 years who had a pertrochanteric fracture of the hip were randomly allocated to group A (200 IU of nasal salmon calcitonin daily for three months) or group B (placebo). Patients in group A showed a significantly higher level of total alkaline phosphatase and osteocalcin on the 15th day after injury and a significantly higher level of bone alkaline phosphatase on the 90th day after surgery. These patients also had significantly lower levels of urinary C-telopeptide (CrossLaps) on the 15th, 45th and 90th days after injury and lower levels of urinary hydroxyproline on the 15th and 45th days after injury. Patients in group A had significantly higher bone mineral density at all recorded sites except the greater trochanter at three months and one year after operation. After a four-year period of clinical observation, five patients (24%) in group B sustained a new fracture, in four of whom (20%) it was of the contralateral hip. Our findings show that calcitonin reduces acute bone loss in patients with pertrochanteric fractures and may prevent the occurrence of new fractures of the contralateral hip in the elderly