1 . Standard lumbar laminectomy was performed at multiple levels in thirty dogs, and manipulations were carried out in the spinal canal to observe their effects on periradicular adhesion formation. The canal was scarified, packed with Gelfoam, or treated with three varieties of Silastic membranes. The results were serially assessed from three days to twelve weeks by gross observation, nerve conduction studies, histological examination of transverse sections of the spine, myelin study of lumbar roots and micropaque study of the arterial supply to the roots. 2. The results were consistent biologically. The principal source of scar is dorsally in the fibrous tissue elements of the erector spinae muscle mass. This scar, the laminectomy membrane, covers the laminectomy defect and extends into the canal bilaterally to adhere to the dura and nerve roots. 3. Gelfoam does not contribute to scar formation, but instead acts as an effective interposing membrane. Silastic membranes are capable of providing protection against nerve root adhesions without interfering with the anatomical or physiological integrity of the nerves. 4. Certain clinical implications of the study are discussed

We present the electromyographic (EMG) results ten years after open decompression of the median nerve at the wrist and compare them with the clinical and functional outcomes as judged by Levine’s Questionnaire. This retrospective study evaluated 115 patients who had undergone carpal tunnel decompression at a mean of 10.47 years (9.24 to 11.36) previously. A positive EMG diagnosis was found in 77 patients (67%), including those who were asymptomatic at ten years. It is necessary to include both clinical and functional results as well as electromyographic testing in the long-term evaluation of patients who have undergone carpal tunnel decompression particularly in those in whom revision surgery is being considered. In doubtful cases or when there are differing outcomes, self-administered scales such as Levine’s Questionnaire should prevail over EMG results when deciding on the need for revision surgery

1. The amount of orthopaedic surgery which is possible in patients with leprosy is immense. It is likely to decline with improved medical care as deformity rarely begins after the start of medical treatment. In spite of prolonged chemotherapy, skin smears often remain positive for more than five years and lifelong treatment may be necessary. 2. In Hong Kong the disease affects mainly those in the best working years of their lives and at an age when they should be best able to understand the benefits that treatment confers. Education of the public must be one of the main points of disease control. This education should extend to enable patients with anaesthetic extremities to learn the limitations that the disease places upon their activities. Thus they will be less liable to injure themselves and better able to prevent minor injuries from becoming serious. Ulceration only occurs in areas lacking protective sensation but, although bilateral anaesthesia is common, bilateral ulceration is not often seen. 3. In patients with diminished sensation or with paralysed muscle groups there is usually enlargement of the nerves but this may be difficult to detect. 4. Clawing of the fingers is best treated by standard surgical procedures but opposition transplant in the combined median and ulnar nerve paralysis of leprosy is less satisfactory. Any transplant must prevent hyperextension at the metacarpo-phalangeal joint and this is best done by providing a double insertion for the transplant. If the soft tissues between the first and second metacarpals are contracted it is better to perform osteotomy of the base of the first metacarpal bone rather than to perform the standard operation of soft-tissue release and skin grafting. 5. The value of tibialis posterior transplantation in drop-foot has been confirmed. 6. The problem of fitting an artificial limb to an anaesthetic stump has not been solved. It was often found that ulcers of the stump occurred even with well-fitting sockets and cooperative patients. If amputation above the foot is necessary it is usually wiser to try a through-knee amputation. 7. Return of power or sensation after the start of medical treatment is unusual but it is also unusual for these symptoms to be noted for the first time when the patient is taking sulphones. It would be worth while investigating the effects of decompression of the median nerve at the level of the wrist by dividing the carpal ligament in those patients developing symptoms and signs of impaired median nerve function. Nerve decompression should also be performed in patients showing tender, swollen nerves in acute lepromatous reactions where steroid therapy fails to bring improved function within six hours. 8. It is essential that surgical methods of limiting disability such as incision, decapsulation or transposition of nerves, which have received favourable comment in the past, should be repeated in a controlled series. Series, so far, have lacked reference to the natural history of the condition under medical treatment alone and have often lacked adequate follow-up. 9. Acute lepromatous reactions in the foot often subside with little bone destruction if the patient is rested in bed with the foot immobilised in plaster. If deformity occurs it may be corrected by triple arthrodesis or pantalar arthrodesis. Shortening of the limb may be necessary to prevent stretching the posterior tibial artery. The use of staples at operation greatly eases the task of maintaining the position. Surgery is not always contra-indicated in the presence of long-standing ulceration

Aims

To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach.

The medial displacement osteotomy of Chiari has an established place in the management of older children and adults with severe hip dysplasia. The results claimed for the operation are, however, variable. There have also been reports of sciatic nerve lesions. In this study ten cadavers were operated upon. Chiari osteotomy was performed upon five, and five acted as controls. The hemipelvis was removed from each cadaver; each specimen was deep-frozen and sectioned transversely. The distance of the sciatic nerve from the nearest bony point was measured in each section and the results were recorded graphically. A further radiographic and photographic study was performed to determine whether apparent displacement at the osteotomy might be misleading. The conclusion was drawn that the sciatic nerve is angulated at the osteotomy and further endangered by the risk of bone splintering at the sciatic notch. The radiographic study suggested that some poor clinical results may be explained by a radiological artefact, because there is a tendency for the osteotomy to hinge posteriorly at the sciatic notch opening anteriorly like a book. Radiographs may suggest excellent medial displacement whereas in fact the femoral head is very poorly covered

Aims

High-grade dysplastic spondylolisthesis is a disabling disorder for which many different operative techniques have been described. The aim of this study is to evaluate Scoliosis Research Society 22-item (SRS-22r) scores, global balance, and regional spino-pelvic alignment from two to 25 years after surgery for high-grade dysplastic spondylolisthesis using an all-posterior partial reduction, transfixation technique.

Aims

Patients with a triangular fibrocartilage complex (TFCC) injury report ulnar-sided wrist pain and impaired function. The surgical procedure of TFCC reinsertion aims to improve function in patients with this injury in whom conservative treatment has failed. The purpose of this study was to investigate the outcomes of open TFCC reinsertion.

Aims

Use of the direct anterior approach (DAA) for total hip arthroplasty (THA) has increased in recent years due to proposed benefits, including a lower risk of dislocation and improved early functional recovery. This study investigates the dislocation rate in a non-selective, consecutive cohort undergoing THA via the DAA without any exclusion or bias in patient selection based on habitus, deformity, age, sex, or fixation method.

Aims

We compared the clinical outcomes of curved intertrochanteric varus osteotomy (CVO) with bone impaction grafting (BIG) with CVO alone for the treatment of osteonecrosis of the femoral head (ONFH).

We describe a 23-year-old woman with neuritis ossificans involving the tibial, common peroneal and lateral sural nerves. She presented with chronic debilitating posterior knee pain. An MRI scan showed masses in these nerves, biopsy of which revealed a histological diagnosis of neuritis ossificans. Treatment with OxyContin and Neurotin for two years resulted in resolution of symptoms. Follow-up MRI demonstrated a resolution of two of the three masses. There was a persistent area of ossification without associated oedema in the common peroneal nerve. Neuritis ossificans has the histological appearance of myositis ossificans and follows a similar clinical course. The success of conservative treatment in this case suggests that the potential complications of surgical excision can be avoided

Of a total of 330 patients requiring operation on a lumbar disc, 20 (6.1%) with lateral disc prolapse had a new muscle-splitting, intertransverse approach which requires minimal resection of bone. There were 16 men and 4 women with a mean age of 52 years. All had intense radicular pain, 15 had femoral radiculopathy and 19 a neurological deficit. Far lateral herniation of the disc had been confirmed by MRI. At operation, excellent access was obtained to the spinal nerve, dorsal root ganglion and the disc prolapse. The posterior primary ramus was useful in locating the spinal nerve and dorsal root ganglion during dissection of the intertransverse space. At review from six months to four years, 12 patients had excellent results with no residual pain and six had good results with mild discomfort and no functional impairment. Two had poor results. There had been neurological improvement in 17 of the 20 patients. We report a cadaver study of the anatomy of the posterior primary ramus. It is readily identifiable through this approach and can be traced down to the spinal nerve in the intertransverse space. We recommend the use of a muscle-splitting intertransverse approach to far lateral herniation of the disc, using the posterior primary ramus as the key to safe dissection

Aims

To compare the functionality of adults with displaced mid-shaft clavicular fractures treated either operatively or nonoperatively and to compare the relative risk of nonunion and reoperation between the two groups.

Aims

The value of core decompression (CD) in the treatment of osteonecrosis of the femoral head (ONFH) remains controversial. We conducted a systematic review and meta-analysis to evaluate whether CD combined with other treatments could improve the clinical and radiological outcomes of ONFH patients compared with CD alone.

Aims

To describe the risk of periprosthetic joint infection (PJI) and reoperation in patients who have an acute, traumatic wound dehiscence following total knee arthroplasty (TKA).

1 . In the common type of Volkmann's ischaemic contracture affecting the forearm flexors, the infarct takes the form of an ellipsoid with its axis in the line of the anterior interosseous artery and with its central point a little above the middle of the forearm. The greatest damage is at the centre and usually falls most heavily on flexor digitorum profundus and flexor pollicis longus, which are often necrotic. Those muscles more superficially placed, and sometimes the deep extensors, are more likely to exhibit fibrosis. 2. The median nerve runs near the centre of the ellipsoid and may exhibit profound ischaemia. The ulnar nerve, lying at the edge of the ischaemic zone, tends to be less severely affected. 3. The treatment for this condition is excision of all tissues irreparably damaged by ischaemia. If this operation is performed within twelve months from the time of injury, correction of the contracture should be almost complete. The tendons of shortened but active muscles are lengthened or transplanted. 4. After such excision it is possible to carry out reconstructive procedures commonly used in the surgery of lower motor neurone disorders and of trauma. A wide variety of tendon transplantations is available. The median nerve may be repaired either by a free graft or, in cases where both nerves have been extensively damaged by ischaemia, by an ulnar to median nerve-pedicle graft

1. Between 1936 and 1945, 525 patients with sciatic pain were treated at the Princess Elizabeth Orthopaedic Hospital, Exeter. Of these, 225 had neurological signs and they were selected for review; 147 were traced. 2. Of these, 123 were treated by means of plaster jackets and twenty-four were treated by other methods. The late results of treatment in the two groups were about the same, roughly one-third being "cured," one-third "relieved," and one-third "not relieved.". 3. Nevertheless examination of the immediate results suggests that protection by means of a plaster jacket had at least a palliative effect, relieving acute symptoms and allowing early rehabilitation. Moreover it should be emphasised that in limiting the investigation to cases of sciatica with evidence of nerve root pressure only the more severe cases have been included. 4. Permanent relief after immobilisation in plaster was greatest when the duration of symptoms was short, and when the patient was treated during his first attack. It was least in patients who showed all three signs of nerve root pressure—diminished ankle jerks, hypo-aesthesia, and muscle hypotonicity. 5. Absence of tendon reflexes due to nerve root pressure, and areas of hypo-aesthesia, tend to remain permanently; but diminution of reflexes and loss of muscle power may recover

Intra-operative, peri-articular injection of local anaesthesia is an increasingly popular way of controlling pain following total knee replacement. At the same time, the problems associated with allogenic blood transfusion have led to interest in alternative methods for managing blood loss after total knee replacement, including the use of auto-transfusion of fluid from the patient’s surgical drain. It is safe to combine peri-articular infiltration with auto-transfusion from the drain. We performed a randomised clinical trial to compare the concentration of local anaesthetic in the blood and in the fluid collected in the knee drain in patients having either a peri-articular injection or a femoral nerve block. Clinically relevant concentrations of local anaesthetic were found in the fluid from the drains of patients having peri-articular injections (4.92 μg/ml (. sd. 3.151)). However, none of the patients having femoral nerve blockade had detectable levels. None of the patients in either group had clinically relevant concentrations of local anaesthetic in their blood after re-transfusion. The evidence from this study suggests that it is safe to use peri-articular injection in combination with auto-transfusion of blood from peri-articular drains during knee replacement surgery