A white child with a long history of illness from the age of six was thought at first to have Hodgkin's disease. There followed an acute illness with lesions involving glands, lungs, bone and skin. Mycobacterium avium-intracellulare group (Battey) was isolated from various lesions at the age of thirteen. After six years of continuous treatment the patient, now eighteen, is living a normal life

We describe a case of pyoderma gangrenosum which presented with severe wound breakdown after elective hip replacement. The patient was treated successfully with minimal wound debridement and steroids. This diagnosis should always be considered when confronted with an enlarging painful skin lesion which does not grow organisms when cultured and fails to respond to antibiotic therapy, especially if there are similar lesions in other sites. In patients who have a past history of pyoderma gangrenosum, prophylactic steroids may be indicated at the time of surgery or may be required early in the postoperative period

A lesion similar to that described by Bankart in recurrent dislocation of the shoulder was seen in seven patients with recurrent dislocation of the peroneal tendons. Detachment of the periosteum had resulted in the formation of a false pouch on the surface of the lower end of the fibula; into this pouch the peroneal tendons could easily dislocate. Reattachment of the periosteum to drill holes in the fibula prevented dislocation, and this anatomical method of repair is described. This lesion is one of the causes of recurrent dislocation of the peroneal tendons

Controversy surrounds the aetiology of obstetric brachial plexus lesions. Most authors consider that it is caused by traction or compression of the brachial plexus during delivery. Some patients, however, present without a history of major traction during delivery, and some delivered by Caesarean section also suffer the injury. In our series of 42 infants, 28 had an Erb’s palsy, and the remaining 14 presented with a more extensive lesion, involving the lower roots. In five of these, a complete ossified cervical rib was found. We believe that anatomical variations, such as cervical ribs or fibrous bands, can cause narrowing of the supracostoclavicular space, and render the adjacent nerves more susceptible to external trauma

The clinical, radiological and pathological features of hallux rigidus affecting nine toes (in seven patients) are described. Characteristic chondral and osteochondral lesions are seen to occur at a specific site on the metatarsal head, and account for the limitation of dorsiflexion but relatively unrestricted plantarflexion typical of hallux rigidus. Radiologically these lesions are often missed because they are mainly cartilaginous and are later obscured by secondary degenerative changes. Histological evidence indicates a traumatic aetiology and a mechanism of injury is suggested

Aims

The aim of this study was to present the long-term surgical outcomes, complications, implant survival, and causes of implant failure in patients treated with the modified Harrington procedure using antegrade large diameter pins.

We review the case of a 58-year-old man with a benign osteoblastic lesion. This originated in the base of the right second metacarpal and eventually involved several adjacent bones, persisting for at least 27 years despite 11 operations. It was originally reported in the literature as a recurrent osteoid osteoma, but we believe it is more properly diagnosed as an aggressive osteoblastoma, since the histological pattern did not change over the years. The lesion has remained locally aggressive with no evidence of malignant characteristics

In cerebral palsy, the site and severity of the brain lesion are directly linked to gross motor function and the development of musculoskeletal deformities. The relationship between walking ability and orthopaedic surgery in children with cerebral palsy is not fully understood. The development of new tools such as the Functional Assessment Questionnaire and the Functional Mobility Scale can be used to give new insights on the functional impact of multilevel surgery. These scales are most useful as part of systematic, long-term follow-up

Eleven patients with arthrogryposis multiplex congenita neurologica have been reviewed. Distinct patterns of deformity and muscle activity were identified which have been correlated with specific levels of segmental neurological motor deficit without sensory loss. The clinical picture was consistent with localised lesions of the anterior horn cell cell columns. This finding agreed with the recorded pathological lesions. Orthopaedic treatment should take account of the paralytic nature of the deformities

1. Of forty-seven patients with histologically proven myeloma of the spine, thirty-three had multiple lesions at the time of the first examination and fourteen were solitary. 2. Five of the solitary cases, in which the patients are alive and well without signs of dissemination four to fourteen years after diagnosis, are considered in detail and the differences in clinical presentation and prognosis are discussed. 3. A sixth case, described in detail, showed scattered osteolytic lesions after ten years

Animal studies have shown that implanted anterior cruciate ligament (ACL) grafts initially undergo a process of revascularisation prior to remodelling, ultimately increasing mechanical strength. We investigated whether minimal debridement of the intercondylar notch and the residual stump of the ruptured ACL leads to earlier revascularisation in ACL reconstruction in humans. We undertook a randomised controlled clinical trial in which 49 patients underwent ACL reconstruction using autologous four-strand hamstring tendon grafts. Randomised by the use of sealed envelopes, 25 patients had a conventional clearance of the intercondylar notch and 24 had a minimal debridement method. Three patients were excluded from the study. All patients underwent MR scanning postoperatively at 2, 6 and 12 months, together with clinical assessment using a KT-1000 arthrometer and International Knee Documentation Committee (IKDC) evaluation. All observations were made by investigators blinded to the surgical technique. Signal intensity was measured in 4 mm diameter regions of interest along the ACL graft and the mid-substance of the posterior cruciate ligament. Our results indicate that minimal debridement leads to earlier revascularisation within the mid-substance of the ACL graft at two months (paired t-test, p = 0.002). There was a significant reduction of mid-substance signal six months after the minimal debridement technique (paired t-test, p = 0.00007). No statistically significant differences were found in tunnel placement, incidence of Cyclops lesions, blood loss, IKDC scores, range of movement or Lachman test between the two groups

1. Epidural abscess should be suspected in patients with lumbar and sciatic pain who have a history of staphylococcal skin infections or of diabetes. 2. The diagnosis of epidural abscess should be considered before that of herniation of a disc if the patient presents an otherwise unexplained pyrexia. The absence of radiographic changes is no bar to this diagnosis. 3. The hazards of lumbar puncture in cases of epidural abscess are obvious. 4. Early diagnosis and operation are essential to control the infective lesion and to ensure recovery of the neural lesion

1. The supraspinatus group of lesions constitutes one of the two common causes of the painful shoulder. 2. Most, but not all, of these lesions resolve either spontaneously or after conservative treatment. 3. When conservative treatment fails symptoms can be relieved by excision of the acromion process, provided that sufficient bone is removed to relieve all pressure on the tendon throughout a full range of shoulder movement. 4. Excision of the acromion is contra-indicated if there is doubt as to the diagnosis or if there is true limitation of shoulder movement

We have investigated the effectiveness of the transplantation of bone-marrow-derived mononuclear cells (BMMNCs) with interconnected porous calcium hydroxyapatite (IP-CHA) on early bone repair for osteonecrosis of the femoral head. We studied 22 patients (30 hips) who had osteonecrosis with a minimum follow-up of one year after implantation of BMMNCs. The mean age at surgery was 41 years (18 to 64) and the mean period of follow-up was 29 months (19 to 48). In a control group, cell-free IP-CHA was implanted into a further eight patients (9 hips) with osteonecrosis of the femoral head and the outcomes were compared. A reduction in the size of the osteonecrotic lesion was observed subsequent to hypertrophy of the bone in the transition zone in the BMMNC group. In three patients in the treatment group progression to extensive collapse was detected. In the control group subtle bone hypertrophy was observed, but severe collapse of the femoral head occurred in six of eight hips. In this limited study the implantation of BMMNCs and IP-CHA appears to confer benefit in the repair of osteonecrosis and in the prevention of collapse

Primary subacute haematogenous osteomyelitis (PSHO) of the small bones of the foot is a rare and infrequently considered cause of a limp in children. We describe 11 patients with PSHO, of whom nine were under three years of age, who had a limp with few symptoms. The talus was involved in 36%. Bone scans were positive in all patients and led to localisation of the lesion in two. The radiological features included soft-tissue swelling, an osteolytic lesion in the talus and the calcaneus and a sclerotic appearance of the cuboid and the navicular bones. All patients except one were cured with antibiotics

Aims

To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP).

Thirty patients with osteochondritis dissecans of the ankle have been followed up for an average of 21 years. The histories and radiographs were reviewed, and it was found that most patients had only minor radiographic changes and symptoms. Two patients had developed osteoarthritis but in only one was this severe. Osteochondritis dissecans in the ankle thus seems to differ from the same lesion in the knee where late osteoarthritis often occurs. Two lesions were located on the joint surface of the distal tibia, a site not previously reported

Radiopharmaceuticals have been successfully used to detect occult neoplasms and infective lesions. Bone scans using 99mTc-labelled methylene diphosphonate located osteoid osteomas accurately in a series of 30 symptomatic patients. A portable radiation detector system has been designed to help intra-operative localisation and facilitate complete excision of the lesions with minimal damage to normal tissue. A sodium iodide detector with a fibre-optic link was used at first, but a cadmium telluride system has provided a more durable, reliable and sensitive sterilisable probe

1 . An epileptic patient with Dupuytren's contracture of the palms, severe plantar fibromatosis, prominent knuckle pads, periarthritis of the shoulders and hyperplasia of the gums is described. 2. The plantar lesions recurred despite radical excision. The knuckle pads on one hand disappeared after radiotherapy. 3. The association of each of these conditions with epilepsy and with Dupuytren's contracture is reviewed, and it is suggested that the hyperplasia of the gums may be a hitherto unrecognised feature. 4. The characteristic histological appearances of the plantar lesions are described and the risk of confusion with fibrosarcoma is emphasised