1. Thirty-eight cases of tuberculosis of the greater trochanter have been reviewed. 2. Classification into bursal and osseous infections is discussed, and reasons have been given for our belief that either lesion may be the primary one. 3. An attempt has been made to assess available methods of treatment. In general, conservative measures are recommended for primary lesions, and surgery for recurrences. We have the impression that chemotherapy is of definite value. 4. The incidence of spread of tuberculosis to the hip joint is discussed. In this connection, reasons have been given for condemning excision of the trochanter

Dorsal root ganglion neurones with dichotomising axons are present in several species and are considered to play a role in referred pain. Clinically, patients with lesions in the lower lumbar discs occasionally complain of pain in the groin. We investigated the existence of dichotomising afferent neurones projecting axons both to the lumbar disc and to the groin skin, using the double fluorescent-labelling technique in rats. We observed neurones labelled with a tracer applied at the ventral portion of the L5-L6 disc and another tracer placed on the groin skin in L1 and L2 dorsal root ganglia. Our results showed that the double-labelled neurones had peripheral axons which dichotomised into both the L5-L6 disc and the groin skin, indicating the convergence of afferent sensory information from the disc and groin skin. Our findings provide a possible neuroanatomical mechanism for referred groin pain in patients with disc lesions

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

Lateral oblique radiographs are considered important for the identification of spondylolytic lesions, but these projections will give a clear view only when the radiological beam is in the plane of the defect. We studied the variation in orientation of spondylolytic lesions on CT scans of 34 patients with 69 defects. There was a wide variation of angle: only 32% of defects were orientated within 15° of the 45° lateral oblique plane. Lateral oblique radiographs should not be considered as the definitive investigation for spondylolysis. We suggest that CT scans with reverse gantry angle are now more appropriate than oblique radiography for the assessment of spondylolysis. Variation in the angle of the defect may also need consideration when direct repair is being planned

1. The treatment is described of a consecutive series of fourteen patients suffering from rheumatoid arthritis causing a slip of the cervical vertebrae, mainly at the C.1-2 level, and a cord lesion. 2. The importance of a change of symptoms and signs in these patients, especially the occurrence of the so-called "alarm signs", is stressed. 3. In twelve patients the combination of this kind of cervical instability with a cord lesion was treated by fusion, most frequently of occiput to C.2 and 3. 4. In the eleven patients who survived the operation the results with a follow-up period of one to eight years are considered highly gratifying. 5. Technical details and various problems associated with treatment are discussed

1. Twenty-eight patients with pyogenic infection of the spine are reported. 2. Diagnosis was by clinical, radiological and bacteriological means. Investigations of the spinal lesions by needle aspiration or open operation was needed in four patients. 3. Treatment consisted primarily of antibiotics and rest. 4. Twenty-five patients were fit and well after follow-up of one to fifteen years. Three deaths occurred, but only one was directly connected with the infection ; urinary infection with paraplegia and haemophilia were the cause in two others. 5. The relatively benign course is stressed, as are some of the diagnostic pitfalls in the early stages, particularly with thoracic lesions

1. Hereditary multiple exostosis has been studied in fifty-six patients and their relatives. In most cases previous records were available and the progress of the disease could be traced over many years. 2. The characteristic lesions are described and the complications encountered in the present series of cases are noted. The disease is inherited in approximately two-thirds of the cases and invariably produces detectable lesions in the heterozygote. 3. The cartilage-capped exostoses are confined to the endochondral skeleton where their incidence is closely related to the growth potential of the sites involved. 4. An attempt has been made to explain the curious distribution of the exostoses, and the likely theories of the pathogenesis of the disease are discussed

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

In a retrospective review of 302 clinically suspected cases of congenital syphilis, bone changes were found in 197. The skeletal manifestations were periostitis (102 cases), osteitis (20), and metaphyseal changes (71). Combinations of more than one lesion were found in 61. Pseudoparalysis was a presenting sign in 34 infants; 12 of these were found to have had pathological fractures and four had dactylitis. Complete radiological healing without residual changes was seen in all 59 cases that were recalled for review. The orthopaedic surgeon should consider the diagnosis of congenital syphilis when destructive lesions of bone are seen in an infant

Low back injuries account for the greatest loss of playing time for professional fast bowlers in cricket. Previous radiological studies have shown a high prevalence of degeneration of the lumbar discs and stress injuries of the pars interarticularis in elite junior fast bowlers. We have examined MRI appearance of the lumbar spines of 36 asymptomatic professional fast bowlers and 17 active control subjects. The fast bowlers had a relatively high prevalence of multi-level degeneration of the lumbar discs and a unique pattern of stress lesions of the pars interarticularis on the non-dominant side. The systems which have been used to classify the MR appearance of the lumbar discs and pars were found to be reliable. However, the relationship between the radiological findings, pain and dysfunction remains unclear

Primary malignant tumours should be resected with wide margins. This may be difficult to apply to lesions of the spine. We undertook total vertebrectomy on seven patients, four males and three females with a mean age at operation of 26.5 years (6.3 to 45.8). The mean follow-up was 52.3 months. Histological examination revealed a Ewing’s sarcoma in two patients and osteosarcoma, leiomyosarcoma, spindle-cell sarcoma, chondrosarcoma and malignant schwannoma in one each. In five patients, histological examination showed that a wide resection had been achieved. At follow-up there was no infection and a permanent neurological deficit was only seen in those patients in whom the surgical procedure had required resection of nerve roots. Despite the high demands placed on the surgeon and anaesthetist and the length of postoperative care we consider total vertebrectomy to be an appropriate procedure for the operative treatment of primary malignant lesions of the spine

Of 899 patients with sickle-cell disease, aged between 6 and 28 years, who attended clinics in the Guinea Savannah of Nigeria in 1982 and 1983, 29 had symptoms of avascular necrosis of the femoral head. This group was studied in detail. Twenty-eight patients had haemoglobin-SS electrophoretic patterns and one had haemoglobin-SC. The male to female ratio was 1 to 1.6, and most of the patients were aged between 6 and 15 years at the onset of hip symptoms. These symptoms correlated with the radiographic lesions, but were not related to the age or sex of the patient. The radiographic lesions varied widely and were related to the age at onset of hip symptoms. A new radiological classification is proposed

The clinical and pathological features of six cases of desmoplastic fibroma of bone are presented. Desmoplastic fibroma is rarely seen as a primary tumour of bone; when it does occur the sites of predilection are the long bones, but other sites such as the scapula and os calcis can be involved. Radiographically the lesion tends to expand the bone from within; it is well-demarcated and lytic, often with a trabeculated soap-bubble appearance. The cellular structure and the morphological arrangement are similar to those of aggressive fibromatosis of soft tissues. Differential diagnosis from malignant spindle-cell lesions of bone is important because the treatment of choice for desmoplastic fibroma of bone is simply excision with a thin layer of healthy tissue

A series of 100 patients with pain in the leg was studied and the accuracy of electrical studies in the diagnosis of nerve root lesions was investigated before operation. The electrical studies which were performed on all the patients, included recordings of fibrillation potentials, H-reflex and ankle reflex latencies. This diagnosis technique was found to be more accurate than radiculography or clinical examination and did not give false evidence. Seventy patients were classed as having a lesion of the nerve root. Fifty of these patients were treated surgically. The operation revealed compression of the nerve root by osteophytes arising from degenerative and incompletely dislocated posterior facet joints in 43 patients

1. A review of 193 African and Indian children suffering from spina bifida has been made. Forty-three were seen on the first day of life and the remainder during subsequent weeks of life. 2. For the baby with mild or moderate paralysis and an open spinal lesion early closure was of value in preventing progressive neural damage. 3. For the baby with severe paralysis and an open myelomeningocele early operation was not of value in preventing further neural damage, and all remained severely paralysed. immediate operation to close the spinal lesion is not justified in babies with severe paralysis: survivors may be treated by later operation to prevent recurrent meningitis

1. In this analysis of forty-three patients with syringomyelia, twenty-seven (63 per cent) had scoliosis. This association is probably due to the early involvement of the ventro-medial and dorso-medial nuclei of the spinal cord by expanding lesions. 2. The literature makes no reference to the treatment of scoliosis associated with syringomyelia. Two cases are presented of attempts to correct this scoliosis–one because of increasing deformity, the other for increasing backache. 3. Due to the presence of cystic lesions characteristic of syringomyelia, corrective operative treatment of scoliosis may present an added risk. 4. Because of the high incidence of scoliosis in patients with syringomyelia, any patient with scoliosis should be examined for evidence of neurological deficit

We reviewed 277 patients with soft-tissue sarcoma (STS) treated between 1975 and 1995 to study the incidence, distribution, time of appearance, and radiological findings of skeletal metastases. Of these, 28 (10.1%) had metastases within a mean period of 18.6 months after admission. The incidence of skeletal metastases differed among the histological subtypes of sarcoma; alveolar soft-part sarcoma, dedifferentiated liposarcoma, angiosarcoma, and rhabdomyosarcoma tended to show higher incidences. The regional bones close to the primary tumour were affected in 13 (46.4%) of the 28 patients, and the axial bones in 18 (64.3%). Radiologically, the metastatic bony lesions predominantly showed osteolytic changes, and there were pathological fractures in 21 of 44 lesions

We have treated 175 patients with a chordoma over a ten-year period. Only two had a family history of the condition and we describe these in this paper. In one patient the tumour was at the craniocervical junction and in the other the lesion affected the sacrum. We have undertaken a literature review of familial chordoma and have identified chromosomal abnormalities associated with the condition

Aims

The use of frozen tumour-bearing autograft combined with a vascularized fibular graft (VFG) represents a new technique for biological reconstruction of massive bone defect. We have compared the clinical outcomes between this technique and Capanna reconstruction.

From 1975 to 1988, operative treatment was performed on 50 feet in 45 patients with tarsal tunnel syndrome. The causes of this syndrome were correlated with operative findings and included ganglia in 18, and a bony prominence from talocalcaneal coalition in 15. Five feet had sustained an injury, tumours were found in three and there was no obvious cause in nine. In most cases in need of operative treatment, there was a space-occupying lesion. Classifying the results according to causes, those with coalition or a tumour fared better, and idiopathic and traumatic cases had a worse outcome. In cases with a definite lesion, an excellent result can be expected from surgical treatment carried out soon after onset of the condition