1. After limb injuries with loss of skin and subcutaneous tissue, full-thickness skin flaps afford the most satisfactory cover. It is particularly important to replace unstable and scarred skin before attempting bone reconstruction and similar operations. 2. In the leg and foot, full-thickness skin cover is conveniently obtained by the cross-leg flap technique. The blood supply of such flaps is considered and the technique of operation is described. Free excision of avascular scar tissue is essential. 3. "Delayed transfer" of the flap is advisable unless conditions are favourable; two methods are considered. 4. Immobilisation in plaster is the most satisfactory method of fixation of the limbs after attachment of the flap. Muscle exercises are performed throughout the period of treatment in order to minimise joint stiffness and shorten convalescence. 5. The cross-leg flap technique should not usually be used in children, young women, or the aged and mentally infirm. Contra-indications include arthritis of the knee and hip joints because there is danger of joint stiffness. 6. Vascular complications of cross-leg skin grafting are discussed

Tibiotalar fusion is considered to be the standard treatment for end-stage post-traumatic arthritis of the ankle. We report a retrospective, objective long-term study of the quality of life of 17 patients with 18 arthrodeses of the ankle, over a period of more than 20 years. We looked particularly for correlation between clinical and radiological signs of osteoarthritis in adjoining joints. At serial physical examinations, clinical grades were awarded according to the Olerud Molander Ankle (OMA) score. Any degree of degenerative change in the adjoining joints was recorded on standing radiographs. Patients filled out a SF-36 Health Survey form. Subjectively, 50% of patients were not handicapped in the performance of daily activities and 44% were in the same job as at the time of injury. At follow-up the mean OMA score was 59.4 points, the visual analogue scale was 1.99 and the radiological score was 2.7. The SF-36 for physical function, emotional disturbance and bodily pain revealed significant deficits. There was a significant correlation between the OMA and the radiological score (p = 0.05), and between the clinical and the SF-36 score (p = 0.01), but no significant correlation between the radiological score and the SF-36 score. Arthrodesis of the ankle leads to deficits in the functional outcome, to limitations in the activities of daily living and to radiological changes in the adjoining joints. The clinical outcome score correlates closely with the SF-36 score

We describe 22 patients who presented between the ages of 4 and 14 years with gradual onset of malaise and pain at the sites of multiple bone lesions. The symptoms from the bone lesions were sometimes sequential in onset and often relapsing. The radiological findings were typical of osteomyelitis. Radioisotope bone scans identified some clinically silent lesions. Bone biopsies were performed in 20 patients and the changes of osteomyelitis were seen in 17; microbiological culture was positive in only one. Seven patients had polyarthritis, two had palmoplantar pustulosis and one had psoriasis. Some symptomatic relief was obtained with anti-inflammatory agents and, to a less extent, with antibiotics. No patient had primary immunodeficiency. The mean duration of symptoms from the bone lesions was two years (1 to 4). When arthritis was present the joint symptoms lasted considerably longer (mean 7 years; range 4 to 10). The long-term prognosis was generally good. There was no evidence of altered bone growth or abnormal joint development. One patient developed a progressive kyphosis requiring fusion, but no other surgical intervention was necessary

In 1957 Somerville and Scott presented their principles of management for the older child with congenital hip dislocation. They advocated preliminary traction followed, in those hips which remained dislocated, by excision of the limbus and subsequent derotation varus osteotomy of the femur. As alternative regimes are advocated it becomes increasingly important to subject each method to detailed long-term review. One hundred and forty-seven hips in 121 patients aged between 12 months and three years and treated by the standard Somerville and Scott regime have been reviewed. The age at review ranged from 16 to 31 years. The recall rate was 91 per cent. Each patient was seen regularly in a special clinic where detailed notes, radiographs and records were available. The results have been assessed clinically and radiographically by modifications of Severin's criteria to enable comparisons to be made with other published series. Attention has been focused on the good and the bad prognostic factors and on the long-term complications. The most worrying feature has been the premature onset of degenerative arthritis even in hips which seemed to have been satisfactorily reduced

1. It is well known that the administration of corticosteroids may result in necrosis and progressive destruction of the femoral head. Identical changes have been found in chronic alcoholics, in South African negroes suffering from iron-overload osteoporosis and in patients with arthritis of the hip treated with non-steroid anti-inflammatory and analgesic preparations. The term "drug-induced arthropathy" is used to describe the common pathological lesion. 2. Seventy-two patients with this complication have been investigated and forty-two femoral heads were available for detailed study. The characteristic change is subchondral fragmentation and osteonecrosis, followed later by reactive bone formation and the typical increased radiographic density. 3. The frequent occurrence of fat occupying the Haversian canals in the affected femoral heads has not been adequately explained and its relationship to the destructive arthropathy remains obscure. The findings presented here do not support the theory that fat emboli are responsible for the subchondral bone changes. 4. More credence is given to the theory of subchondral microfracture in osteoporotic bone. The destructive arthropathy invariably follows the administration of some anti-inflammatory or analgesic preparation. It is postulated that a state of diminished sensibility predisposes to microtrauma in osteoporotic bone resulting in subarticular collapse of the femoral head

1. One hundred and twenty cervical spines removed at routine necropsy from elderly patients dying in a general hospital have been examined. 2. There was some degree of degeneration of intervertebral discs in 110 cases–in forty-six this was severe. 3. Degenerative disc disease was found at an earlier age in men; mild damage preceded severe degeneration and collapse by about a decade. 4. Discs of the lower spine were most frequently and most severely affected. 5. Alterations of the normal cervical lordosis were produced by disc disease in thirty-two cases. 6. Osteoarthritis of the apophysial joints was found in seventy-eight, and by contrast to disc degeneration was commonest in the mid-cervical and upper cervical regions. In eighteen it was severe. 7. Degeneration and scarring of nerve roots was frequently associated with diseased discs; apophysial joint arthritis was found to be an important additional factor when it occurred in the lower cervical region. 8. No nerve root changes could be attributed to ischaemia resulting from narrowing or distortion of the vertebral arteries. 9. Cystic arachnoidal diverticula which excavate the posterior root ganglia were found in thirty-six cases

Aims

The aim of this study was to evaluate the diagnostic accuracy of the synovial alpha-defensin enzyme-linked immunosorbent assay (ELISA) for the diagnosis of prosthetic joint infection (PJI) in the work-up prior to revision of total hip (THA) and knee arthroplasty (TKA).

The division of osteoarthritis into primary and secondary varieties implies that these are aetiologically distinct entities, the former being due to some intrinsic defect of cartilage and the latter resulting from previous articular damage. This traditional concept is questioned and the hypothesis is advanced that osteoarthritis is always secondary to some underlying abnormality of the joint. A detailed clinical, radiographic and morbid anatomical study of 327 cases of osteoarthritis of the hip is presented. In all but twenty-seven some predisposing abnormality of the joint was diagnosed: 107 (33%) were associated with major pathology such as Perthes' disease or epiphysiolysis; minor acetabular dysplasia was present in sixty-seven (20%), with a male: female ratio of 1:10; minimal femoral head tilt was demonstrated in fifty-nine (18%), the male: female ratio being 14:1; and in forty-three (13%) there were features suggesting an underlying inflammatory arthritis. On the basis of this study a new classification is proposed and osteoarthritis of the hip is divided into three pathogenetic groups: 1) failure of essentially normal cartilage subjected to abnormal or incongruous loading for long periods; 2) damaged or defective cartilage failing under normal conditions of loading; 3) break-up of articular cartilage due to defective subchondral bone

Between 1995 and 2000, 19 consecutive patients with fractures of the distal humerus were treated by primary total elbow replacement using the Coonrad-Morrey prosthesis. No patient had inflammatory or degenerative arthritis of the elbow. The mean age at the time of injury was 73 years (61 to 95). According to the AO classification, 11 patients had suffered a C3 injury, two a B3 and two an A3. One fracture was unclassified. Two patients died from unrelated causes and one was unable to be assessed because of concurrent illness. The mean time to follow-up was three years (1 to 5.5). At follow-up 11 patients (68%) reported no pain, four (25%) had mild pain with activity and one had mild pain at rest. The mean flexion arc was 24° to 125°. The mean supination was 90° (70 to 100) and pronation 70° (50 to 110). No elbow was unstable. The mean Disabilities of the Arm, Shoulder and Hand score was 23 (0.92 to 63.3) and the mean Mayo elbow performance score was 93 (80 to 100). Of the 16 patients, 15 were satisfied with the outcome. Radiological evaluation revealed only one patient with a radiolucent line at the cement-bone interface. It was between 1 and 2 mm in length, was present on the initial postoperative radiograph and was non-progressive at the time of follow-up. Primary total elbow arthroplasty is an acceptable option for the management of comminuted fractures of the distal humerus in elderly patients when the configuration of the fracture and the quality of the bone make reconstruction difficult

Many authors have recommended undercorrection of the deformity when carrying out unicompartmental knee arthroplasty (UKA). The isolated effect of alignment of the knee on the outcome of UKA has, however, received little attention. We reviewed 185 UKAs at a minimum of five years after surgery. They had been carried out by a single surgeon using metal-backed tibial components in the management of arthritis of the medial compartment. We measured the tibiofemoral angle (TFA) before and at four months after operation and at the most recent assessment. The amount of correction of the TFA and any subsequent loss were recorded. While adjusting for the effects of age, weight and gender of the patients and the type and thickness of the implants, the mean correction was significantly less for those with a Marmor rating of failure (6.8°) than for those rated excellent (9.2°). The mean correction was also significantly less for patients with a Marmor rating of failure (6.8°) than for those rated poor (11.1°). The mean correction for the UKAs which were revised (6.6°) was significantly less than for those not revised (9.1°). Additionally, revised UKAs had a significantly higher percentage (63%) of thinner tibial implants (< 8 mm) than the surviving UKAs (27%). These findings suggest that undercorrection of the TFA in UKA of the medial compartment should be avoided, particularly if a thin tibial polyethylene insert is used

Aims

Patient-specific instrumentation of total knee arthroplasty (TKA) is a technique permitting the targeting of individual kinematic alignment, but deviation from a neutral mechanical axis may have implications on implant fixation and therefore survivorship. The primary objective of this randomized controlled study was to compare the fixation of tibial components implanted with patient-specific instrumentation targeting kinematic alignment (KA+PSI) versus components placed using computer-assisted surgery targeting neutral mechanical alignment (MA+CAS). Tibial component migration measured by radiostereometric analysis was the primary outcome measure (compared longitudinally between groups and to published acceptable thresholds). Secondary outcome measures were inducible displacement after one year and patient-reported outcome measures (PROMS) over two years. The secondary objective was to assess the relationship between alignment and both tibial component migration and inducible displacement.

Aims

The aim of this study was to report the outcomes of different treatment options for glenoid loosening following reverse shoulder arthroplasty (RSA) at a minimum follow-up of two years.

1. Although fractures and dislocations of the talus have been described since 1608 the rarity of the more severe and complicated injuries has meant a dearth of accurate descriptions or classification in the literature. 2. A series of 228 injuries of the talus occurring in members of the Royal Air Force between 1940 and 1943 has been reviewed. 3. A simple but comprehensive classification of injuries of the talus is presented, together with a review of the pathological anatomy, clinical features, and methods of treatment. The importance of distinguishing between fractures and fracture-dislocations, and of watching carefully for displacements of the subtalar joint, is emphasised. 4. The important complications—infection, avascular necrosis and traumatic arthritis of the ankle or subtalar joint—are discussed. Infection may be the result of a compound injury, or may follow sloughing of the skin stretched over a displaced talus. Early reduction is, therefore, of great urgency in closed injuries. Avascular necrosis of the talus occurs in gross injuries when all or most of the soft-tissue attachments to the bone are severed. Revascularisation and regeneration will take place with patient conservative treatment. 5. The mechanism of injury is discussed. 6. The results of excision of the talus are poor. Every effort should be made to preserve the body of the talus, but if its loss is inevitable a useful foot can be regained by deliberate fusion of the tibia to the calcaneum

Aims

The Bundled Payments for Care Improvement (BPCI) initiative has identified pathways for improving the value of care. However, patient-specific modifiable and non-modifiable risk factors may increase costs beyond the target payment. We sought to identify risk factors for exceeding our institution’s target payment, the so-called ‘bundle busters’.

Between 1978 and 1986, 59 patients received a GSB III elbow prosthesis, six of them in both elbows. Rheumatoid arthritis (RA) was the underlying cause in 51 of the patients and post-traumatic osteoarthritis (PTOA) in eight. Of these, 24 patients (28 prostheses) have since died; two, both operated on bilaterally, had had their implants for more than ten years and had already been assessed for inclusion in the long-term follow-up. Two patients, each with one elbow prosthesis, have been lost to follow-up and three males who are still living (two with PTOA, one with juvenile RA) had their prosthesis removed before ten years had elapsed. The remaining 32 patients (28 RA, 4 PTOA) with 36 GSB III elbows were examined clinically and radiologically after a mean period of 13.5 years. Pain was considerably reduced in 91.6%. Mobility was increased by 37° in those with RA and by 67° in those with PTOA. There were three cases of aseptic loosening and three of deep infection. The main complication was disassembly of the prosthetic component in nine elbows (13.8%). This last group included two patients with postoperative fractures unrelated to the operative technique and one with neuropathic arthritis. Ulnar neuritis occurred in two patients. Since 87.7% of all the GSB III prostheses implanted in this period remained in situ, our results are comparable with those for hip and knee arthroplasty