We have reviewed, retrospectively, all children with a lower limb deformity who underwent an acute correction and lengthening with a monolateral fixator between 1987 and 1996. The patients were all under the age of 19 years and had a minimum follow-up of eight months after removal of the fixator. A total of 41 children had 57 corrections and lengthening. Their mean age was 11.3 years (3.2 to 18.7) and there were 23 girls and 18 boys.

The mean maximum correction in any one plane was 23° (7 to 45). In 41 bony segments (either femur or tibia) a uniplanar correction was made while various combinations were carried out in 16. The site of the osteotomy was predominantly diaphyseal, at a mean of 47% (17% to 73%) of the total bone length and the mean length gained was 6.4 cm (1.0 to 17.0).

Univariate analysis identified a moderately strong relationship between the bone healing index (BHI), length gained, maximum correction and grade-II to grade-III complications. For logistic regression analysis the patients were binary coded into two groups; those with a good outcome (BHI ≤ 45 days/cm) and those with a poor outcome (BHI > 45 days/cm). Various factors which may influence the outcome were then analysed by calculating odds ratios with 95% confidence intervals.

This analysis suggested a dose response between increasing angular correction and poor BHI which only reached statistical significance for corrections of larger magnitude. Longer lengthenings were associated with a better BHI while age and the actual bone lengthened had little effect.

Those patients with a maximum angulatory correction of less than 30° in any one plane had an acceptable consolidation time with few major complications. The technique is suitable for femoral deformity and shortening, but should be used with care in the tibia since the risk of a compartment syndrome or neurapraxia is much greater.

Giant-cell tumour of the tendon sheath (GCT-TS) is a benign solitary tumour which usually arises in the limbs. It occurs most often in the hand where local recurrence after excision has been reported in up to 45% of cases. It is less common in the foot where the biological behaviour and risk of local recurrence have not been defined. We have studied 17 cases of GCT-TS of the foot and ankle in which treatment was by excision. Fifteen presented as a solitary, painless, slow-growing soft-tissue swelling. One lesion was associated with sensory deficit of a digital nerve and one with pain on walking. Thirteen cases originated from the periarticular tendon-sheath complex of the small joints of the toes and four from the capsule or long tendons of the ankle. A correct preoperative diagnosis was made in only three cases. MRI proved to be the most useful preoperative investigation as GCT-TS has a characteristic appearance which allows planned local excision to be carried out. None of the patients with histologically confirmed GCT-TS required further surgery. There was no local recurrence in 15 patients who were available for follow-up at a mean of 85 months.

There is a close link between the embryological development of the musculoskeletal system and all other main organ systems. We report a prospective series of 202 patients with congenital vertebral abnormalities and document the associated abnormalities in other systems. There were 100 boys and 102 girls. In 153 there were 460 associated abnormalities, a mean of 2.27 abnormalities for each patient. Intravenous pyelography was carried out on 173 patients (85.6%) and ultrasonography on the remaining 29 (14.4%). Patients with genitourinary anomalies were more likely to have musculoskeletal (p = 0.002), gastrointestinal (p = 0.02) and cardiac abnormalities (p = 0.008) than those without genitourinary involvement. A total of 54 (26.7%) had at least one genitourinary abnormality, the most frequent being unilateral renal agenesis. There was urinary obstruction in six (3%). There was no association between genitourinary abnormality and the place of birth, parental age, birth order, level of spinal curvature, or the number, type and side of spinal anomaly. There was, however, a statistically significant association (p = 0.04) between costal and genitourinary abnormalities. The incidence of genitourinary abnormalities (26.7%) was similar to that of previously reported series. The diagnosis of a congenital vertebral abnormality should alert the clinician to a wide spectrum of possible associated anomalies most of which are of clinical importance.

Using a dynamic biomechanical model of malunion of the shoulder, we have determined the change in deltoid force required for abduction with various combinations of superior and posterior displacement of fractures of the greater tuberosity of the humerus. We tested eight fresh human cadaver shoulders in a dynamic shoulder-testing apparatus during cycles of glenohumeral abduction from 0° to 90°. The greater tuberosities were osteotomised and stabilised to represent malunion with combinations of superior and posterior displacements of 1 cm and less. The peak force was measured for each displacement in each specimen and statistically compared with values of no displacement using a repeated-measures analysis of variance.

The abduction force was significantly increased by 16% (p = 0.006) and 27% (p = 0.0001) by superior displacements of 0.5 cm and 1 cm, respectively, while combined superior and posterior displacement of 1 cm gave an increase in force of 29% (p = 0.001). While treatment criteria for acceptable residual displacement of the greater tuberosity are widely used, there is little information on the direct biomechanical effects of displacement on shoulder mechanics. Although the results of conservative treatment are influenced by a number of factors, including associated injuries, rehabilitation and the pre-existing function of the shoulder, our data suggest that small amounts of residual displacement may alter the balance of forces required to elevate the arm at the glenohumeral joint.

Osteoarthritis of the wrist is a complication of a number of common traumatic conditions. Arthrodesis of the radiocarpal joint, proximal row carpectomy and excision of the scaphoid, combined with midcarpal arthrodesis, have all been reported as surgical options. There have been no randomised studies comparing these procedures, and the feasibility of conducting this type of trial is limited.

We used decision analysis to compare the three surgical techniques. The variables for the model used were based principally on data from the literature. Extensive sensitivity analyses were carried out to test the impact of the values given to these variables on the outcome of the model. The model indicated that the preferred treatment is proximal row carpectomy.

Decision analysis allows a comparison between alternative treatments, when evidence from a randomised trial is lacking or unobtainable. The decision-analysis model may also provide insight into aspects of a problem which would be difficult, or impossible, to evaluate by a cohort study.

Age-related localised deposition of amyloid in connective tissue has been found in degenerative articular and periarticular tissue. Biopsies of the supraspinatus tendon of 28 patients undergoing repair of the rotator cuff were analysed histologically for the presence of localised deposition of amyloid. There was a long history of impingement in 20 patients, and eight patients had suffered an acute traumatic tear with no preceding symptoms. Localised deposition of amyloid identified by Congo Red staining was detected in 16 samples (57%). Amyloid was present in 14 (70%) of the degenerative tears, but in only two (25%) of the acute tears. Immunohistochemical staining showed that the amyloid deposits were positive for P component, but negative for κ and λ light chains, prealbumin, and β2 microglobulin. Critical electrolyte staining revealed highly-sulphated glycosaminoglycans at sites of deposition of amyloid. The presence of localised deposition of amyloid in tears of the rotator cuff is likely to represent irreversible structural changes. These findings support the theory that impingement and tears are due to intrinsic degenerative changes within the tendons of the rotator cuff.

We present three cases of recurrent instability of the elbow in association with the Ehlers-Danlos syndrome. The pattern of instability has not previously been reported. We describe our procedure for achieving stability using a bone graft to the olecranon fossa which gave a functional range of movement.

Distraction osteogenesis is widely used for leg lengthening, but often requires a long period of external fixation which carries risks of pin-track sepsis, malalignment, stiffness of the joint and late fracture of the regenerate.

We present the results of 20 cases in which, in an attempt to reduce the rate of complications, a combination of external fixation and intramedullary nailing was used. The mean gain in length was 4.7 cm (2 to 8.6). The mean time of external fixation was 20 days per centimetre gain in length. All distracted segments healed spontaneously without refracture or malalignment. There were three cases of deep infection, two of which occurred in patients who had had previous open fractures of the bone which was being lengthened. All resolved with appropriate treatment.

This method allows early rehabilitation, with a rapid return of knee movement. There is a lower rate of complications than occurs when external fixation is used on its own. The time of external fixation is shorter than in other methods of leg lengthening. The high risk of infection calls for caution.

The Gorham-Stout Syndrome (Gorham’s massive osteolysis) is a rare condition in which spontaneous, progressive resorption of bone occurs. The aetiology is poorly understood. We report six cases of the condition and present evidence that osteolysis is due to an increased number of stimulated osteoclasts. This suggests that early potent antiresorptive therapy such as with calcitonin or bisphosphonates may prevent local progressive osteolysis.

In impaction grafting of contained bone defects after revision joint arthroplasty the graft behaves as a friable aggregate and its resistance to complex forces depends on grading, normal load and compaction. Bone mills in current use produce a distribution of particle sizes more uniform than is desirable for maximising resistance to shear stresses.

We have performed experiments in vitro using morsellised allograft bone from the femoral head which have shown that its mechanical properties improve with increasing normal load and with increasing shear strains (strain hardening). The mechanical strength also increases with increasing compaction energy, and with the addition of bioglass particles to make good the deficiency in small and very small fragments. Donor femoral heads may be milled while frozen without affecting the profile of the particle size. Osteoporotic femoral heads provide a similar grading of sizes, although fewer particles are obtained from each specimen. Our findings have implications for current practice and for the future development of materials and techniques.

Isolated neuropathy of the cutaneous branch of the radial nerve is a rarely recognised condition. Five cases were described in 1932 by Wartenberg, who suggested the name cheiralgia paraesthetica. The condition has also been described as Wartenberg's disease. Twelve cases of isolated neuropathy of the cutaneous branch of the radial nerve are described, the literature is reviewed and the clinical picture outlined. In six of the cases the condition subsided without treatment, in two there was a good response to local injection of hydrocortisone, and in four cases a satisfactory result followed resection of the nerve. The course and distribution of the superficial branch of the radial nerve are described. The need to avoid the nerve during operations around the wrist is stressed.

A boy aged fourteen trapped and tore at its origin a branch of the terminal part of the superficial femoral artery over a cancellous exostosis during extension of the knee from the position of full flexion. Three months later an expanding false aneurysm necessitated arteriography, after which suture of the tear gave a successful result.

Two cases of adamantinoma of the tibia are reported. The first patient has survived twenty years after above-knee amputation and shows no sign of recurrence. The second patient shows no evidence of recurrence two and a half years after amputation through the knee.

The clinical picture of the tumour is described and the theories of histogenesis are outlined.

The changes in a number of haemostatic factors after fractures of the tibia or femur were compared with those observed in patients with fat embolism complicating such fractures. After fractures uncomplicated by fat embolism there was a rise in the fibrinogen, α₁-antitrypsin and serum activation inhibitor. The plasminogen level and platelet count initially fell, but later increased to above the initial levels. Patients whose fractures were complicated by fat embolism had the same pattern of changes but quantitatively greater.

1. A specially designed loading apparatus and dyeing technique have been used to demonstrate the weight-bearing areas in fifty-one normal adult hip joints.

2. Under loads and positions typical of the stance phase of walking the entire articular surface of the acetabulum is involved in weight-bearing. This contact area is reproduced on the femoral head, and its position determined by the attitude of the femur to the acetabulum.

3. With loads typical of the swing phase, the dome of the acetabulum and corresponding areas on the femoral head are not involved in weight-bearing.

4. The results are compared with the conclusions of previous investigators and their possible significance with regard to joint degeneration is discussed.

1. The routes by which adult human articular cartilage can receive its nutrition is still a subject of controversy.

2. Microscopic examination of normal adult human femoral heads has revealed vascular channels which penetrate the subchondral plate and calcified cartilage. These channels bring the medullary soft tissue into contact with the articular cartilage.

3. A fluorescent dye migration technique was used to show that the observed vascular channels are pathways for dye from the medullary cavity to the articular cartilage. It is suggested that these pathways could also be routes by which articular cartilage receives part of its nutrition.

4. The nutritional mechanism in the mature rabbit and adult human femoral heads cannot be compared because histological studies revealed differences in their subchondral structures.

1. The cause of cyst formation lies in the major overloading of certain regions caused by the unevenness of the articular surface produced by the arthritic process.

2. Photoelasticity investigations disclose an overburdening of the bone beneath the surface of the joint, which in turn markedly resembles the shapes of actual cysts.

3. The results of this investigation fit organically into the logical sequence of processes in accordance with our theory.

4. This theory is further borne out by the successful formation of cyst phenomena in healthy joints by overloading (Trias 1961).

5. Our theory has no immediate practical bearing on the treatment of arthritic cysts. However, it uncovers certain interesting aspects of the behaviour of bone tissues under mechanical overloading above the limits of biological, though below those of mechanical bearing capacity. Conclusions arising therefrom might in many respects be useful in research into the physiology of bone.

1 . Twenty patients with fibrous dysplasia, confirmed histologically, are reported and discussed in regard to classification, etiology, pathogenesis and treatment. The various fibrous or fibrocystic lesions of bone are characterised briefly for purpose of contrast, and the position of fibrous dysplasia in this heterogeneous collection is suggested.

2. The classification of fibrous dysplasia based on the degree of skeletal involvement is used, and the diagnostic, therapeutic and prognostic implications of this classification emphasised. The authors endorse the opinion that fibrous dysplasia is a developmental defect. Clinical, histological and radiographic evidence is presented to point to the distinct evolution of the monostotic lesions, to which a positive and aggressive approach is recommended.

A minority of cases of osteopetrosis show in addition syndactyly and distal phalangeal anomalies. The seven cases that have been reported with this combination have had an unusual degree of density and thickening of the skull vault, face and mandible, and of the shafts of the metacarpals, metatarsals, proximal phalanges and clavicles. It is submitted that these features constitute a distinct morphological variety of osteopetrosis.