Intramedullary rods manufactured from polyacetal were used to fix diaphyseal fractures in osteoporotic bone. They are pliable and can be introduced without further damage to such bone. Their low elastic modulus induces abundant callus. They can be locked with cortical bone screws without the need of jigs or radiographic control. Nine femoral and five tibial fractures were fixed in 10 patients, all with osteoporosis; 13 united primarily; one required bone grafting. No implant broke; however, no ambulant patient weighed more than 75 kg. The rods offer a promising treatment for diaphyseal fractures in osteoporotic bone

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

Aims

The aim of this prospective study was to evaluate the intermediate-term outcomes after revision anatomical ankle ligament reconstruction augmented with suture tape for a failed modified Broström procedure.

Inter-observer agreement and reproducibility of opinion were assessed for the radiographic diagnosis of union of scaphoid fractures on films taken 12 weeks after injury. Weighted kappa statistics were used to compare the opinions of eight senior observers reviewing 20 sets of good quality radiographs on two occasions separated by two months. There was poor agreement on whether trabeculae crossed the fracture line, whether there was sclerosis at or near the fracture and on whether the proximal part of the scaphoid was avascular. As a consequence, agreement on union also was poor; it appears that radiographs taken 12 weeks after a scaphoid fracture do not provide reliable and reproducible evidence of healing

Forty-four rabbits were operated on when five weeks old; in one group a 2 mm drill-hole was made in the intercondylar portion of the right femur across the central portion of the growth plate up to the diaphysis, while in the other group a similar drill-hole of 3.2 mm was made. At 3, 6, 12 and 24 weeks after operation, specimens from the growth plates of both femora were analysed using radiographic, microradiographic, histological and histomorphometric techniques. It was found that destruction of 7% of the cross-sectional area of the growth plate caused permanent growth disturbance and shortening of the femur

A prospective study was made of 119 children with transient synovitis or any other cause for synovial effusion and elevated intra-articular pressure. During a follow-up of one year not one case of Perthes' disease was diagnosed and the late clinical and radiographic changes were minimal with moderate overgrowth of the femoral head in 33% and widening of the joint space in 14.2%. Our results do not support the widely accepted concept that Perthes' disease develops as a result of the period of elevated intra-articular pressure found in transient synovitis. Further research into this and Perthes' disease should follow the premise that they are two different diseases without any aetiological connection

Splitting fractures of the humeral head are rare; part of the humeral head dislocates and the unfractured part remains attached to the shaft. We report eight cases in young patients. In five the diagnosis was made at presentation: three had minimal internal fixation using a superior subacromial approach, one had a closed reduction and one a primary prosthetic replacement. All five patients regained excellent function with no avascular necrosis at two years. In three the injury was initially unrecognised; two developed a painless bony ankylosis and one is awaiting hemiarthroplasty. It is important to obtain the three trauma radiographic views to diagnose these unusual fractures reliably. CT delineates the configuration of the fracture. In young patients open reduction and internal fixation seems preferable to replacement of the humeral head, since we have shown that the head is potentially viable

We have reviewed 61 children treated for septic arthritis from 1972 to 1981. The diagnosis in all cases was confirmed by bacteriology or by radiographic changes. Routine arthrotomy was not performed, but most patients had a joint aspiration. The management and outcome are described. We suggest that arthrotomy should be selective rather than mandatory. Septic arthritis of the hip in infants requires arthrotomy, but in the older child an infected hip can be treated by aspiration if the duration of symptoms is less than four days; arthrotomy may be needed if there has been more delay. Infected joints other than the hip can be satisfactorily managed by aspiration

We report the cases of three children with chronic injuries of the medial tibial malleolus caused by traction injuries during sport. All three had the triad of swelling of the medial malleolus, tenderness over its anterior part, and pain on forced valgus movement of the foot. Radiographs showed bilateral accessory ossification centres and MRI demonstrated partial avulsion or avulsion fracture of the apophyseal cartilage and fragmentation of the accessory centres. A review of 134 young basketball players showed that 25% had tenderness of the anterior medial malleolus. This high rate indicates that traction apophysitis of the medial malleolus is not uncommon in children as a sports-related disorder

Two boys with entrapment of the median nerve in the elbow joint after closed reduction of a posterior dislocation with fracture of the medial epicondyle showed a characteristic radiological sign in the anteroposterior radiograph after two to three months. The sign was a depression in the cortex on the ulnar side of the distal humeral metaphysis, with interruption of the local periosteal reaction. At operation in both patients the depression was found to correspond with the place where the median nerve reached the posterior surface of the humerus. Radiographs taken after transverse section of the nerve above and below the joint capsule and end-to-end suture showed gradual disappearance of the cortical depression

Although an osteosarcoma appears to be a solitary lesion clinically, as in this instance, only routine radiographic skeletal survey in such cases will detect multiple osseous involvement. Ross (1964) reported that in ninety-eight cases of osteosarcoma arising in apparently normal bone, fifteen showed metastases to other bones, a much higher incidence than previously recorded. It is also possible that multicentric osteosarcomata, although undoubtedly rare, may be discovered more often if a radiological survey is done. In many large series of osteosarcomata no mention of a skeletal survey has been made, and, while this is routine in some centres, it is not yet general practice

A technique for epiphysiodesis using a cannulated tubesaw has been developed to combine the precision of the original Phemister method with newer percutaneous methods. The approach is unilateral, and requires minimal access. Reinsertion of the removed core of bone reduces haemorrhage from the defect and augments arrest of the growth plate. In 35 patients treated by this method predicted discrepancies of 2 to 4.5 cm were reliably reduced to 0.7 ± 0.6 cm, with no serious complications. The timing of surgery is critical, and relies upon careful monitoring of the pattern of discrepancy over several years, using clinical and radiographic measurements. Undercorrection of the disparity in three patients was the direct result of late referral

Out of a total of 623 patients who, over a ten-year period, underwent primary total knee replacement (TKR) without patellar resurfacing, 20 underwent secondary resurfacing for chronic anterior knee pain. They were evaluated pre- and postoperatively using the clinical and radiological American Knee Society score. The mean follow-up was 36.1 months (12 to 104). The mean knee score improved from 46.7 to 62.2 points and the mean functional score from 44.7 to 52.2 points. Only 44.4% of the patients, however, reported some improvement; the remainder reported no change or deterioration. The radiographic alignment of the TKR did not influence the outcome of secondary resurfacing of the patella. Complications were noted in six of the 20 patients including fracture and instability of the patella and loss of movement. Anterior knee pain after TKR remains difficult to manage. Secondary resurfacing of the patella is not advocated in all patients since it may increase patient dissatisfaction and hasten revision

We compared the results of primary ultrasonographic examination of 163 children with 224 suspected fractures with the subsequent radiological findings. The aim was to assess the value of ultrasound in the diagnosis of fractures in children. We found a good correlation for fractures of the long bones of the upper and lower limbs. Ultrasound was most reliable for the detection of simple femoral and humeral diaphyseal fractures and fractures of the forearm. It was less dependable for compound injuries and fractures adjacent to joints, lesions of the small bones of the hand and foot, non-displaced epiphyseal fractures (Salter-Harris type 1) or those with a fracture line of less than 1mm. We were able to distinguish several types of fracture in which the use of ultrasound alone gave reliable information and further radiography was unnecessary. We discuss the advantages and disadvantages of skeletal ultrasonographic studies in children

A strong clinical impression exists that joint lavage often provides symptomatic relief for painful osteoarthritis of the knee. A controlled trial was conducted to test this hypothesis. A group of 37 painful osteoarthritic knees were treated by arthroscopic lavage and physiotherapy, and a control group of 24 knees were treated by physiotherapy alone. There was better relief of pain in the lavage group, and the effect was still present at one year. An improvement in the signs of inflammation lasted for about three months. Pain was relieved more effectively in patients with slight radiographic changes than in those with advanced changes. Our results confirm the effectiveness of joint lavage in the management of painful osteoarthritis of the knee

Fresh frozen allogeneic tendon was used to reconstruct the lateral ligaments in 17 ankles. Two or more years later, 13 returned for follow-up examination. The mean age at operation was 23 years (range 15 to 39); the interval between injury and operation varied from six months to 20 years. There were no infections and no immunological rejections, and according to Sefton's criteria, nine patients were excellent and four good. No patient complained of instability of the ankle and stress radiography confirmed this improvement. Allograft reconstruction of the lateral ligaments of the ankle is a new method of treatment which restores stability without sacrificing normal tendons

We compared the clinical outcome with femoral subsidence and radiographic changes in 102 patients at 9 to 13 years after low friction arthroplasty. In 92 cases with a satisfactory outcome there was an average of 2.3 radiological signs and mean subsidence of less than 5 mm. An unsatisfactory outcome was associated with 3.4 signs per film and with subsidence of more than 5 mm. The radiological signs we describe are often the hallmark of successful load transmission, but if they increase with time or are associated with subsidence of over 5 mm, then clinical failure is likely. Fracture of the cement tip is associated with increased subsidence and adversely affects the long-term clinical outcome

A retrospective study of 23 acetabular fractures in patients up to 17 years of age is presented, with an average follow-up of eight years. Good or excellent functional results were achieved in 21 patients; radiographic results were good or excellent in 16. Conservative treatment gave consistently good results in fractures with minimal initial displacement, stable posterior fracture-dislocations and Salter-Harris type 1 and 2 triradiate cartilage fractures. Less favourable results were seen in type 5 triradiate cartilage fractures and in comminuted fractures, but operation was no better. Unstable posterior fracture-dislocations and irreducible central fracture-dislocations need operative treatment but the results may still be unsatisfactory

Fifty-six patients with displaced malleolar fractures had open reduction and fixation of the fracture fragments using, by random selection, either biodegradable implants or metal AO plates and screws. The cylindrical biodegradable implants were made of polylactide-glycolide copolymer (polyglactin 910). The complications, radiographic results and functional recovery were studied prospectively. After follow-up of at least one year, no significant differences emerged in the complication rate or in the results of treatment between the two methods of fixation. Because of the advantage of avoiding the need to remove metal fixation after union, we now use biodegradable internal fixation routinely to treat displaced malleolar fractures

Ten patients with humeral shaft fractures and no clinical or radiographic signs of healing after at least six weeks' immobilisation were treated by flexible intramedullary nailing using a closed retrograde technique. Bone grafting was not performed, and active movement was encouraged after operation. Nine fractures healed; the mean time to union was 10.5 weeks (range 6 to 22 weeks). One patient needed compression plating and bone grafting at 22 weeks, and another required re-operation for distal migration of the rods. There were no infections, nerve palsies or other complications. Stiffness of the shoulder which had developed during early treatment improved after operation