We made a prospective study of angulated radial neck fractures in children reduced by leverage with a percutaneous Kirschner wire. Of 36 consecutive cases with angulation of more than 30 degrees reduction was successful in 33. We obtained an excellent or good final result in 31 (94%)

We report a prospective study of 26 cases of fracture of the distal third of the femur treated with the Derby intramedullary nail. This new design controls rotation and allows compression of the fracture, permitting early weight-bearing. All the fractures united in good position within four months, 12 of them with minimal external callus. There were no implant failures and the only serious complication was one case of deep infection

We made a randomised prospective comparison of the Dynamic Hip Screw and the Gamma locking nail for the internal fixation of 200 petrochanteric femoral fractures in elderly patients. There was less intraoperative blood loss and a lower rate of wound complications in the patients treated by the Gamma nail. They had, however, a high incidence of femoral shaft fracture which we relate in part to implant design. We do not recommend the use of the Gamma nail for these fractures

In a prospective study of 295 male Israeli military recruits a 31% incidence of stress fractures was found. Eighty per cent of the fractures were in the tibial or femoral shaft, while only 8% occurred in the tarsus and metatarsus. Sixty-nine per cent of the femoral stress fractures were asymptomatic, but only 8% of those in the tibia. Even asymptomatic stress fractures do, however, need to be treated. Possible explanations for the unusually high incidence of stress fractures in this study are discussed

Twenty-four hips in twenty children affected by Group 1 Perthes' disease have been reviewed to assess the radiographic result after a minimum follow-up of four years. The children were allocated to Group 1 prospectively after examination of the early radiographs and no specific treatment of the affected hip was provided. The radiographic end results assessed by three methods were good even in those cases in which the additional stress of containment splintage of the contralateral hip was applied

This prospective study was performed to determine the true incidence of deep vein thrombosis of the lower limb in children who had undergone halo-femoral traction to correct scoliosis before operation. Bilateral ascending phlebography of the lower limbs was performed on 54 children two days before spinal fusion and Harrington rod instrumentation. Two patients developed clinical evidence of thrombosis whilst on traction. This diagnosis was confirmed by phlebography. The other 52 children had no clinical evidence of thrombosis and their venograms were normal. The incidence of thrombosis was 3.7 per cent and clinically silent thrombosis did not occur

Fifty patients with adolescent idiopathic scoliosis treated by posterior fusion and Harrington instrumentation augmented by a Cotrel bar or by sublaminal Luque wires were studied in a prospective trial to ascertain the need for postoperative bracing. Twenty-five patients wore a plaster brace postoperatively for six months, while 25 were managed without a brace. The mean loss of correction from the first standing postoperative radiograph to one obtained two years later was 7 degrees in the braced group, and 6.3 degrees in the unbraced group, the difference not being statistically significant. We conclude that postoperative bracing is unnecessary after augmented Harrington instrumentation

We describe a simple, quick ultrasound screening test for CDH, and its use in a prospective study of babies with a 'high risk' factor, over one year from January 1987. From a birth population of 3,879, 812 hip scans were performed on 406 babies and 98 babies were abnormal. So far, there have been no late cases of CDH. Family history, breech malposition, and postural foot deformities were confirmed to be important risk factors, but babies with a simple click were equally at risk. Our early results indicate that a large proportion of the potential late cases are contained within our extended high-risk group

In a 10-year prospective study, 561 displaced subcapital fractures of the femoral neck in 546 patients were treated with the Hastings bipolar hemiarthroplasty. Within six months of their operations, 148 patients had died. In 322 hips followed up, 243 with adequate serial radiographs separated by more than one year, only 14 (5.6%) showed acetabular erosion. A group of 91 had been reviewed for between three and nine years (mean, 4 years 10 months) and of these, 95% had no pain or slight pain only. Comparison with an earlier series of conventional hemiarthroplasties reported from this institution showed that the clinical results were similar, but that the erosion rate had been halved

In a prospective study, 170 impacted femoral neck fractures were treated by early mobilisation and weight-bearing. The overall mortality at one year was 16%. In the 167 patients who were followed up until fracture healing or secondary instability, 143 fractures (86%) united. Instability occurred only in patients over 70 years of age, and in younger patients with a short life expectancy. Stepwise logistic regression analysis indicated that poor general health and old age (over 70 years) were risk factors. None of the other variables, such as the Garden index, Pauwels' type, and time to full weight-bearing had any influence on the development of secondary instability. Delayed operation after secondary instability caused no increase in mortality, nonunion or avascular necrosis. Functional treatment of all patients with impacted femoral neck fractures seems therefore to be justified

We performed a prospective, double-blind, randomised, clinical trial to investigate the efficacy of two regimes of rehabilitation for knees with anterior cruciate ligament deficiency (ACLD). Fifty ACLD patients were randomly allocated to one of two treatment groups: a programme of muscle strengthening (T) or a programme designed to enhance proprioception and improve hamstring contraction reflexes (P). An indirect measure of proprioception, the reflex hamstring contraction latency (RHCL), and a functional scoring system were used to record the status of the knee before and after the 12-week course of physiotherapy. Sagittal knee laxity was also measured. There was improvement in mean RHCL and in the mean functional score in both groups after treatment. The improvement in group P was significantly greater than that in group T. There was no significant change in joint laxity after treatment in either group. In both groups there was a positive correlation between improvement in RHCL and functional gain

We compared the outcome of closed intramedullary nailing with minimally invasive plate osteosynthesis using a percutaneous locked compression plate in patients with a distal metaphyseal fracture in a prospective study. A total of 85 patients were randomised to operative stabilisation either by a closed intramedullary nail (44) or by minimally invasive osteosynthesis with a compression plate (41). Pre-operative variables included the patients’ age and the side and pattern of the fracture. Peri-operative variables were the operating time and the radiation time. Postoperative variables were wound problems, the time to union of the fracture, the functional American Orthopaedic Foot and Ankle surgery score and removal of hardware. We found no significant difference in the pre-operative variables or in the time to union in the two groups. However, the mean radiation time and operating time were significantly longer in the locked compression plate group (3.0 vs 2.12 minutes, p < 0.001, and 97.9 vs 81.2 minutes, p < 0.001, respectively). After one year, all the fractures had united. Patients who had intramedullary nailing had a higher mean pain score, but better function, alignment and total American Orthopaedic Foot and Ankle surgery scores, although the differences were not statistically significant (p = 0.234, p = 0.157, p = 0.897, p = 0.177 respectively). Three (6.8%) patients in the intramedullary nailing group and six (14.6%) in the locked compression plate group showed delayed wound healing, and 37 (84.1%) in the former group and 38 (92.7%) in the latter group expressed a wish to have the implant removed. We conclude that both closed intramedullary nailing and a percutaneous locked compression plate can be used safely to treat Orthopaedic Trauma Association type-43A distal metaphyseal fractures of the tibia. However, closed intramedullary nailing has the advantage of a shorter operating and radiation time and easier removal of the implant. We therefore prefer closed intramedullary nailing for patients with these fractures

Patellofemoral problems are a common cause of morbidity and reoperation after total knee arthroplasty. We made a prospective study of 52 patients who had bilateral arthroplasty (104 knees) and in whom the patella was resurfaced on one side and not on the other. A movable-bearing prosthesis with an anatomical femoral groove was implanted on both sides by the same surgeon using an otherwise identical technique. The mean follow-up was 5.24 years (2 to 10). In the 30 available patients (60 knees) there was no difference between the two sides in subjective preference, performance on ascending and descending stairs or the incidence of anterior knee pain. Radiographs showed no differences in prosthetic alignment, femoral condylar height, patellar congruency or joint line position. The use of an appropriate prosthetic design and careful surgical technique can provide equivalent results after knee arthroplasty with or without patellar resurfacing. Given the indications and criteria, which we discuss, retention of the patellar surface is an acceptable option

Autologous chondrocyte implantation (ACI) and mosaicplasty are both claimed to be successful for the repair of defects of the articular cartilage of the knee but there has been no comparative study of the two methods. A total of 100 patients with a mean age of 31.3 years (16 to 49) and with a symptomatic lesion of the articular cartilage in the knee which was suitable for cartilage repair was randomised to undergo either ACI or mosaicplasty; 58 patients had ACI and 42 mosaicplasty. Most lesions were post-traumatic and the mean size of the defect was 4.66 cm. 2. The mean duration of symptoms was 7.2 years and the mean number of previous operations, excluding arthroscopy, was 1.5. The mean follow-up was 19 months (12 to 26). Functional assessment using the modified Cincinatti and Stanmore scores and objective clinical assessment showed that 88% had excellent or good results after ACI compared with 69% after mosaicplasty. Arthroscopy at one year demonstrated excellent or good repairs in 82% after ACI and in 34% after mosaicplasty. All five patellar mosaicplasties failed. Our prospective, randomised, clinical trial has shown significant superiority of ACI over mosaicplasty for the repair of articular defects in the knee. The results for ACI are comparable with those in other studies, but those for mosaicplasty suggest that its continued use is of dubious value

We compared the outcome of patients treated for an intertrochanteric fracture of the femoral neck with a locked, long intramedullary nail with those treated with a dynamic hip screw (DHS) in a prospective randomised study. Each patient who presented with an extra-capsular hip fracture was randomised to operative stabilisation with either a long intramedullary Holland nail or a DHS. We treated 92 patients with a Holland nail and 98 with a DHS. Pre-operative variables included the Mini Mental test score, patient mobility, fracture pattern and American Society of Anesthesiologists grading. Peri-operative variables were anaesthetic time, operating time, radiation time and blood loss. Post-operative variables were time to mobilising with a frame, wound infection, time to discharge, time to fracture union, and mortality. We found no significant difference in the pre-operative variables. The mean anaesthetic and operation times were shorter in the DHS group than in the Holland nail group (29.7 vs 40.4 minutes, p < 0.001; and 40.3 vs 54 minutes, p < 0.001, respectively). There was an increased mean blood loss within the DHS group versus the Holland nail group (160 ml vs 78 ml, respectively, p < 0.001). The mean time to mobilisation with a frame was shorter in the Holland nail group (DHS 4.3 days, Holland nail 3.6 days, p = 0.012). More patients needed a post-operative blood transfusion in the DHS group (23 vs seven, p = 0.003) and the mean radiation time was shorter in this group (DHS 0.9 minutes vs Holland nail 1.56 minutes, p < 0.001). The screw of the DHS cut out in two patients, one of whom underwent revision to a Holland nail. There were no revisions in the Holland nail group. All fractures in both groups were united when followed up after one year. We conclude that the DHS can be implanted more quickly and with less exposure to radiation than the Holland nail. However, the resultant blood loss and need for transfusion is greater. The Holland nail allows patients to mobilise faster and to a greater extent. We have therefore adopted the Holland nail as our preferred method of treating intertrochanteric fractures of the hip

We undertook a prospective, randomised study of 135 total knee arthroplasties to determine the most accurate and reliable technique for alignment of the tibial prosthesis. Tibial resection was guided by either intramedullary or extramedullary alignment jigs. Of the 135 knees, standardised postoperative radiographs suitable for assessment were available in 100. Correct tibial alignment was found in 85% of the intramedullary group compared with 65% of the extramedullary group (p = 0.019). We conclude that intramedullary guides are superior to extramedullary instruments for alignment of the tibial prosthesis

Excessive foot pronation has been considered to be related to anterior knee pain. We undertook a prospective study to test the hypothesis that exertional anterior knee pain is related to the static and dynamic parameters of foot pronation. Two weeks before beginning basic training lasting for 14 weeks, 473 infantry recruits were enrolled into the study and underwent two-dimensional measurement of their subtalar joint displacement angle during walking on a treadmill. Of the 405 soldiers who finished the training 61 (15%) developed exertional anterior knee pain. No consistent association was found between the incidence of anterior knee pain and any of the parameters of foot pronation. While a statistically significant association was found between anterior knee pain and pronation velocity (left foot, p = 0.05; right foot, p = 0.007), the relationship was contradictory for the right and left foot. Our study does not support the hypothesis that anterior knee pain is related to excessive foot pronation

We performed a prospective study on 96 patients with extra-articular or intra-articular fractures of the distal radius with a dorsally displaced posteromedial fragment. After closed reduction, we compared trans-styloid fixation and immobilisation with Kapandji fixation and early mobilisation. Forty-two patients of mean age 57.1 years +/- 18.1 (SD) were treated by trans-styloid K-wire fixation and 45 days of short-arm cast immobilisation. Fifty-four patients of mean age 57.7 years +/- 18.7 (SD) had Kapandji fixation and immediate mobilisation according to the originator. All the patients had clinical and radiological review at about six weeks and at 3, 6, 12 and 24 months after the operation. Pain, range of movement and grip strength were tested clinically, and changes in dorsal tilt, radial tilt, ulnar variance, and radial shortening were assessed radiologically. Statistical analysis was applied to comparisons with the normal opposite wrist. Pain and reflex sympathetic dystrophy were more frequent after Kapandji fixation and early mobilisation, but the range of motion was better although this became statistically insignificant after six weeks. The radiological reduction was better soon after Kapandji fixation, but there was some loss of reduction and increased radial shortening during the first three postoperative months. The clinical result at two years was similar in both groups

We performed a prospective randomised trial on matched groups of patients with displaced tibial shaft fractures to compare conservative treatment with closed intramedullary nailing. The results showed conclusively that intramedullary nailing gave more rapid union with less malunion and shortening. Nailed patients had less time off work with a more predictable and rapid return to full function. We therefore consider that closed intramedullary nailing is the most efficient treatment for displaced fractures of the tibial shaft

Exposure to blood is a hazard for all surgeons. We assessed the incidence of glove perforation and needlestick injury from a new blunt taperpoint needle designed to penetrate tissues other than skin with the minimum of force. We performed a prospective, randomised trial comparing the incidence of perforations of surgical gloves with the new needle and a standard cutting needle during wound closure after hip arthroplasties. There was at least one glove perforation in 46 of 69 such procedures (67%). The use of the taperpoint needle produced a significant decrease in perforations (p = 0.049)