A series of 103 acute fractures of the coronoid process of the ulna in 101 patients was reviewed to determine their frequency. The Regan-Morrey classification, treatment, associated injuries, course and outcomes were evaluated. Of the 103 fractures, 34 were type IA, 17 type IB, ten type IIA, 19 type IIB, ten type IIIA and 13 type IIIB. A total of 44 type-I fractures (86%) were treated conservatively, while 22 type-II (76%) and all type-III fractures were managed by operation. At follow-up at a mean of 3.4 years (1 to 8.9) the range of movement differed significantly between the types of fracture (p = 0.002). Patients with associated injuries had a lower Mayo elbow performance score (p = 0.03), less extension (p = 0.03), more pain (p = 0.007) and less pronosupination (p = 0.004), than those without associated injuries. The presence of a fracture of the radial head had the greatest effect on outcome. An improvement in outcome relative to that of a previous series was noted, perhaps because of more aggressive management and early mobilisation. While not providing complete information about the true details of a fracture and its nature, the Regan-Morrey classification is useful as a broad index of severity and prognosis

We reviewed 33 children with tuberculosis of the knee treated during the period from 1979 to 1991. All were treated with triple chemotherapy, using rifampicin, isoniazid and pyrazinamide for nine months. No patient had a synovectomy; surgery was limited to open biopsy or salvage procedures such as posterior release and arthrodesis for late stages of the disease. The radiological appearance of the knee at presentation predicted the outcome. The 30 patients with stage-1 (normal) or stage-2 (osteomyelitic) disease had excellent or good results; the three with narrowed joint spaces in stage 3 or stage 4 (arthritic) had fair or poor results. Early active mobilisation, as against long-term immobilisation, seemed to have no effect on the outcome of stage-1 or stage-2 disease

Reimplantation is a well-established procedure in reconstructive surgery. This is especially so after amputation of the upper limb since prostheses provide limited function. In unilateral amputation of the lower leg orthotopic reimplantation is the treatment of choice. With bilateral amputation, in which orthotopic reimplantation is not possible because of the complexity of the trauma, heterotopic reimplantation is an option. We report five patients who received orthotopic and two who received heterotopic reimplantations of the lower leg. We assessed the functional outcome with reference to cutaneous sensation, mobility, pain, and the cosmetic result. The functional outcome was good, as was the patients’ satisfaction. Their mobility, stability, and psychological state were satisfactory. Patients with heterotopic reimplantations preferred the reimplanted leg to a prosthesis. Although reimplantation of the lower leg requires prolonged hospitalisation, delayed mobilisation and secondary operations, we conclude that there is an indication for this operation in order to improve the patient’s quality of life

We prospectively randomised 100 patients undergoing cemented total knee replacement to receive either a single deep closed-suction drain or no drain. The total blood loss was significantly greater in those with a drain (568 ml versus 119 ml, p < 0.01; 95% CI 360 to 520) although those without lost more blood into the dressings (55 ml versus 119 ml, p < 0.01; 95% CI −70 to 10). There was no statistical difference in the postoperative swelling or pain score, or in the incidence of pyrexia, ecchymosis, time at which flexion was regained or the need for manipulation, or in the incidence of infection at a minimum of five years after surgery in the two groups. We have been unable to provide evidence to support the use of a closed-suction drain in cemented knee arthroplasty. It merely interferes with mobilisation and complicates nursing. Reinfusion drains may, however, prove to be beneficial

The conservative management of chronic calcaneal paratenonitis is time-consuming and often unsatisfactory. A new, safe and simple technique is described. The crural fascia on both sides of the tendon is incised and left open, adhesions around the tendon are trimmed away, the strongly hypertrophied portions of the paratenon are removed and mobilisation is begun immediately after operation. Between 1961 and 1978 201 such operations were performed on 182 patients 62 of whom were top-ranking Finnish athletes. Only five patients were not athletes. The results, including early return to full activity, were excellent in 169, good in 25 and poor in seven cases. After operation one of the patients gained an Olympic gold medal; others have attained international prominence

To assess the stability of the hip after acetabular fracture, dynamic fluoroscopic stress views were taken of 41 acetabular fractures that met the criteria for non-operative management. These included roof arcs of 45°, a subchondral CT arc of 10 mm, displacement of less than 50% of the posterior wall, and congruence on the AP and Judet views of the hip. There were three unstable hips which were treated by open reduction and internal fixation. The remaining 38 fractures were treated non-operatively with early mobilisation and delayed weight-bearing. At a mean follow-up of 2.7 years, the results were good or excellent in 91% of the cases. Three fair results were ascribed to the patients’ other injuries. Dynamic stress views can identify subtle instability in patients who would normally be considered for non-operative treatment

Open reduction and internal fixation was employed in the treatment of 25 severely displaced fractures and fracture-dislocations of the proximal humerus. Our aims were accurate reduction and stable fixation to allow early mobilisation and to achieve full functional recovery. In 15 fractures an AO T-plate was used and in 10 a bent semitubular plate was employed as a blade plate. Excellent or satisfactory results were obtained in all six patients with two-part fractures involving the surgical neck; in four of the five patients with three-part fractures involving the surgical neck and tuberosities; in nine of the 11 patients with fracture-dislocation; and in two of the three patients with split fractures of the humeral head. Overall results were good or satisfactory in 21 of the 25 cases. Unsatisfactory results were associated with rotator cuff damage

Repair of the rotator cuff requires secure reattachment, but large chronic defects cause osteoporosis of the greater tuberosity which may then have insufficient strength to allow proper fixation of the tendon. Recently, suture anchors have been introduced, but have not been fully evaluated. We have investigated the strength of suture-to-anchor attachment, and the use of suture anchors in repairs of the rotator cuff either to the greater tuberosity or the lateral cortex of the humerus. The second method gave a significant increase in the strength of the repair (p = 0.014). The repairs were loaded cyclically and failed at low loads by cutting into bone and tendon, casting doubt on the integrity of the repair in early mobilisation after surgery. Repairs with suture anchors did not perform better than those with conventional transosseous attachment

1. Six cases of development of heterotopic bone around joints in association with paralysis from intracranial lesions are presented. It is suggested that such bone may occur more commonly than is realised. 2. The features of these cases are very similar to those seen in association with paraplegia. 3. Extensive new bone is usually associated with fixed contractures. 4. Operation is hazardous in paraplegia but should not necessarily be so in other paralytic conditions. 5. In the presence of returning motor function excision of the bone, allowing correction of the deformity together with some movement, is a worthwhile procedure. In the hip, osteotomy alone usually requires plaster fixation with the attendant risks of venous thrombosis. Previous excision of the bone allows internal fixation of the osteotomy with early mobilisation

We report 33 cases of femoral supracondylar fracture in elderly or debilitated patients treated by Zickel supracondylar nails. Most of the patients were female and their mean age was 79 years. All had concurrent medical problems and only nine could walk unaided. The operating time averaged one hour and mean blood loss was 100 ml. Postoperative management was by mobilisation in a cast brace or plaster. Six patients died before fracture union; all the others achieved union at an average of 12 weeks. The results were excellent in terms of pain relief, movement and function; there were no infections or nonunions. The locking screws backed out or broke in 26% but this did not prejudice the outcome. Use of the Zickel system is recommended for this group of frail patients

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

Fractures of the femoral shaft are generally considered to affect young patients, but we have reviewed 24 cases in patients over 60 years who have been treated by locked nailing, usually by closed methods. Most were women with low-velocity injuries, but despite this, 14 fractures were significantly comminuted. The complication rate was 54% with a peri-operative mortality of 17%. Most complications were the general ones of operating on elderly patients. Specific complications included: fractures below an abnormal hip, proximal fracture related to the nail and poor purchase in the distal femur. In all survivors, the femoral shaft fractures united satisfactorily, and the fixation allowed early mobilisation. The locking nail appears to be an effective method of managing femoral shaft fractures in the elderly patient

The management of traumatic dislocation of the knee in 40 patients (41 knees) with a mean age of 26.3 years is described. They were treated by primary repair and reconstruction with autologous grafting of the anterior (ACL) and posterior cruciate ligaments (PCL) and repair injuries to the collateral ligament and soft-tissue. The ACL and PCL were reconstructed using the patellar tendon and the gracilis and semitendinosus tendons, respectively. Early mobilisation using a continuous-passive-movement machine and active exercises was started on the second day after operation. At a mean follow-up of 39 months no patient reported ‘giving way’ and all except one had good range of movement. Of the 41 knees, 21 were rated as excellent, 15 good, four fair and one poor. Early reconstruction of the cruciate ligaments and primary repair of the collateral ligaments followed by an aggressive rehabilitation programme are recommended for these young, active patients

A prospective randomised trial of surgical treatment for the displaced subcapital femoral fracture in patients of 70 years or more is presented. Two hundred and eighteen patients were randomly allocated into one of three treatment groups: manipulative reduction and internal fixation using Garden screws; Thompson hemiarthroplasty through a posterior (Moore) approach; and Thompson hemiarthroplasty through an anterolateral (McKee) approach. There is no significant difference in the mortality of the internal fixation and posterior arthroplasty groups. Both groups showed a significantly higher mortality than patients operated on through the anterior approach. The technical results of operation were worse in the internally fixed group, with only 40 per cent being satisfactory. Mobilisation was best achieved after the posterior approach. It is concluded that Thompson hemiarthroplasty, using an anterolateral approach, is the safest operation in this group of patients

1. Avascular necrosis of the bony epiphysis or necrosis of the articular cartilage of the hip joint–without bony necrosis–can occur after a slipped upper femoral epiphysis. 2. In avascular necrosis of the bony epiphysis the prognosis depends upon the degree of revascularisation that occurs and upon survival of the articular cartilage. The articular cartilage can survive and a good functioning hip result especially if aided by mobilisation without weight bearing. 3. The prognosis after necrosis of the articular cartilage is poor. This complication occurs more often when conservative treatment is used. 4. A certain number of hips will show poor results no matter what treatment is used. 5. Nutrition of the articular cartilage is probably by the synovial fluid. 6. Strong traction may damage the soft-tissue structure of the hip joint. 7. It is not advisable to perform an osteotomy soon after a slip of the epiphysis. It is better to wait until good function is assured in the joint

We reviewed 13 patients with a complex fracture-dislocation of the proximal interphalangeal joint of a finger and one patient with a complex fracture-dislocation of the interphalangeal joint of thumb. We had treated these injuries using a pins and rubbers traction system which had been modified to avoid friction of the pins against the bone during mobilisation of the joint in order to minimise the risk of osteolysis. A Michigan hand outcome questionnaire was used for subjective assessment. The active range of movement (AROM) of the proximal and distal interphalangeal joints and the grip strength were used for objective assessment. The mean follow-up was 34 months (12 to 49). The mean normalised Michigan hand outcome score was 84. The mean AROM of the proximal interphalangeal joint was 85° and that of the distal interphalangeal joint 48°. The mean grip strength was 92% of the uninvolved hand. Twelve patients have returned to their original occupations. There has been no radiological osteolysis or clinical osteomyelitis. This modified traction system has given acceptable results with a low rate of complications. It is light, cheap, effective and easy to apply

We report the long-term results of the surgical treatment of chronic rupture of tendo Achillis using polyester tape. This requires minimal postoperative splintage and allows early mobilisation and a prompt return to work and sport. We reviewed 16 patients (10 women and 6 men) at a mean period of three years after surgery. The median time from injury to operation was 16.8 months (3.9 months to 13 years), and the median age of the patients was 52 years (27 to 78). The median time to full weight-bearing was 40 days and the median time for return to sport was 18 weeks (5.4 to 32). One patient required further surgery and one had numbness along the distribution of the sural nerve. After surgery only two patients had increased dorsiflexion of the ankle compared with the uninjured side. There were no cases of rerupture. We recommend this technique for the treatment of chronic rupture of tendo Achillis

In a prospective, randomised study we have compared the pertrochanteric external fixator (PF) with the sliding hip screw (SHS) in 100 consecutive patients who were allocated randomly to the two methods of treatment. Details of the patients and the patterns of fracture were similar in both groups. Follow-up was for six months. Use of the PF was associated with significantly less blood loss, a shorter operating time, reduced postoperative pain, shorter hospitalisation (p < 0.001), earlier mobilisation (p < 0.001) and a reduced rate of mechanical complications (p < 0.01). Superficial infection was significantly more common with the PF (p < 0.01), but without long-term adverse consequences. There were no differences in the healing of the fracture, mortality or final functional outcome. Our results indicate that the external fixator is an effective and safe device for treating pertrochanteric fractures and should be considered as a useful alternative to conventional fixation with the sliding hip screw

This is a retrospective study of primary repairs of flexor pollicis longus in 16 children under 15 years of age. Patients with injuries to the median or ulnar nerve at the wrist, crush injuries, skin loss or fracture were excluded. Repairs were carried out within 24 hours using a modified Kessler technique. The mean follow-up was for two years. The final results were evaluated using the criteria of Buck-Gramko and Tubiana. They were good or excellent in all except one patient who had a secondary tendon rupture. When compared with the non-injured thumb, however, there was a significant decrease in active interphalangeal flexion (> 30°) in one-third of cases. A new method of assessment is proposed for the recovery of function of the flexor pollicis tendon which is more suitable for children. Postoperative immobilisation using a short splint had a negative effect on outcome. The zone of injury, an early mobilisation programme or concurrent injury to the digital nerve had no significant effect on the final result

Adolescent idiopathic scoliosis in 152 patients was treated by Luque L-rod instrumentation and early mobilisation without external support. This series was compared with a matched group of 156 patients treated by Harrington instrumentation and immobilised in an underarm jacket for nine months. All the operations in both groups were performed by one surgeon and the patients were followed prospectively for more than two years. Correction of the scoliosis in the frontal plane was similar in both groups. However, the normal sagittal contour was better maintained with Luque rods, especially in the thoracolumbar and lumbar regions, and provided less loss of correction than with Harrington rods. Neither method significantly derotated the scoliosis. All the patients with Luque instrumentation developed a solid fusion despite breakage of the sublaminar wires at one or two levels in 4.9%. There were no major neurological complications with either type of instrumentation