For the purpose of investigating the effect of an insole with a lateral wedge, we studied 30 patients (31 knees) aged from 46 to 78 years with idiopathic osteonecrosis of the knee for at least three years. The 18 knees treated with an insole (group I) were matched by age, gender, obesity index, area of lesion, femorotibial angle, stage, and clinical evaluation with 13 treated conservatively without an insole (group II). The clinical results, as rated by a knee score, improved significantly more in group I than in group II. Radiologically, the necrotic area and ratio decreased in group I, whereas in group II they increased. In advanced cases, with stage 4 or a femorotibial angle of more than 180°, the use of an insole did not improve the clinical or radiological findings. The insole is a valuable method of conservative treatment for the early stages of osteonecrosis of the medial femoral condyle

We have reviewed 12 cases of fracture-separation of the distal humeral epiphysis, three of which were initially misdiagnosed as fractures of the lateral condyle and one as an elbow dislocation. Cubitus varus deformity is as common after this fracture-separation as it is following supracondylar fracture, and is most common in children under two years of age. Closed reduction and simple immobilisation is adequate for the older child, but we recommend for those under two years of age that closed reduction should be followed by percutaneous pinning, so that the carrying angle can be assessed immediately after reduction. If the elbow is then in varus the wires should be removed, reduction repeated and treatment by straight lateral traction used to maintain a valgus carrying angle

The Ilizarov apparatus was used to carry out opening-wedge callotasis of the proximal tibia in ten patients who had suffered premature asymmetrical closure of the proximal tibial physis and subsequent genu recurvatum. In four knees, the genu recurvatum was entirely due to osseous deformity, whereas in six it was associated with capsuloligamentous abnormality. Preoperatively, the angle of recurvatum averaged 19.6° (15 to 26), the angle of tilt of the tibial plateau, 76.6° (62 to 90), and the ipsilateral limb shortening, 2.7 cm (0.5 to 8.7). The average time for correction was 49 days (23 to 85). The average duration of external fixation was 150 days (88 to 210). Three patients suffered complications including patella infera, pin-track infection and transient peroneal nerve palsy. At a mean follow-up of 4.4 years, all patients, except one, had achieved an excellent or good radiological and functional outcome

1. Lateral radiographs of fifty-seven club feet and seventeen normal feet were taken in forced flexion and forced extension. On these, the arcs traversed by the talus, the sole and the calcaneus were measured, as was the talo-calcaneal angle. 2. It was found that the ankle in club feet usually contributed more than half of the total sagittal movement of the foot. 3. Occasional cases were encountered in which the ankle was so damaged that it contributed only half or less than half of this movement. In such cases wedge excision of the ankle joint is theoretically justified in preference to wedge tarsectomy. 4. The talo-calcaneal angle is much reduced in club foot, and this element of deformity is extremely resistant to manipulative treatment. The reasons for this and a possible method of treatment are discussed

We have examined the effect of the Wagner spherical acetabular osteotomy on preserving the joint in 38 hips with a mean follow-up of 17 years. At the time of the initial operation, 55% of patients had clinical symptoms and 30 joints showed minimal or absent radiological signs of osteoarthritis. At follow-up, 54% of patients had a good functional result. The osteotomy improved the mean centre-edge angle from −3° to +15°, the mean anterior centre-edge angle to 23° and the acetabular head index to 75%. The obliquity of the acetabular roof decreased from 28° to 16°. One patient improved, but 14 deteriorated with joint degeneration. Of these, one progressed because of postoperative deep-tissue infection and five due to undercorrection. One patient needed total joint replacement after 14 years. At 17 years after operation, Wagner osteotomy had prevented progression of secondary arthritis in 63% of cases

We reviewed 14 patients (16 hips) treated by open reduction and upper femoral derotation osteotomy for congenital dislocation of the hip. Nine patients with 11 treated hips had growth deformities of the proximal femur; in all of them the top screw of the fixation plate lay within the cartilaginous precursor of the greater trochanter. In the five control hips the top screw was more distal. In the nine patients (mean follow-up 10.8 years) there was an increase of 14 degrees in the neck-shaft angle (p = 0.01) and of 18 degrees in the angle between the capital femoral physis and the shaft (p = 0.01) compared to the control group. This indicates that growth disturbance of the greater trochanteric apophysis as a result of plate fixation leads to long-term deformity

We reviewed 47 patients with neurofibromatosis and dystrophic spinal deformities; 32 of these patients had been untreated for an average of 3.6 years and in them the natural history was studied. The commonest pattern of deformity at the time of presentation was a short angular thoracic scoliosis, but with progression the angle of kyphosis also increased. Deterioration during childhood was usual but its rate was variable. Severe dystrophic changes in the apical vertebrae and in particular anterior scalloping have a poor prognosis for deterioration. The dystrophic spinal deformity of neurofibromatosis requires early surgical stabilisation which should be by combined anterior and posterior fusion if there is an abnormal angle of kyphosis or severely dystrophic apical vertebrae. Some carefully selected patients can be treated by posterior fusion and instrumentation alone

Using a new, non-invasive method, we measured the patellofemoral force (PFF) in cadaver knees mounted in a rig to simulate weight-bearing. The PFF was measured from 20° to 120° of flexion before and after implanting three designs of knee prosthesis. Medial unicompartmental arthroplasty with a meniscal-bearing prosthesis and with retention of both cruciate ligaments caused no significant change in the PFF. After arthroplasty with a posterior-cruciate-retaining prosthesis and division of the anterior cruciate ligament, the PFF decreased in extension and increased by 20% in flexion. Implantation of a posterior stabilised prosthesis and division of both cruciate ligaments produced a decrease in the PFF in extension but maintained normal load in flexion. There was a direct relationship between the PFF and the angle made with the patellar tendon and the long axis of the tibia. The abnormalities of the patellar tendon angle which resulted from implantation of the two total prostheses explain the observed changes in the PFF and show how the mechanics of the patellofemoral joint depend upon the kinematics of the tibiofemoral articulation

Narrowing of the femoral neck after resurfacing arthroplasty of the hip has been described previously in both cemented and uncemented hip resurfacing. The natural history of narrowing of the femoral neck is unknown. We retrospectively measured the diameter of the femoral neck in a series of 163 Birmingham hip resurfacings in 163 patients up to a maximum of six years after operation to determine the extent and progression of narrowing. There were 105 men and 58 women with a mean age of 52 years (18 to 82). At a mean follow-up of five years, the mean Harris hip score was 94.8 (47 to 100) and the mean flexion of the hip 112.5° (80° to 160°). There was some narrowing of the femoral neck in 77% (125) of the patients reviewed, and in 27.6% (45) the narrowing exceeded 10% of the diameter of the neck. A multiple logistic regression analysis showed a significant association (chi-squared test (derived from logistic regression) p = 0.01) of narrowing with female gender and a valgus femoral neck/shaft angle. There was no significant association between the range of movement, position or size of the component or radiological lucent lines and narrowing of the neck (chi-squared test; p = 0.10 (flexion), p = 0.08 (size of femoral component), p = 0.09 (size of acetabular component), p = 0.71 (femoral component angulation), p = 0.99 (lucent lines)). There was no significant difference between the diameter of the neck at a mean of three years (2.5 to 3.5) and that at five years (4.5 to 5.5), indicating that any change in the diameter of the neck had stabilised by three years (sign rank test, p = 0.60). We conclude that narrowing of the femoral neck which is found with the Birmingham hip resurfacing arthroplasty is in most cases associated with no adverse clinical or radiological outcome up to a maximum of six years after the initial operation

We reviewed our experience with a modified triple innominate osteotomy for hip instability and limb shortening due to poliomyelitis in 62 adolescent and adult patients, treated from 1973 to 1990. Their ages at surgery ranged from 12 years to 35 years (average 22.3). At a mean follow-up of 4 years (2 to 18) 59 of the patients (95.2%) had substantial improvement in hip stability, and all but one had radiological improvement as determined by the acetabular angle, centre-edge angle and acetabulum-head quotient. In 59 cases in which transiliac limb lengthening was attempted, the mean gain was 1.7 cm (0.6 to 3.0). When the abductor muscles had been partially paralysed, the operation produced an appreciable increase in power in 12 of the 39 hips examined

We investigated the reproducibility of the various radiological methods of assessment of hip dysplasia by making 474 assessments of hips and quantifying the inter-observer and intra-observer variation. There was a wide range of variability between the readings made by different observers and by one observer on two occasions. A measurement of acetabular index has to be given a range of +/- 6 degrees in order to be 95% confident of including the true measurement. We found the most helpful measurements to be the acetabular index, up to the age of eight years; the centre-edge angle, over the age of five years; and Smith's c/b ratio and neck-shaft angle. We feel, however, that the change in value over a series of radiographs in the same child is much more valuable. Single readings of all the radiological measurements investigated in this study were unreliable

Lack of full extension of the elbow is a common abnormality in patients with achondroplasia. We studied 23 patients (41 elbows) clinically and radiologically. Extension of the elbow was assessed clinically and the angle of posterior bowing of the distal humerus was measured from lateral radiographs. There was limited extension of the elbow in 28 (68.3%) and the mean loss of extension was 13.1°. Posterior bowing of the humerus was seen in all elbows with a mean angle of 17.0°. There was a positive correlation between these two measurements. Posterior bowing greater than 20° caused a loss of full elbow extension. Posterior dislocation of the radial head was seen in nine elbows (22.0%). The mean loss of extension of the elbows was 28.7° which was significantly greater than that of these elbows in which the head was not dislocated (8.7°), although posterior bowing was not significantly different between these two groups (19.3° and 16.3°). Posterior bowing of the distal humerus is a principal cause of loss of extension of the elbow. Posterior dislocation of the radial head causes further limitation of movement in the more severely affected joints

In 12 infants aged under 16 months with unilateral club foot we used MRI in association with multiplanar reconstruction to calculate the volume and principal axes of inertia of the bone and cartilaginous structures of the hindfoot. The volume of these structures in the club foot is about 20% smaller than that in the normal foot. The reduction in volume of the ossification centre of the talus (40%) is greater than that of the calcaneus (20%). The long axes of both the ossification centre and the cartilaginous anlage of the calcaneus are identical in normal and club feet. The long axis of the osseous nucleus of the talus of normal and club feet is medially rotated relative to the cartilaginous anlage, but the angle is greater in club feet (10° v 14°). The cartilaginous structure of the calcaneus is significantly medially rotated in club feet (15°) relative to the bimalleolar axis. The cartilaginous anlage of the talus is medially rotated in both normal and club feet, but with a smaller angle for club feet (28° v 38°). This objective technique of measurement of the deformity may be of value preoperatively

Aims

The aim of this study was to establish the results of isolated exchange of the tibial polyethylene insert in revision total knee arthroplasty (RTKA) in patients with well-fixed femoral or tibial components. We report on a series of RTKAs where only the polyethylene was replaced, and the patients were followed for a mean of 13.2 years (10.0 to 19.1).

Aims

In patients with a rotator cuff tear, tear pattern and tendon involvement are known risk factors for the development of pseudoparalysis of the shoulder. It remains unclear, however, why similar tears often have very different functional consequences. The present study hypothesizes that individual shoulder anatomy, specifically the moment arms (MAs) of the rotator cuff (RC) and the deltoid muscle, as well as their relative recruitment during shoulder abduction, plays a central role in pseudoparalysis.

Spontaneous correction of deformity is produced by bone remodelling during the period of growth. The purpose of this experimental study was to find out in which phase and to what extent asymmetrical epiphysial growth participated in the correction of an experimentally produced deformity. Transverse wedge osteotomy was performed in the legs of twenty growing mongrel dogs, the fragments being fixed with bent AO-plates. From radiographs taken at intervals of two weeks the epiphysial and axial angles were measured. Nine dogs were given tetracycline ten to twenty days before death and the cut surfaces were photographed in reflected ultra-violet light. It was found that epiphysial growth played an important role in the remodelling process. This factor accounted for roughly half of the total correction and averaged 12-5 degrees during the observation time of 160 days. The greatest correction occurred during the first weeks. Correction of the epiphysial angle took place with acceleration of growth

We have observed the natural history without treatment of 46 limbs in 29 patients with infantile tibia vara and a metaphyseal-diaphyseal angle (MDA) of more than 11°. The femorotibial angle (FTA) and MDA were measured, and Langenskiöld’s classification of radiological changes in the proximal medial metaphysis of the tibia was used. In 22 limbs which were not in Langenskiöld stages II to III the condition resolved spontaneously without treatment. Of the remaining 24 which were in stages II to III, in 18 it resolved spontaneously by the age of six years, but six showed little or no improvement at the latest follow-up. It was impossible to differentiate by measuring the FTA or MDA whether spontaneous resolution could be expected before the age of four years. There was no difference in the rate of resolution of the deformity between those patients who had been treated by a brace and those who had received no treatment. We advise no initial treatment but review at six-monthly intervals until the age of four years, even in patients with Langenskiöld stage-II to stage-III deformity. When a deformity persisted or progressed we carried out a corrective osteotomy after the age of four years