We made a prospective study of 208 patients with tibial fractures treated by reamed intramedullary nailing. Of these, 11 (5.3%) developed dysfunction of the peroneal nerve with no evidence of a compartment syndrome. The patients with this complication were significantly younger (mean age 25.6 years) and most had closed fractures of the forced-varus type with relatively minor soft-tissue damage. The fibula was intact in three, fractured in the distal or middle third in seven, with only one fracture in the proximal third. Eight of the 11 patients showed a ‘dropped hallux’ syndrome, with weakness of extensor hallucis longus and numbness in the first web space, but no clinical involvement of extensor digitorum longus or tibialis anterior. This was confirmed by nerve-conduction studies in three of the eight patients. There was good recovery of muscle function within three to four months in all cases, but after one year three patients still had some residual tightness of extensor hallucis longus, and two some numbness in the first web space. No patient required further treatment

We studied 16 club feet and 27 normal feet from spontaneously aborted human fetuses in the second trimester of gestation and measured the length of the spring ligament, and the declination angle and size of the talus. We also studied the cellular characteristics of the spring ligament and the immunohistochemical features of the medial ankle ligaments using monoclonal antibodies against type-III collagen, desmin, vimentin, and smooth muscle actin. Histomorphometric results indicated that the talar deformity was not the primary lesion. Histological and immunohistochemical findings showed that the cells and collagen fibres of the medial ankle ligaments of club feet appeared to be the site of the earliest changes, in that they had lost their spatial orientation and had contracted. In severe club feet before the third trimester of gestation, myofibroblast-like cells seemed to create a disorder of the ligaments resembling fibromatosis. This led to contraction and resulted in typical club-foot deformity

We reviewed a series of 53 patients with closed traumatic complete injuries of the cervical spinal cord. They were admitted within two days to a spinal injuries centre, treated conservatively by six weeks of bedrest and skull traction, then mobilised in a neck support for six weeks. Eight patients had temporary neurological deterioration, four spontaneously and four after cervical manipulation; seven of these recovered to the initial neurological level without surgery. Of 40 patients followed for more than 12 months, 19 recovered useful motor power in local muscles which were initially paralysed (zonal recovery); one patient showed distal motor recovery. Zonal recovery did not correlate with the mechanism of skeletal injury or with the degree of residual canal stenosis. Sensory sparing and an initial neurological level higher than the level of skeletal injury were both good prognostic signs for zonal recovery

The quantification of local bone blood flow in man has not previously been possible, despite its importance in the study of normal and pathological bone. We report the use of positron emission tomography, using 15O-labelled water, to measure bone blood flow in patients with closed unilateral fractures of the tibia. We compared fractured and unfractured limbs; alterations in blood flow paralleled those found in animal models. There was increased tibial blood flow at the fracture site as early as 24 hours after fracture, reaching up to 14 times that in the normal limb at two weeks. Blood flow increase was less in displaced than in undisplaced fractures. The muscle to bone ratios of blood flow were similar to those in previous animal work using other techniques. Positron emission tomography will allow study of human bone blood flow in vivo in a wide variety of pathological conditions

We reviewed 55 patients with mid-lumbar myelomeningocele (L3 and L4) first seen over a 17-year period from 1970 to 1986 and followed up for an average of ten years. We assessed a number of factors which might affect hip stability and ability to walk, recording the natural history of clinical and radiological hip deformity. Two-thirds of the hips had become dislocated or subluxed by the end of the first year of life, involving 86% of hips in patients with an L3 level and 45% of those with an L4 level. All the hips that developed instability secondary to muscle imbalance did so within the first year. The neurological level was the most significant determinant of walking ability: all patients with L4 neurological levels could walk but only one-third of those with L3 lesions could do so. Hip stability, intelligence quotient and fixed deformity did not influence walking ability

Seven pectoralis major transfers in children suffering from bilateral paralysis of elbow flexion due to arthrogryposis or to trauma are reported. A technique is described in which the muscle is mobilised from the clavicle to allow the tendon of insertion to be attached to the biceps tendon at the elbow. The biceps tendon was found to be present and could be mobilised forwards in all the arthrogrypotic elbows. Subjectively, the results were considered by patients or parents to be very good in six cases and fair in one. Elbow flexion power against gravity and against some resistance was achieved in all patients except one. The overall function was very good in one elbow, good in two, fair in three and poor in only one. The merits of the various procedures described for the restoration of elbow flexion in arthrogryposis are discussed. It is concluded that total pectoralis major transfer by the method described here has given the best results

A model of tourniquet ischaemia was developed in the hind limb of the rat, and the metabolic changes that occurred in the calf muscles were monitored by the non-invasive technique of phosphorus-31 nuclear magnetic resonance spectroscopy. During ischaemia the intramyocellular pH became acidic as the level of phosphocreatine declined and that of inorganic phosphate rose. Phosphocreatine was no longer detectable after approximately 2 hours and ATP was depleted after approximately 3.5 hours. Metabolic recovery was rapid (1 hour) if ATP was present when the tourniquet was released but was prolonged (3 or more hours) if ATP was depleted. Hourly release of the tourniquet for 10 minutes ensured the maintenance of ATP and rapid metabolic recovery. Release for intervals of only 5 minutes did not have the same protective effect and in fact worsened tissue pH during the period of tourniquet ischaemia. Heparin and corticosteroids were without effect during and after periods of tourniquet ischaemia

We assessed peripheral nerve function during and after lower-limb lengthening by callotasis in 14 patients with short stature, using motor conduction studies. Four patients with short stature of varying aetiology showed unilateral and one showed bilateral weakness of foot dorsiflexion. Both clinical and electrophysiological abnormalities consistent with involvement of the peroneal nerve were observed early after starting tibial callotasis. There was some progressive electro-physiological improvement despite continued bone distraction, but two patients with Turner’s syndrome had incomplete recovery. A greater percentage increase in tibial length did not correspond to a higher rate of peroneal nerve palsy. The function of the posterior leg muscles and the conduction velocity of the posterior tibial nerve were normal throughout the monitoring period. The F-wave response showed a longer latency at the end of the bone distraction than in basal conditions; this is probably related to the slowing of conduction throughout the entire length of the nerve

Although a variety of techniques have been used with varying success to induce scoliosis in animals, primates have rarely been used. A series of monkeys is presented where scoliosis developed incidentally during the routine virulence testing of live, attenuated, oral poliomyelitis vaccines by intraspinal injection. The site and extent of histological damage in the different anatomical areas of the spinal cord were examined in 25 scoliotic monkeys and 25 matched controls. Analysis of the data demonstrated that there was significantly greater damage on the convex side of the spinal cords of the scoliotic animals, particularly in the sensory areas-the posterior horn and Clarke's column. Scoliosis was not thought to be caused by clinical poliomyelitis as the involvement of the anterior horn was not significantly greater than in the scoliotic animals than in the controls. These observations are taken to support the view that scoliosis may develop as a result of asymmetrical weakness of the paraspinal muscles due to the loss of proprioceptive innervation

Thirty-four patients wtih fibrodysplasia (syn., myositis) ossificans progressiva are described. Marked delay in diagnosis was usual, but all had characteristic skeletal malformations and ectopic ossification. The clinical features included: four types of malformation of the big toe, reduction defects of all digits, deafness, baldness of the scalp, and mental retardation. Progression of disability was erratic in all, but severe restriction of movement of the shoulder and spine was usual by the age of 10 years; the hips were usually involved by the age of 20 years; and most patients were confined to a chair by the age of 30 years. Exacerbating factors included trauma to the muscles, biopsy of the lumps, operations to excise ectopic bone, intramuscular injections, careless venepuncture and dental therapy. Progression of disability did not appear to be influenced by any form of medical treatment and therefore management of the patients must concentrate on the avoidance of exacerbating factors

Failure of union of the tibia with a large defect is difficult to treat, especially in the presence of sepsis and adherent scars. Conventional methods of fixation and bone grafting are not easily applicable. Experiments on Macaca monkeys showed that a vascularised pedicle graft of the shaft of the ipsilateral fibula could be fixed across a defect in the tibia and remain viable, even if it was isolated from surrounding soft tissues. Transfer of part of the shaft of the ipsilateral fibula on a vascular and muscle pedicle was carried out in 11 patients with large tibial defects and sepsis. There was one failure because of severe infection, but the other 10 patients gained sound union in about four months. The tibia was then protected by a caliper for the 18 months of full reconstitution. The bone infection healed and there was no evidence of avascular necrosis. Although the salvaged limbs were scarred, stiff and ugly, none of the patients suffered from pain, recurrent oedema or persistent infection

1. Recurrence of deformity after operations for drop foot is often associated with opening of the front of the ankle joint: this has previously been regarded as a complication of the operation. 2. This study of sixty paralytic drop feet treated conservatively reveals that this laxity was in fact present in no less than 43 per cent. 3. The laxity is most commonly found when the calf muscle is strong and it can occur within a year of the onset of the paralysis. It is not always prevented by wearing a toe-raising spring. 4. Such anterior laxity may well be a common cause of failure of many of the standard operations for drop foot. 5. Before operation for drop foot is undertaken a lateral radiograph of the ankle should be taken in forced plantar-flexiori. If this demonstrates anterior laxity any standard operation is unlikely to succeed unless the anterior fibres of the collateral ligaments are protected from strain by simultaneous tendon transplantation or unless the ankle is included in the arthrodesis

Aims

Anatomical atlases document classical safe corridors for the placement of transosseous fine wires through the calcaneum during circular frame external fixation. During this process, the posterior tibial neurovascular bundle (PTNVB) is placed at risk, though this has not been previously quantified. We describe a cadaveric study to investigate a safe technique for posterolateral to anteromedial fine wire insertion through the body of the calcaneum.

Surgical dislocation of the hip is rarely undertaken. The potential danger to the vascularity of the femoral head has been emphasised, but there is little information as to how this danger can be avoided. We describe a technique for operative dislocation of the hip, based on detailed anatomical studies of the blood supply. It combines aspects of approaches which have been reported previously and consists of an anterior dislocation through a posterior approach with a ‘trochanteric flip’ osteotomy. The external rotator muscles are not divided and the medial femoral circumflex artery is protected by the intact obturator externus. We report our experience using this approach in 213 hips over a period of seven years and include 19 patients who underwent simultaneous intertrochanteric osteotomy. The perfusion of the femoral head was verified intraoperatively and, to date, none has subsequently developed avascular necrosis. There is little morbidity associated with the technique and it allows the treatment of a variety of conditions, which may not respond well to other methods including arthroscopy. Surgical dislocation gives new insight into the pathogenesis of some hip disorders and the possibility of preserving the hip with techniques such as transplantation of cartilage

Of 935 consecutive patients referred with shoulder pain, 50 fitted the criteria for primary frozen shoulder. Twelve patients who failed to improve after conservative treatment and manipulation had excision of the coracohumeral ligament and the rotator interval of the capsule. The specimens were examined histologically, using special stains for collagen. Immunocytochemistry was performed with monoclonal antibodies against leucocyte common antigen (LCA, CD45) and a macrophage/synovial antigen (PGMI, CD68) to assess the inflammatory component, and vimentin and smooth-muscle actin to evaluate fibroblasts and myofibroblasts. Our histological and immunocytochemical findings show that the pathological process is active fibroblastic proliferation, accompanied by some transformation to a smooth muscle phenotype (myofibroblasts). The fibroblasts lay down collagen which appears as a thick nodular band or fleshy mass. These appearances are very similar to those in Dupuytren's disease of the hand, with no inflammation and no synovial involvement. The contracture acts as a check-rein against external rotation, causing loss of both active and passive movement

Aims

Patellofemoral problems are a common complication of total knee arthroplasty. A high compressive force across the patellofemoral joint may affect patient-reported outcome. However, the relationship between patient-reported outcome and the intraoperative patellofemoral contact force has not been investigated. The purpose of this study was to determine whether or not a high intraoperative patellofemoral compressive force affects patient-reported outcome.

The clinical and radiological state of the hips of a group of children with cerebral palsy treated without operation is compared with that in a group treated by operation to correct adduction and flexion deformity and to obtain balanced action in the hip muscles. In the first group, 11 per cent of hips were dislocated, 28 per cent subluxated, 46 per cent dysplastic and 15 per cent normal. In the second group no hip was dislocated, 13 per cent were subluxated, 35 per cent dysplastic and 52 per cent normal. Surgical intervention is indicated clinically for a range of abduction diminishing to less than 45 degrees and–on radiological criteria–for early dysplastic changes, especially a break in Shenton's line, irrespective of the patient's age, severity of involvement or neurological maturity. Prevention of subluxation or dislocation improves function and diminishes the liability to develop a painful hip in adolescence or early adult life

1. Sixty feet operated upon either by triple or pantalar tarsal fusion for instability after poliomyelitis were re-examined ten to twenty-four years later. 2. After triple fusion with preservation of the ankle joint there was a striking absence of late osteoarthritis of the ankle, and only a low incidence of troublesome lateral instability of the ankle. The results were generally good provided the patient had reasonable power of extension of the knee. 3. Triple arthrodesis for completely flail foot in patients without active muscle control of the knee was often disappointing, so far as the limb as a whole was concerned, because of a persistent flexion deformity of the knee which usually necessitated the wearing of an appliance. 4. The results of pantalar arthrodesis for the flail foot were satisfactory. When this operation was performed (with the foot in slight equinus) in patients who lacked active extension of the knee it helped to stabilise the knee in walking by encouraging hyperextension

Estimates of knee joint loadings were calculated for 12 normal subjects from kinematic and kinetic measures obtained during both level and downhill walking. The maximum tibiofemoral compressive force reached an average load of 3.9 times body-weight (BW) for level walking and 8 times BW for downhill walking, in each instance during the early stance phase. Muscle forces contributed 80% of the maximum bone-on-bone force during downhill walking and 70% during level walking whereas the ground reaction forces contributed only 20% and 30% respectively. Most total knee designs provide a tibiofemoral contact area of 100 to 300 mm. 2. The yield point of these polyethylene inlays will therefore be exceeded with each step during downhill walking. Future evaluation of total knee designs should be based on a tibiofemoral joint load of 3.5 times BW at 20° knee flexion, 8 times BW at 40° and 6 times BW at 60°