Management of the failed total knee replacement is a formidable problem. In a 13-year period, 24 patients with above knee amputation following unsuccessful knee replacement were referred for prosthetic limb fitting. Adequate data was available for 23 patients. At review (or at the time of death), an average of 48.6 months after amputation, only seven of the 23 patients were regular daily walkers, although 10 patients had managed to walk for more than two years; 20 of the 23 used a wheelchair for some part of the day and 12 were confined to a wheelchair

Aims

The purpose of this study was to evaluate the long-term outcome of adolescents with cerebral palsy who have undergone single-event multilevel surgery for a flexed-knee gait, followed into young adulthood using 3D motion analysis.

In paralytic lesions in which the triceps surae is the only active muscle in the leg, elongation or division of the tendo calcaneus alone may not be enough to prevent recurrence of equinus deformity. In 10 patients (13 limbs) with this pattern of muscle activity, equinus deformity was treated by hemitransplantation of the tendo calcaneus. At follow-up, which was beyond the end of growth in seven limbs, there was no recurrence of deformity in nine. In three of the four failures, a technical fault may have caused loss of activity in the transplanted part of the tendon. The two-stage operation described is recommended in the management of this pattern of paralytic deformity

1. The conservative school of treatment of fractures of the tibia, which bases part of its criticism of internal fixation on the ultimate risk of amputation, does not often publish its own rates of amputation. 2. Statistics from a hospital that treats one-third of closed fractured tibiae and two-thirds of compound fractures by internal fixation are therefore put up as a basis for criticism. 3. Comparisons are made with the few available statistics in the literature of conservative treatment. 4. Almost all of the causes for secondary amputation are now curable and in recent years the number of limbs being saved is increasing

Posterior dislocation of the shoulder is an unusual injury and there is often much delay before the diagnosis is made. Nevertheless, if the condition is borne in mind when examining the patient and studying the X-ray films the diagnosis should not be missed. A single antero-posterior radiograph of the shoulder joint is inadequate. For the radiologist a pair of stereoscopic films is desirable; but for routine emergency work in hospital other projections are necessary. A vertical view should be taken, either with the limb abducted and the tube in the axilla, or with the tube above the shoulder and a curved cassette in the axilla. When this is impossible a profile or posterior oblique view of the scapula may be substituted

1. Small indian ink marks were made at intervals along the length of tendons in the limbs of young rabbits, and the distance between the marks was measured during the operation. The rabbits were killed two to three months later, and the amount of longitudinal growth that had occurred was determined by re-measuring the distance between the marks. 2. The experiments showed that the whole of the tendon grows interstitially in length, but that maximal growth occurs near the muscle-tendon junction. 3. Histological examination of the tendons and control experiments involving adult tendons indicated that growth was not significantly interfered with by marking the tendons

We compared the safety and outcome of one-stage bilateral total hip arthroplasty with those of a two-stage procedure during different admissions in a prospective, randomised controlled trial in an Asian population. Of 168 patients included in the study, 83 had a single- and 85 a two-stage procedure. Most of the patients (59.9%) suffered from inflammatory arthritis. The intra-operative complications, early systemic complications, the operating time, positioning of the components, the functional score, restoration of limb length and survival rates at 96 months were similar in the two groups. The total estimated blood loss was significantly lower in patients undergoing a one-stage procedure than in patients who had a two-stage procedure, but the transfusion requirements were significantly higher in the former group (p = 0.001). The hospital stay was significantly shorter in the one-stage group, 7.25 days (. sd. 1.30; 5 to 20) compared with 10 days (. sd. 1.65; 8 to 24) in the two-stage group (p = 0.023). We believe that a one-stage procedure is safe and appropriate in our population

We carried out extensible endoprosthetic replacement of the proximal or total humerus in 18 children aged between six and 12 years, after resection of primary bone tumours mainly for osteosarcoma and Ewing’s sarcoma. In 11 patients we performed 44 lengthening procedures, with an average of two per child annually and a mean total extension of 29.9 mm per patient. We were able to achieve lengthening of the operated limb with few complications and a mean functional rating of 79.3% according to the Enneking system. Progressive lengthening of these prostheses does not adversely affect the overall function of the arm, and superior subluxation of the head of the prosthesis has not been a problem

Thirty-three patients with reflex sympathetic dystrophy were studied prospectively to ascertain the pressure-pain threshold of affected and unaffected limbs. The affected side had a lower threshold which was found to be statistically significant. In all 18 patients with upper limb involvement, the pain threshold was reduced on the affected side, but this applied to only 11 of the 15 with leg involvement. This difference may be because patients with lower limb symptoms had been referred later in the course of the syndrome. We showed by repeated tests that after an average of 49 days there was a slow return to normality. The estimation of pressure-pain thresholds may help in the earlier diagnosis of reflex sympathetic dystrophy

One method of reconstruction in limb salvage surgery for bone tumours is wide resection, extracorporeal devitalisation of the excised segment by autoclaving, and reimplantation of the segment. We have studied the changes in temperature in the medullary cavity, the head, the medial condyle and lateral condyle of calf femora during autoclaving at 134 degrees C in two different autoclaves. There were impressive differences of temperature at different sites. The most unfavourable position was the lateral condyle, which consists mainly of cancellous bone: a short programme of 11 minutes produced a lowest temperature in the series of only 45 degrees C, which may not be sufficient to kill all tumour cells

The place of the myo-electric prosthesis in below-elbow amputees has been reviewed. Forty-three patients were seen and all possessed both a myo-electric prosthesis and a standard artificial limb. Nearly half the patients used the newer device almost all the time at work and many of these wore it for the majority of their waking hours. Its use at work was mainly related to the patient's type of job and here in turn there was concern about damaging the device. It is suggested that acceptance would be further increased if greater attention were paid to the durability of the arm and its glove. Criteria for prescription and future developments are discussed

1. Opinion is divided as to the value of synovectomy of the knee in juvenile rheumatoid arthritis. 2. Between 1964 and 1970 thirty synovectomies of the knee were performed in twenty-seven children, who have now been kept under review for one to eight years. Three have required a second operation. 3. The operative findings at various stages are presented and discussed, with special reference to the effect on growth of the limb. 4. Synovectomy is a useful procedure which should be reserved for cases where effusion persists despite nine months of conservative treatment and performed before signs of bone erosion appear

1. All traceable Syme amputees attending the Edinburgh limb centre have been seen and reviewed. They number sixty-seven. Forty had amputations twenty-five or more years before. 2. There are seventy-one surviving stumps. One has failed. 3. Records of all the below-knee amputees reveal five further failures of Syme stumps. The causes of failure are discussed. 4. Problems in the Syme stump are rare after the first year. The early difficulties are discussed. 5. We conclude that a patient with Syme's amputation can expect his stump to give a lifetime of service

1. Three cases of injury to the femoro-popliteal artery complicating fracture of the femoral shaft are described. 2. In all three cases restoration of peripheral circulation by arterial repair carried out within ten hours of injury succeeded in saving the limb from permanent damage. 3. The importance of adequate resuscitation, early diagnosis and early adequate surgical intervention is stressed. 4. The mechanism of injury and the clinical features of help in early diagnosis are discussed. 5. The place of internal fixation of the femoral fragments is discussed and its advantages and disadvantages are compared with those of treatment by skeletal or skin traction

1. The prognosis of paralytic scoliosis has been studied by defining curve patterns and establishing the natural development as seen in fully grown patients who have not had surgical correction. 2. The prognosis, unlike that in idiopathic scoliosis, is related to the age of onset of the curvature and the degree of muscle imbalance rather than the site of the primary curve. 3. Paralysis of limb muscles is shown to be unrelated to the development of scoliosis. The intercostal muscles and the lateral abdominal flexors produce scoliosis when weaker on the convex side of the curve. Gravity and the other trunk muscles certainly play a part in the development of lumbar curves but their importance is difficult to assess

1 . Twenty-four patients complaining of severe pain after nerve injuries have been considered from a diagnostic and therapeutic point of view. 2. The typical syndrome of causalgia develops only when the median or internal popliteal nerves are injured. It is doubtful whether pain associated with injury in the peripheral part of the limb, or of the brachial plexus, should be classed as causalgia. 3. The importance of novocaine block of the sympathetic ganglia as a diagnostic test is stressed, and its usefulness as a therapeutic measure is considered. 4. Sympathectomy is shown to be a reliable method of treatment in suitable cases. 5. The limited field of application of radiotherapy is also indicated

Aims

The purpose of this study was to describe the effect of histological grade on disease-specific survival in patients with chondrosarcoma.