In 44 consecutive patients, 60 porous-coated anatomic total knee (PCA) prostheses with a porous-coated central tibial stem were implanted without using cement. The clinical results and bony remodelling have been assessed after five years' follow-up. The average Hospital for Special Surgery knee score was 33.1 before operation and 95.7 at the latest follow-up, while the average range of movement improved from 63 degrees to 123 degrees. No subsidence or migration of the components was seen. A radiodense line appeared around the components at six months to one year after the operation and became more dense with time. There was no evidence of bone resorption related to stress-shielding in the tibial plateau

We reviewed the results of 14 total hip replacements in patients with juvenile chronic arthritis. The mean age at operation was 16 years (range 12 to 22 years); follow-up was from four to 11 years (mean 8.5 years). Postoperatively pain relief was sustained in all but one hip, while movement generally remained significantly restricted. No hip has as yet required a revision operation, although eight hips (57%) show radiological changes suggestive of impending failure. All patients had severe polyarticular involvement with associated restriction of locomotor activity. Potential causes contributing to loosening such as continuing diaphyseal bone growth and increased immunocompetence in adolescence are discussed

We describe a new technique for open reduction, bone grafting and fixation with a single Kirschner wire of unstable fractures of the distal radius. Of the 83 patients treated by this technique, most had regained volar tilt when seen at an average of 13 months after injury. Malunion was seen in 18 patients due either to poor placement of the graft and Kirschner wire or because of both volar and dorsal comminution. Assessment of hand and wrist function showed an average recovery of 63% of mass grip strength with an excellent return of specialised grip strength and range of movement. The advantages of this technique over closed methods include the ability to regain the volar tilt of the distal radius and to achieve reduction at any time before union of the fracture

The appearance and the biochemical, cytological and bacteriological findings were studied in synovial fluid obtained from the knees of 72 patients from south-west India. We report a group of 12 patients with 'eosinophilic synovitis'. In these patients, all below the age of 20 years with an acute onset of severe pain in the knee, there was a large effusion with painful limitation of movement. Their blood leucocyte count averaged 11,200 per mm3 with a mild eosinophilia of 6%. Biochemical examination of synovial fluid was normal, but cytology showed an increase in leucocytes ranging from 1200 to 20,500 (mean 9525) with between 75% and 90% of eosinophils in eight patients and 60% to 75% in four. All the patients responded well to a course of diethylcarbamazine

When cerebral palsy involves the entire body pelvic asymmetry indicates that both hips are ‘at risk’. We carried out a six-year retrospective clinical, radiological and functional study of 30 children (60 hips) with severe cerebral palsy involving the entire body to evaluate whether bilateral simultaneous combined soft-tissue and bony surgery of the hip could affect the range of movement, achieve hip symmetry as judged by the windsweep index, improve the radiological indices of hip containment, relieve pain, and improve handling and function. The early results at a median follow-up of three years showed improvements in abduction and adduction of the hips in flexion, fixed flexion contracture, radiological containment of the hip using both Reimer’s migration percentage and the centre-edge angle of Wiberg, and in relief of pain. Ease of patient handling improved and the satisfaction of the carer with the results was high. There was no difference in outcome between the dystonic and hypertonic groups

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

Techniques for the selective cutting of ligaments in cadaver knees defined the static contributions of the posterolateral structures to external rotation, varus rotation and posterior tibial translation from 0° to 120° of flexion under defined loading conditions. Sectioning of the popliteofibular ligament (PFL) (group 1) produced no significant changes in the limits of the knee movement studied. Sectioning of the PFL and the popliteus tendon (femoral attachment, group 2) produced an increase of only 5° to 6° in external rotation from flexion of 30° to 120° (p < 0.001). Even when other ligaments were sectioned first (group 3), the maximum effect of the PFL was negligible. Our findings show that the popliteus muscle-tendon-ligament complex, lateral collateral ligament, and posterolateral capsular structures function as a unit. No individual structure alone is the primary restraint for the movements studied. Operative reconstruction should address all of the posterolateral structures, since restoration of only a portion may result in residual instability

This paper describes a new technique for greater trochanteric hip arthroplasty in which the femur is divided at the subtrochanteric level and the upper fragment rotated through 180 degrees to place the greater trochanter deeply in the acetabulum; with the lower limb in the weight-bearing position the fragments are then fixed with a short intramedullary nail. This operation was carried out in a boy aged 4 years 6 months in whom the femoral head and neck had been destroyed by septic arthritis. Ten years later leg-lengthening was performed. When reviewed at the age of 20, he had a stable hip, a satisfactory range of painless movement, and shortening of only 2.5 cm; he could walk and run for long distances with only a slight abductor lunch

The passage of technetium-labelled methylene diphosphonate (99mTc-MDP) across rat bone was examined by autoradiography. The autoradiographs showed that shortly after an injection of the bone-seeking agent there was activity outside the bone, within the bone marrow and also adjacent to the highly vascular epiphysial plate; the distribution of the isotope in the incubated bone appeared to be non-uniform, a high concentration being seen adjacent to the epiphysial plate and also on the surfaces of the bone. The evidence suggested that a two-fold mechanism resulted in the uneven distribution of 99mTc-MDP. The first factor probably represented the regional distribution of blood flow with a transcapillary movement of the tracer from the capillary bed to the extravascular space; the subsequent incorporation of the tracer into bone appeared to depend on the nature of the bone matrix

A prospective trial has been carried out to determine the value of suction drainage in the operation of meniscectomy. One hundred operations were analysed, in half of which drains had been used. The use of the drain could not be shown to result in any sustained advantages. The demand for analgesics after the operation was reduced but not to a statistically significant level. The size of the early effusion was significantly reduced, but this benefit was lost when the knee was mobilised. The return of power to the quadriceps and of movement to the knee were not hastened. The average volume of fluid drained was 134 millilitres and it has been shown that forty-eight hours is a suitable time for removal of the drain. The use of suction drainage is not advocated for the uncomplicated operation of meniscectomy

Intertrochanteric osteotomy gives compensatory correction for the severely slipped upper femoral epiphysis without endangering its blood supply. The results of thirty-five such osteotomies carried out over an eighteen-year period are reviewed. The indication for operation was a chronic slip of a third or more of the growth plate in the lateral radiograph. The mean age at operation was fourteen years and the mean follow-up period seven and a half years. The results showed that even a moderate correction of deformity as shown by the radiograph could produce a hip with a functionally satisfactory range of movement. Chondrolysis was the most serious complication and occurred in four hips. The radiological results are discussed in relation to details of operative technique and also to long-term prognosis

1. The results of synovectomy of the knee in eighty-five patients with rheumatoid arthritis are presented. 2. When reviewed between five and nine years after operation 55 per cent of 122 knees still had improvement in pain. 3. Only 31 per cent of knees lost movement. 4. Recurrence of symptoms in nearly all cases was related to the recurrence of active rheumatoid synovitis. 5. Recurrence of symptoms was a little less likely when the generalised disease improved, when the Rose-Waaler test was negative, when only one knee was involved and when the operation had been carried out within three years of the onset of disease in that knee

1. The hyaluronate of synovial fluid is an acidic linear polymer which can effectively resist the diffusion of other macromolecules into its domain. Gelatin was used as an experimental model for hyaluronate, to investigate its effect upon the diffusion of protein-polysaccharides from cartilage slices. 2. The concentration of protein-polysaccilaride in the extracting medium was quantitated by uronic acid estimation and liquid scintillation spectrometry of . 35. sulphate-labelled proteinpolysaccharide. 3. Concentrations of gelatin in excess of 20 per cent (W/v) significantly retarded diffusion of protein-polysaccharides out of cartilage slices, but evidently not the movement of these molecules within cartilage. 4. It is suggested that disaggregation of both the protein-polysaecharide molecules of cartilage and the hyaluronate of synovial fluid contribute to cartilage breakdown

It has been shown by mechanical analysis that by using cement to bond the stem of a femoral head prosthesis to bone two advantages are obtained when the conditions are compared with conventional methods. 1. "Fretting" between the implant and the living bone is eliminated. This source of persistent relative movement is probably the most important starting point for the progressive loosening of weight-bearing implants. 2. When cement is used the bond with the bone is exposed to stresses which are of an order three hundred times less than the shear strength of bone. The conventional prostheses expose the bond to compressive stresses which are near to the failure limits of the compressive strength of bone, especially in elderly patients with atrophic cortical bone in the femoral neck

1. Open osteotomy near the tuberosity of the radius to enable correction of fixed supination deformity of the forearm in children is an alternative to Blount's closed osteoclasis of both bones. 2. In five out of six cases with residual obstetrical palsy substantial correction of the deformity was maintained. 3. The cosmetic result was impressive, especially in girls, but an improved function was also observed. If the hand is paralysed, correction of supination facilitates reconstruction. 4. Complications such as angulation, displacement, delayed union and synostosis of the proximal radius and ulna did not affect the final results. 5. With the method described a more or less permanent "blocking" of rotatory movement in the forearm was observed but this did not seem to impair the functional result

1. The dynamics of synovial joints depends upon the geometry of the articular surfaces, which are always curved. 2. There are two types of articular curvature: ovoid (synclastic) and sellar (anticlastic). 3. The sellar type is mechanically more suited to movements in which sliding is combined with medial or lateral rotation (monodal conjunct rotation). 4. The movement of any hinge-joint is accompanied by a monodal conjunct rotation. This carries the moving part along a path that approximates (at least) to a path of minimal wear. The same is true of the paths of habitual effort-movement (ergodes) of other kinds of joint. 5. Evidence for the foregoing statements is drawn from both normal and abnormal joints, and a clinical application is suggested

We reviewed eight children (ten shoulders) who had suffered neonatal sepsis, after a mean follow-up of 14 years (11 to 15). The delay between the onset of symptoms and diagnosis was one day in five patients, two days in three and seven days in one. All ten shoulders were treated by aspiration, followed by arthrotomy in two. At follow-up, five of the ten shoulders had a full range of movement and the others had minimal restriction of external rotation. Shortening of 10 cm was present in one patient, while two with bilateral involvement had disproportionally short humeri. Early diagnosis and treatment favour the outcome in septic arthritis of the shoulder. With late diagnosis, deformation of the humeral head and shortening of the humerus cause marked cosmetic abnormality but negligible functional loss

Revision of a total knee arthroplasty may require an extensile approach to permit a satisfactory exposure without compromising the attachment of the patellar tendon. It has been assumed that a rectus snip is a relatively benign form of release, but the effect of using this approach on function, pain and patient satisfaction is not known. From January 1997 to December 1999, 107 patients who underwent revision of total knee arthroplasty were followed up at a minimum of two years (mean 40.5 months) and assessed by the Oxford Hip Score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Short-Form (SF)-12 and patient satisfaction. Co-morbidity, surgical exposure, the Hospital for Special Surgery (HSS) knee scores and the range of movement were also used. A standard medial parapatellar approach was used in 57 patients and the rectus snip in 50. The two groups were equivalent for age, sex and co-morbidity scores. The WOMAC function, pain, stiffness and satisfaction scores demonstrated no statistical difference. The use of a rectus snip as an extensile procedure has no effect on outcome

We evaluated the long-term results of 109 tibial plateau fractures, 61 treated by skeletal traction and early knee movement and 48 treated by surgery, at an average follow-up of 70 months. The functional results were much the same, though meniscectomy had been performed in almost half of the surgical patients. Time in bed and duration of hospital stay were clearly shorter after surgery (p less than 0.0001). We concluded that conservative management is a valid alternative to surgery, but should probably be reserved for cases where operation is undesirable. Future studies should compare surgery without meniscectomy and conservative treatment using cast braces to reduce the time in traction

The axis of the talo-crural joint was analysed by roentgen stereophotogrammetry in eight healthy volunteers. Examinations were performed at 10 degrees increments of flexion and pronation/supination of the foot as well as medial and lateral rotation of the leg. Results indicate that the talo-crural joint axis changes continuously throughout the range of movement. In dorsiflexion it tended to be oblique downward and laterally. In rotation of the leg, the axis took varying inclinations between horizontal and vertical. All axes in each subject lay close to the midpoint of a line between the tips of the malleoli. Our study indicates that the talo-crural joint axis may alter considerably during the arc of motion and differ significantly between individuals. This prompts caution in the use of hinge axes in orthoses and prostheses for the ankle