1. The anatomy of the forefoot in hallux valgus is compared with the normal, with a review of the literature and descriptions of anatomical preparations, observations at operation and radiographs. 2. The early and essential lesions are stretching of the ligaments on the medial side of the metatarso-phalangeal joint that attach the medial sesamoid and basal phalanx to the metatarsal, and erosion of the ridge that separates the grooves for the sesamoids on the metatarsal head. 3. In established hallux valgus a sagittal groove, formed where the cartilage is free from pressure by either the phalanx or the ligaments, cuts off a medial eminence, which articulates with the stretched ligaments, from a restricted area for the phalanx. 4. Apart from osteophytic lipping which squares off the outline of the eminence as it is seen in radiographs and a small amount of lipping of the ridge on the metatarsal there is no evidence of new bone growth. In chronic cases the eminence may degenerate or disappear. 5. The articular surfaces at the cuneo-metatarsal joint become adapted to the changed positions of the metatarsal without gross pathological change. 6. The four deep transverse ligaments that bind together the five plantar pads of the metatarso-phalangeal joints are not unduly stretched, so that as the metatarsals spread it is the ligaments that bind the pads to the heads of the metatarsals that give way. 7. The plantar metatarsal artery to the first space pursues a tortuous course between the two heads of the flexor hallucis brevis. In hallux valgus the course becomes still more tortuous and part of the pain experienced may be due to ischaemic effects

We compared the peripheral blood and periprosthetic tissues of 53 patients at revision arthroplasty with those of 30 patients at primary arthroplasty to determine whether there is a systemic difference in lymphocytes in patients with worn hip implants. The absolute number and relative proportion of lymphocytes bearing CD2, CD3, CD4, CD8, CD16, CD19, HLA-DR, kappa and lambda antigens were compared with the levels of IL-1β, IL-6 and PGE. 2. in the pseudosynovial membrane as well as with a semiquantitative estimate of metal and polyethylene particles, necrosis and chronic inflammation and the total concentration of metals within the periprosthetic tissues. There was a significant increase in the relative proportion of CD2-positive T-cells and CD16-positive natural killer cells in the peripheral blood at revision arthroplasty compared with primary arthroplasty and an increased proportion of CD8-positive T-cells and a decreased ratio of CD4 to CD8 (helper inducer/suppressor cytotoxic cells). Three control patients, who went on to have revision surgery, had values at primary arthroplasty which were similar to those of patients at the time of revision surgery. These differences did not correlate with the local concentration of metal, plastic or cement or inflammatory response or the type of prosthesis. An inverse correlation was noted between the necrosis in the periprosthetic tissue and both the local production of IL-6 and the absolute numbers of T-cells in peripheral blood. We conclude that there may be several cell-mediated systemic immune responses to aseptic loosening, at least one of which may be directly related to events in the periprosthetic tissues. We cannot exclude the possibility that the changes in the proportion of CD8-positive cells reflected a predisposition, rather than a reaction, to loosening of the implant

Aims

Delayed diagnosis is a well-known complication of a Monteggia fracture-dislocation. If left untreated, the dislocated radial head later becomes symptomatic. The purposes of this study were firstly, to evaluate the clinical and radiological results of open reduction of the radial head and secondly, to identify the factors that may affect the outcome of this procedure.

Aims

The aim of this study was to compare the results of 16S/28S rRNA sequencing with the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and synovial fluid analysis in the diagnosis of prosthetic joint infection (PJI).

Objectives

The incidence of acute Achilles tendon rupture appears to be increasing. The aim of this study was to summarize various therapies for acute Achilles tendon rupture and discuss their relative merits.

Abstract

Nerve transfer has become a common and often effective reconstructive strategy for proximal and complex peripheral nerve injuries of the upper limb. This case-based discussion explores the principles and potential benefits of nerve transfer surgery and offers in-depth discussion of several established and valuable techniques including: motor transfer for elbow flexion after musculocutaneous nerve injury, deltoid reanimation for axillary nerve palsy, intrinsic re-innervation following proximal ulnar nerve repair, and critical sensory recovery despite non-reconstructable median nerve lesions.

Osteoarthritis, as seen in the hip, is a disease which eventually embraces all the tissues of the joint but begins as a reaction of the juxta-chondral blood vessels to a degeneration of the articular cartilage; this reaction results in a hyperaemia of the bone. To our surprise we found that daily use preserves rather than "wears out" articular cartilage; indeed inadequate use is the commonest cause of cartilage degeneration and ensuing vascular invasion. To this factor are added the effects of excessive pressure in the many patients who require surgical treatment for advanced osteoarthritis of a hip the seat of some anatomical incongruity. This etiology based on cartilage suffering does not exclude, but indeed explains, the osteoarthritis implanted on joints of a normal shape which have been previously affected by acute or chronic inflammation or by hormonal dysfunction, such as acromegalic osteoarthritis. The stimulus to vessel growth and invasion is the same in all these cases—namely cartilage damage. Once the vessels have entered the cartilage the bone and marrow of the osteophyte are inevitably laid down. What is so damaging in osteoarthritis seems to be not the degeneration of the cartilage but the vigorous and persistent attempt at repair, an attempt which aggravates the already disordered function of the joint not only by osteophyte formation but by the hypervascularity which weakens the structure of the bone beyond the point where it can carry its increased load. The collapse that follows provokes further reparative efforts with the same deplorable results. The osteoarthritic process thus appears to be an attempt to transform a decaying joint into a youthful one and for this, as in the miraculous rejuvenation depicted in Goethe's Faust, a high price must ultimately be paid

Aims

Double-level lengthening, bone transport, and bifocal compression-distraction are commonly undertaken using Ilizarov or other fixators. We performed double-level fixator-assisted nailing, mainly for the correction of deformity and lengthening in the same segment, using a straight intramedullary nail to reduce the time in a fixator.

Aims

The purpose of this retrospective study was to investigate the clinical relevance of increased facet joint distraction as a result of anterior cervical decompression and fusion (ACDF) for trauma.

Aims

Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent.

Aims

Patients with recurrent anterior dislocation of the shoulder commonly have an anterior osseous defect of the glenoid. Once the defect reaches a critical size, stability may be restored by bone grafting. The critical size of this defect under non-physiological loading conditions has previously been identified as 20% of the length of the glenoid. As the stability of the shoulder is load-dependent, with higher joint forces leading to a loss of stability, the aim of this study was to determine the critical size of an osseous defect that leads to further anterior instability of the shoulder under physiological loading despite a Bankart repair.

Objectives

The purpose of this study was to examine the bactericidal efficacy of hydrogen peroxide (H₂O₂) on Cutibacterium acnes (C. acnes). We hypothesize that H₂O₂ reduces the bacterial burden of C. acnes.

1. Continued follow-up of the 113 children with acute osteomyelitis previously reported and a study of a further thirty-eight proven cases has not changed our opinion that the correct management is rest and effective antibiotics. Operation should be undertaken only if pus is detectable clinically. 2. Bacteriological evidence shows that the flora causing this disease are less sensitive to benzylpenicillin than ten years ago and that a proportion are also likely to become resistant to methicillin and cloxacillin. 3. The most effective antibiotic combination used was fusidic acid and erythromycin. This lowered the failure rate to 10·5 per cent in thirty-eight proven cases. Two of the four failures were in haemophilus infections. No staphylococcal infection of a long bone became chronic, and all lesions were healed within three months of onset. 4. The duration of treatment (twenty-one days) and the method of splintage (removable plaster slabs) remained the same as in the previous series. 5. Careful watch must be kept on the incidence of haemophilus infections. If it rises, increasing the erythromycin or adding ampicillin may be necessary. 6. Use of the newer aqueous suspension of fusidic acid may lower the incidence of troublesome vomiting (12 per cent in this series). 7. Only 7 per cent of staphylococcus aureus infections in this hospital, and 17 per cent of such infections in our thirty-eight cases were sensitive to benzylpenicillin. It is thought that this drug has outlived its usefulness in osteomyelitis. 8. It is recommended that, on diagnosis, fusidic acid aqueous suspension 5 millilitres should be given three times a day to children aged one to five, and 10 millilitres twice a day for children aged six to twelve, with erythromycin stearate 30 milligrams per kilogram of body weight each day in divided doses

Aims

The aim of this study was to evaluate the outcome of spinal instrumentation in haemodialyzed patients with native pyogenic spondylodiscitis. Spinal instrumentation in these patients can be dangerous due to rates of complications and mortality, and biofilm formation on the instrumentation.

Infection after intradiscal injections has been recognised as a distinct entity, but discitis after discography has often been attributed to an aseptic process or a chemical reaction to the contrast material. We examined the hypothesis that discitis after discography is always due to infection, and report a clinical review and an experimental study. Part I. We reviewed the case records and radiographs of 432 patients who had undergone lumbar discography. When an 18-gauge needle without a stilette had been used, discitis was diagnosed in 2.7% of 222 patients but stiletted needles and a two-needle technique at each level reduced the incidence to 0.7%. Seven patients with discitis after discography had undergone anterior discectomy and fusion; in them the histopathological findings were of a chronic inflammatory response. Bacteria were isolated from the discs of three of the four patients who had open biopsy less than six weeks from the time of discography. These findings suggest that bacteria were initiators rather than promoters of the response. Part II. Multiple level lumbar discography was carried out in mature sheep, injecting contrast material with or without various concentrations of bacteria. Radiographs were taken and the discs and end-plates were examined histologically and cultured for bacteria at intervals after injection. None of the controls showed any evidence of discitis but all sheep injected with bacteria had typical radiological and histopathological changes by six weeks, though cultures were almost all negative. However, at one and two weeks after injection, but usually not after three weeks, bacteria could be isolated. We suggest that all cases of discitis after discography are initiated by infection, and that a very strict aseptic technique should be used for all injections into intervertebral discs