1. A method of treatment of posterior malleolar fracture is described which restores the proximal surface of the ankle joint to its normal position. 2. Reduction is achieved with a special clamp and the position held with a strong plate. Early ankle movements may therefore be encouraged without fear of redisplacing the fracture. 3. Perfect reduction is necessary to avoid the later onset of arthritis, and this was achieved in five of six patients reported

A man of 52 years of age had a grand mal seizure. He presented to our unit three months later with irreducible bilateral posterior dislocation of the shoulder. CT scans revealed large compression defects on the anteromedial aspect of the heads of both humeri. The defect on the right side was of more than 50% of the articular surface, and on the left side of 40%. He was treated by a one-stage operation with a hemiarthroplasty on one side and reconstruction of the head by an osteochondral autograft on the other. Three years later the clinical and radiological results were excellent

We evaluated the efficacy of anterior fusion alone compared with combined anterior and posterior fusion for the treatment of degenerative cervical kyphosis. Anterior fusion alone was undertaken in 15 patients (group A) and combined anterior and posterior fusion was carried out in a further 15 (group B). The degree and maintenance of the angle of correction, the incidence of graft subsidence, degeneration at adjacent levels and the rate of fusion were assessed radiologically and clinically and the rate of complications recorded. The mean angle of correction in group B was significantly higher than in group A (p = 0.0009). The mean visual analogue scale and the neck disability index in group B was better than in group A (p = 0.043, 0.0006). The mean operation time and the blood loss in B were greater than in group A (p < 0.0001, 0.037). Pseudarthrosis, subsidence of the cage, and problems related to the hardware were more prevalent in group A than in group B (p = 0.034, 0.025, 0.013). Although the combined procedure resulted in a longer operating time and greater blood loss than with anterior fusion alone, our results suggest that for the treatment of degenerative cervical kyphosis the combined approach leads to better maintenance of sagittal alignment, a higher rate of fusion, a lower incidence of complications and a better clinical outcome

Persistent back pain in the presence of an intact posterior fusion is commonly seen and is often regarded as being psychogenic in origin. This paper discusses five patients, all of whom were chronically disabled by such pain; all five had a confirmed posterior and/or lateral fusion. In each case lateral discography identified the disc within the fused segment as the source of symptoms and pain relief was obtained with an anterior interbody fusion. This source of pain should be considered as a possibility in similar cases of failed back surgery

Posterior dislocation of the acromioclavicular joint with the lateral end of the clavicle locked behind the acromion has only rarely been described. This paper present such a case diagnosed two weeks after the shoulder was injured in an accident. The clavicle was locked behind the articular surface of the acromion, restricting the movement of the shoulder and causing considerable pain. Anteroposterior radiographs showed a high-riding clavicle but no gap in the joint, but the axial view showed the dislocation. At operation the coracoclavicular ligaments were found overstretched but not ruptured. As reduction of the acromioclavicular joint was not possible, the lateral end of the clavicle was resected. Although the result was perfect, we consider the correct treatment should be early closed or open reduction of the acromioclavicular joint

1. An unusual congenital anomaly of the cervical spine is described. This lesion caused a localised cervical kyphosis and resulted in the development of a mild tetraparesis. 2. The case reported is believed to be the first on record in the English literature of multiple posterior hemivertebrae in the cervical region. 3. The neck deformity was associated with an unusual combination of developmental anomalies–namely, brachyphalangy and bilateral congenital optic atrophy. 4. The importance of differentiating between congenital and acquired causes of kyphosis is emphasised. 5. The radiographic appearances of posterior hemivertebra are described, and the differential diagnosis is considered. 6. The development of the vertebral body, and the relationship between coronal cleft vertebra and posterior hemivertebra, are discussed. The possible role of a disturbance of vascular supply in pathogenesis is mentioned. 7. This report augments the growing literature on congenital skeletal anomalies occurring in combination with isolated congenital ocular defects

We describe 11 cases of posterior fracture-dislocation of the shoulder that required open reduction and fixation. Difficulties with access through anterior approaches led us to use the superior subacromial approach. This is an extension of the approach often used to expose the rotator cuff; the joint is opened by splitting the supraspinatus tendon 5 mm behind the cuff interval. The glenoid, proximal humerus and any fracture fragments can be seen from above, allowing reduction of the dislocation and osteosynthesis to be performed with minimal risk of damage to the humeral head and its blood supply. The proximity of the axillary nerve limits the exposure of the proximal humeral shaft. The superior subacromial approach is ideal for posterior dislocation with fracture of the articular segment, but is not suitable when there is a fracture of the proximal humeral shaft

Our aims were to map the tibial footprint of the posterior cruciate ligament (PCL) using MRI in patients undergoing PCL-preserving total knee replacement, and to document the disruption of this footprint as a result of the tibial cut. In 26 consecutive patients plain radiography and MRI of the knee were performed pre-operatively, and plain radiography post-operatively. The lower margin of the PCL footprint was located a mean of 1 mm (−10 to 8) above the upper aspect of the fibular head. The mean surface area was 83 mm. 2. (49 to 142). One-third of patients (8 of 22) had tibial cuts made below the lowest aspect of the PCL footprint (complete removal) and one-third (9 of 22) had cuts extending into the footprint (partial removal). The remaining patients (5 of 22) had footprints unaffected by the cuts, keeping them intact. Our study highlights the wide variation in the location of the tibial PCL footprint when referenced against the fibula. Proximal tibial cuts using conventional jigs resulted in the removal of a significant portion, if not all of the PCL footprint in most of the patients in our study. Our findings suggest that when performing PCL-retaining total knee replacement the tibial attachment of the PCL is often removed

Long posterior wall (LPW) Charnley acetabular implants are widely used as it is believed that the LPW helps to prevent dislocation. This has, however, not been proven statistically. In a preliminary study of these implants removed at revision marked erosion of the LPW was frequently seen, indicating that repetitive impingement may occur. The influence of the long posterior wall was therefore investigated mathematically. LPW and standard sockets were found to be equally likely to dislocate provided that the standard socket was anteverted 5 degrees more than the LPW socket. With simulated external rotation, LPW sockets impinge 30% earlier than standard sockets. When impingement occurs a torque is applied to the components, which increases the shear stresses at the cement-bone interface. The torques, although not large enough to dislodge the socket immediately, are repetitive and so may contribute to loosening. The LPW socket can generate twice as much torque as the standard socket and therefore is more likely to loosen

Subtalar dislocation is a significant injury characterised by late complications, including subtalar arthritis. We describe a rare case of irreducible posterior subtalar dislocation due to incarceration of a fracture of the anterior process of the calcaneum in the subtalar joint, and discuss appropriate management

1. A case of posterior dislocation of both shoulders, in a patient believed to be epileptic, is described. 2. The difficulties of early diagnosis are discussed

1. Fifty-six cases of tibialis posterior transplant for drop foot are reported. 2. The results are known to be satisfactory in forty-nine of the fifty-six cases. 3. Serious complications have been few. 4. Re-education has been easy in the great majority of cases

We describe a posterior approach to the elbow which combines the advantages of both splitting and reflecting the triceps. It gives protection to the ulnar nerve and its blood supply during the operation while providing excellent exposure of the distal humerus. During closure, the triceps muscle can be tensioned, thereby improving stability of the elbow. This approach has particular relevance to unlinked total elbow arthroplasty allowing early rehabilitation of the joint

Traditional posterior approaches to the neck use a vertical craniocaudal incision which often leaves an unsightly scar. An incision along Langer's transverse lines of tension divides only the cross-fibres of the dermis and we have found the results of this approach encouraging: wound healing was uncomplicated and the cosmetic appearance excellent

1. The arcade of Frohse, a fibrous arch over the posterior interosseous nerve, may well play a part in causing progressive paralysis of the posterior interosseous nerve, both with and without injury. 2. Paralysis of the muscles supplied by this nerve with no evidence of recovery after six weeks, either electromyographic or clinical, should be treated by exploration and splitting of the arcade of Frohse

We reviewed 212 consecutive patients with adolescent idiopathic scoliosis who underwent posterior spinal arthrodesis using all pedicle screw instrumentation in terms of clinical, radiological and Scoliosis Research Society (SRS)-22 outcomes. In Group 1 (51 patients), the correction was performed over two rods using bilateral segmental pedicle screws. In Group 2 (161 patients), the correction was performed over one rod using unilateral segmental pedicle screws with the second. rod providing stability of the construct through two-level screw fixation at proximal and distal ends. The mean age at surgery was 14.8 years in both groups. Comparison between groups showed no significant differences with regard to age and Risser grade at surgery, pre- and post-operative scoliosis angle, coronal Cobb correction, length of hospital stay and SRS scores. Correction of upper thoracic curves was significantly better in Group 1 (p = 0.02). Increased surgical time and intra-operative blood loss was recorded in Group 1 (p < 0.001 and p = 0.04, respectively). The implant cost was reduced by mean 35% in Group 2 due to the lesser number of pedicle screws. Unilateral and bilateral pedicle screw techniques have both achieved excellent deformity correction in adolescent patients with idiopathic scoliosis, which was maintained at two-year follow-up. This has been associated with high patient satisfaction and low complication rates

1. The indications for ischio-femoral arthrodesis are considered. 2. The technique of operation through an open posterior approach is described. 3. Indications for the modified Trumble operation are given. 4. The results of ischio-femoral arthrodesis in a series of forty-seven patients (mostly suffering from tuberculous hip disease) are presented. 5. The writers consider that ischio-femoral arthrodesis is the operation of choice in tuberculous disease of the hip, especially in children

In cases of established calcaneus after anterior poliomyelitis the deformity can be greatly reduced by combining an extensive plantar release with an oblique transverse osteotomy of the calcaneus that permits displacement upwards and backwards of the posterior weight-bearing part of the bone. The procedure greatly improves the mechanical advantage of subsequent tendon transplantations to the heel. Between 1956 and 1969 fifteen such osteotomies were carried out and the long-term results have been reviewed

We report the use of combined anterior and posterior approaches for the reduction and fixation of complex tibial plateau fractures involving a large split posteromedial fragment. In four patients, we used a posterior plate to fix the posteromedial fragment. All fractures united in good position with no significant complications, and all patients had a good range of knee movement. This technique should be considered for complex fractures in which there is a substantial posteromedial fragment (split) component

1. The deep posterior muscles of the neck are innervated by the posterior branches of spinal nerves, which branch off immediately after the root emerges from the intervertebral foramen. Electromyographic examination of these muscles permits a differential diagnosis to be made between intraforaminal and extraforaminal brachial plexus lesions. 2. The earlier diagnosis and prognosis thus achieved permit definitive treatment, in particular suture of the torn nerve trunks in recent extraforaminal cases