In this study we evaluated the results of midtarsal release and open reduction for the treatment of children with convex congenital foot (CCF) (vertical talus) and compared them with the published results of peritalar release. Between 1977 and 2009, a total of 22 children (31 feet) underwent this procedure. In 15 children (48%) the CCF was isolated and in the remainder it was not (seven with arthrogryposis, two with spinal dysraphism, one with a polymalformative syndrome and six with an undefined neurological disorder).

Pre-operatively, the mean tibiotalar angle was 150.2° (106° to 175°) and the mean calcaneal pitch angle was -19.3° (-72° to 4°). The procedure included talonavicular and calcaneocuboid joint capsulotomies, lengthening of tendons of tibialis anterior and the extensors of the toes, allowing reduction of the midtarsal joints. Lengthening of the Achilles tendon was necessary in 23 feet (74%).

The mean follow-up was 11 years (2 to 21). The results, as assessed by the Adelaar score, were good in 24 feet (77.4%), fair in six (19.3%) and poor in one foot (3.3%), with no difference between those with isolated CCF and those without. The mean American Orthopaedic Foot and Ankle Society midfoot score was 89.9 (54 to 100) and 77.8 (36 to 93) for those with isolated CCF and those without, respectively. At the final follow-up, the mean tibiotalar (120°; 90 to 152) and calcaneal pitch angles (4°; -13 to 22) had improved significantly (p < 0.0001). Dislocation of the talonavicular and calcaneocuboid joints was completely reduced in 22 (70.9%) and 29 (93.6%) of feet, respectively. Three children (five feet) underwent further surgery at a mean of 8.5 years post-operatively, three with pes planovalgus and two in whom the deformity had been undercorrected. No child developed avascular necrosis of the talus.

Midtarsal joint release and open reduction is a satisfactory procedure, which may provide better results than peritalar release. Complications include the development of pes planovalgus and persistent dorsal subluxation of the talonavicular joint.

Cite this article: Bone Joint J 2014;96-B:837–44.

We describe 13 patients with cerebral palsy and lordoscoliosis/hyperlordosis of the lumbar spine who underwent a posterior spinal fusion at a mean age of 14.5 years (10.8 to 17.4) to improve sitting posture and relieve pain. The mean follow-up was 3.3 years (2.2 to 6.2).

The mean pre-operative lumbar lordosis was 108^° (80 to 150^°) and was corrected to 62^° (43^° to 85^°); the mean thoracic kyphosis from 17^° (-23^° to 35^°) to 47^° (25^° to 65^°); the mean scoliosis from 82^° (0^° to 125^°) to 22^° (0^° to 40^°); the mean pelvic obliquity from 21^° (0^° to 38^°) to 3^° (0^° to 15^°); the mean sacral slope from 79^° (54^° to 90^°) to 50^° (31^° to 66^°). The mean pre-operative coronal imbalance was 5 cm (0 cm to 8.9 cm) and was corrected to 0.6 cm (0 to 3.2). The mean sagittal imbalance of -8 cm (-16 cm to 7.8 cm) was corrected to -1.6 cm (-4 cm to 2.5 cm). The mean operating time was 250 minutes (180 to 360 minutes) and intra-operative blood loss 0.8 of estimated blood volume (0.3 to 2 estimated blood volume). The mean intensive care and hospital stay were 3.5 days (2 to 8) and 14.5 days (10 to 27), respectively. Three patients lost a significant amount of blood intra-operatively and subsequently developed chest or urinary infections and superior mesenteric artery syndrome.

An increased pre-operative lumbar lordosis and sacral slope were associated with increased peri-operative morbidity: scoliosis and pelvic obliquity were not. A reduced lumbar lordosis and increased thoracic kyphosis correlated with better global sagittal balance at follow-up. All patients and their parents reported excellent surgical outcomes.

Lordoscoliosis and hyperlordosis are associated with significant morbidity in quadriplegic patients. They are rare deformities and their treatment is challenging. Sagittal imbalance is the major component: it can be corrected by posterior fusion of the spine with excellent functional results.

Cite this article: Bone Joint J 2014;96-B:800–6.

We carried out a retrospective review of 155 patients with lumbar spinal stenosis who had been treated surgically and followed up regularly: 77 were evaluated at a mean of 6.5 years (5 to 8) after surgery by two independent observers. The outcome was assessed using the scoring system of Roland and Morris, and the rating system of Prolo, Oklund and Butcher. Instability was determined according to the criteria described by White and Panjabi.

A significant decrease in low back pain and disability was seen. An excellent or good outcome was noted in 79% of patients; 9% showed secondary radiological instability.

Surgical decompression is a safe and efficient procedure. In the absence of preoperative radiological evidence of instability, fusion is not required.

Our aim was to investigate the outcome of excision of osteochondromas. Between 1994 and 1998, 92 symptomatic osteochondromas in 86 patients were excised. There were 40 women and 46 men with a mean age of 20 years (3 to 62). Of these, 56 had a solitary osteochondroma and 30 had multiple hereditary tumours. The presenting symptoms were pain (79.1%), swelling (23.3%), reduced range of movement (19.8%), cosmetic abnormalities (17.4%), and bursitis (12.8%). The most common site (37.6%) was around the knee.

Four patients had major complications (4.7%) including one intra-operative fracture of the femoral neck and three nerve palsies which resolved after decompression. Six patients had minor complications. Overall, 93.4% of the preoperative symptoms resolved after excision of the tumours. Excision is a successful form of treatment for symptomatic osteochondromas with a low morbidity.

We report positive and negative factors associated with the most commonly-used methods of reconstruction after pathological fracture of the proximal femur. The study was based on 142 patients treated surgically for 146 metastatic lesions between 1996 and 2003. The local rate of failure was 10.3% (15 of 146). Of 37 operations involving osteosynthetic devices, six failed (16.2%) compared with nine (8.3%) in 109 operations involving endoprostheses. Of nine cases of prosthetic failure, four were due to periprosthetic fractures and three to recurrent dislocation. In the osteosynthesis group, three (13.6%) of 22 reconstruction nails failed. The two-year risk of re-operation after any type of osteosynthesis was 0.35 compared with 0.18 after any type of endoprosthetic reconstruction (p = 0.07). Endoprosthetic reconstructions are preferable to the use of reconstruction nails and other osteosynthetic devices for the treatment of metastatic lesions in the proximal third of the femur.

We describe an operation to relieve compression of the lateral antebrachial cutaneous nerve at the elbow. Between 1987 and 1997 we operated on seven patients, one with bilateral compression. In two the compression was associated with injury to biceps. A longitudinal or a transverse incision was carried out and the nerve was released from the deep fascia. Partial excision of the biceps aponeurosis was undertaken in the patients who did not have injury to biceps; some additional procedures were required for those patients with injuries. All patients had symptomatic relief.

The outcome of displaced hips treated by Somerville and Scott’s method was assessed after more than 25 years. A total of 147 patients (191 displaced hips) was reviewed which represented an overall follow-up of 65.6%. The median age at the index operation was two years. During the first five years, 25 (13%) hips showed signs of avascular change.

The late development of valgus angulation of the neck, after ten years, was seen in 69 (36%) hips. Further operations were frequently necessary. Moderate to severe osteoarthritis developed at a young age in 40% of the hips. Total hip replacement or arthrodesis was necessary in 27 (14%) hips at a mean age of 36.5 years. Risk factors identified were high dislocation, open reduction, and age at the original operation. Two groups of patients were compared according to outcome. All the radiographic indices were different between the two groups after ten years, but most were similar before. It takes a generation to establish the prognosis, although some early indicators may help to predict outcome.

Two prospective studies of ingrowing toenail management were conducted. In the first, 163 patients (204 ingrowing nail edges) who had not had previous surgery were randomised and treated by total nail avulsion, nail edge excision, or nail edge excision with phenolisation of the germinal matrix; recurrence rates one year postoperatively were 73%, 73% and 9% respectively. In the second study, 63 ingrowing nail edges which had recurred after previous operations underwent nail edge excision and phenolisation. There was a 5% recurrence rate and 5% incidence of dystrophy of the nail one year after operation.

We describe a method for approaching the lower cervical and upper thoracic spine, the brachial plexus and related vessels. The method involves the elevation of the medial corner of the manubrium, the sternoclavicular joint, and the medial half of the clavicle on a pedicle of the sternomastoid muscle. We have used this exposure in 17 cases with few complications and good results. Its successful performance requires high standards of anaesthesia, surgical technique and postoperative care.

Sixty-four patellar fractures treated either by internal fixation or by patellectomy were reviewed retrospectively from 3.5 to 10.1 years (average 6.2 years) after operation. Results were assessed subjectively and objectively. Of the 64 patients, 45% had a good result, 27% fair and 28% poor. On the whole, patellectomy produced better results (60% good, 20% fair, 20% poor), than internal fixation (31% good, 33% fair, 36% poor). Nevertheless, the best results of all were achieved by precise anatomical reduction of the patellar fracture and fixation with K-wires and a tension band. Where this could not be achieved, however, patellectomy gave the best results.

1. The results are recorded of radical excisional surgery for spinal tuberculosis in eighty-five patients.

2. Clinically satisfactory results were obtained in 97 per cent of seventy-one patients followed up. Radiologically the disease was deemed to be cured in 71 per cent of cases.

3. The average period of rest after operation was three and a half months, and the average hospital stay was five and a half months.

4. Total recovery from paraplegia occurred in 84 per cent of patients so affected.

1. Thirteen years of experience in charge of treatment in a Residential School for Cerebral Palsy, and a review of 466 operations performed on children handicapped by this condition, form the basis for this attempt to frame the indications and contra-indications for operation.

2. A brief description is given of the more commonly performed operations, with an indication of the results that are likely to be obtained.

3. Orthopaedic surgery has a worth-while contribution to make in the treatment of cerebral palsy. When the cases are selected with care, when the appropriate orthopaedic measures are skilfully performed and when the patients are adequately supervised afterwards, the benefits of surgery are greater than those provided by any other treatment, and they are achieved more quickly.

4. The desire to improve and the "inner urge" of the patient to succeed may be the most important single factor in his rehabilitation.

1. In the treatment of tarso-metatarsal fracture-dislocations open reduction is advocated whenever closed reduction is found impossible.

2. A technique of operation is described whereby, after reduction, temporary transfixion wires are used to prevent redisplacement.

Painful neuromas may follow traumatic nerve injury. We carried out a double-blind controlled trial in which patients with a painful neuroma of the lower limb (n = 20) were randomly assigned to treatment by resection of the neuroma and translocation of the proximal nerve stump into either muscle tissue or an adjacent subcutaneous vein. Translocation into a vein led to reduced intensity of pain as assessed by visual analogue scale (5.8 (sd 2.7) vs 3.8 (sd 2.4); p < 0.01), and improved sensory, affective and evaluative dimensions of pain as assessed by the McGill pain score (33 (sd 18) vs 14 (sd 12); p < 0.01). This was associated with an increased level of activity (p < 0.01) and improved function (p < 0.01).

Transposition of the nerve stump into an adjacent vein should be preferred to relocation into muscle.

Surgical release of the elbow was performed in 27 patients with post-traumatic stiffness at a mean of 14.5 months after the initial injury. The outcome was related to whether there had been heterotopic ossification, which had occurred in 18 elbows and to whether, if there had been a fracture, it had involved the articular surface, which had occurred in 13 elbows. The final range of movement and the ratio of desired gain in each group were compared at a mean follow-up period of 22.5 months (12 to 43).

The arc of movement of the elbow improved in all patients after the operation. The mean final arc was 110° in those with heterotopic ossification and 86° in those without (p = 0.001). The ratios of desired gain were significantly higher in patients with heterotopic ossification (88.2% vs 54.9%; p < 0.001). There was no significant difference in relation to involvement of the articular surface. Careful assessment of the cause of stiffness is important in order to achieve a satisfactory result from surgery for post-traumatic stiffness of the elbow.