We describe the results of a prospective study of 28 children with spastic diplegia and in-toed gait, who had bilateral femoral derotation osteotomies undertaken at either the proximal intertrochanteric or the distal supracondylar level of the femur. Preoperative clinical evaluation and three-dimensional movement analysis determined any additional soft-tissue surgery. Distal osteotomy was faster with significantly lower blood loss than proximal osteotomy. The children in the distal group achieved independent walking earlier than those in the proximal group (6.9 ± 1.3 v 10.7 ± 1.7 weeks; p < 0.001). Transverse plane kinematics demonstrated clinically significant improvements in rotation of the hip and the foot progression angle in both groups. Correction of rotation of the hip was from 17 ± 11° internal to 3 ± 9.5° external in the proximal group and from 9 ± 14° internal to 4 ± 12.4° external in the distal group. Correction of the foot progression angle was from a mean of 10.0 ± 17.3° internal to 13.0 ± 11.8° external in the proximal group (p < 0.001) compared with a mean of 7.0 ± 19.4° internal to 10.0 ± 12.2° external in the distal group (p < 0.001). Femoral derotation osteotomy at both levels gives comparable excellent correction of rotation of the hip and foot progression angles in children with spastic diplegia

Aims

Cementless femoral stems must be correctly sized and well-seated to obtain satisfactory biological fixation. The change in sound that occurs during impaction of the femoral broach is said to indicate good fit, but this has not been widely studied. We set out to find whether the presence or absence of these sound changes could predict correct sizing.

MRI studies of the knee were performed at intervals between full extension and 120° of flexion in six cadavers and also non-weight-bearing and weight-bearing in five volunteers. At each interval sagittal images were obtained through both compartments on which the position of the femoral condyle, identified by the centre of its posterior circular surface which is termed the flexion facet centre (FFC), and the point of closest approximation between the femoral and tibial subchondral plates, the contact point (CP), were identified relative to the posterior tibial cortex. The movements of the CP and FFC were essentially the same in the three groups but in all three the medial differed from the lateral compartment and the movement of the FFC differed from that of the CP. Medially from 30° to 120° the FFC and CP coincided and did not move anteroposteriorly. From 30° to 0° the anteroposterior position of the FFC remained unchanged but the CP moved forwards by about 15 mm. Laterally, the FFC and the CP moved backwards together by about 15 mm from 20° to 120°. From 20° to full extension both the FFC and CP moved forwards, but the latter moved more than the former. The differences between the movements of the FFC and the CP could be explained by the sagittal shapes of the bones, especially anteriorly. The term ‘roll-back’ can be applied to solid bodies, e.g. the condyles, but not to areas. The lateral femoral condyle does roll-back with flexion but the medial does not, i.e. the femur rotates externally around a medial centre. By contrast, both the medial and lateral contact points move back, roughly in parallel, from 0° to 120° but they cannot ‘roll’. Femoral roll-back with flexion, usually imagined as backward rolling of both condyles, does not occur

We studied 108 patients (116 hips) who were followed for a minimum of six years (73 to 89 months) after primary total hip arthroplasty using an uncemented porous-coated anatomic hip. The average age of the patients at operation was 48.4 years, and the diagnosis was avascular necrosis of the femoral head in 46 hips, neglected femoral neck fracture in 27, osteoarthritis secondary to childhood pyogenic arthritis in 24 and to childhood tuberculous arthritis in five, and miscellaneous in 14. The average preoperative Harris hip score was 55, which improved to 91 at latest follow-up. All patients with loose femoral components or disabling thigh pain had received prostheses which were undersized in the coronal or the sagittal plane, or in both. No patient with a satisfactory fit in both coronal and sagittal planes had loosening of the femoral component or disabling thigh pain. Three acetabular components showed aseptic loosening and 20 showed excessive wear (5 to 11 mm) of the polyethylene liner. Excessive wear was related to young age, but not to body-weight, gender, primary diagnosis, hip score, or range of hip movement. There was a high incidence of osteolysis (38 of 116 hips, 33%). We recommend careful preoperative planning, with the use of a contemporary cemented technique when a satisfactory fit cannot be obtained. The high incidence of excessive wear and of osteolysis needs further investigation

The clinical features, management and outcome of 178 early bleeding episodes into the musculature of the thigh and lower limb of 37 severe haemophiliacs are reported. Ninety-five per cent of all bleeds were treated in under three hours from onset of symptoms and the mean time to complete restoration of function was 3.5 days. The most frequent site of bleeding was the quadriceps (44 per cent) followed by the calf (35 per cent), anterior tibial compartment (seven per cent), adductors of the thigh (seven per cent), hamstrings (six per cent) and sartorius (one per cent). Bleeds of the quadriceps took longest to resolve (mean, four days), significantly longer than bleeds of the calf muscle (3.1 days). The first symptom in 66 per cent of bleeds was pain on movement. When the quadriceps was involved, this rapidly progressed to pain at rest. There was a significant prolongation of recovery time when bleeds of this muscle group were treated more than two hours after the onset of symptoms. Bleeds of the calf muscle required less transfusions and no prolongation in recovery time occurred in bleeds treated up to three hours from the onset of symptoms. The results of this study contrast markedly with earlier reports based on later presentations

1. When cortisone is administered to rabbits there is early rapid resorption of bone and a partial inhibition of new bone formation. After a few days the effect becomes less obvious, so that, if observations are made at later stages, the results may be ascribed then to simple inhibition of bone growth. 2. The effect of mechanical stress has been studied in the jaw. When tooth movement is induced mechanically there is, in ordinary circumstances, a resorption of bone on the side to which the tooth is moving (the "pressure" side) and bone formation on the opposite side (the "tension" side). After administration of cortisone there is increased resorption on the "pressure" side and there is greater resorption of connective tissues here. On the "tension" side there is resorption and inhibition of bone formation. 3. In the areas of stress, when cortisone is administered, collagen fibres are no longer in apposition, being separated by spaces presumably filled with altered ground substance; this kind of change may be responsible for many of the observed phenomena. 4. A.C.T.H. does not produce a demonstrable resorptive effect on bone or connective tissue until it has been administered for periods longer than is required for cortisone (three weeks); even then the change is not pronounced. 5. In the guinea pig there is slight delay in bone formation with large doses of both cortisone and A.C.T.H., but no significant bone resorption occurs

Aims

The primary aim of this study was to compare the wear properties of vitamin E-diffused, highly crosslinked polyethylene (VEPE) and one formulation of moderately crosslinked and mechanically annealed ultra-high molecular weight polyethylene (ModXLPE) in patients five years after primary total hip arthroplasty (THA). The secondary aim was to assess the clinical results of patients treated with VEPE by evaluating patient-reported outcome measures (PROMs), radiological evidence of fixation, and the incidence of mechanical failure.

Aims

Plating displaced proximal humeral fractures is associated with a high rate of screw perforation. Dynamization of the proximal screws might prevent these complications. The aim of this study was to develop and evaluate a new gliding screw concept for plating proximal humeral fractures biomechanically.

Aims

We report the clinical results of glenoid osteotomy in patients with atraumatic posteroinferior instability associated with glenoid dysplasia.

We performed a prospective study on 96 patients with extra-articular or intra-articular fractures of the distal radius with a dorsally displaced posteromedial fragment. After closed reduction, we compared trans-styloid fixation and immobilisation with Kapandji fixation and early mobilisation. Forty-two patients of mean age 57.1 years +/- 18.1 (SD) were treated by trans-styloid K-wire fixation and 45 days of short-arm cast immobilisation. Fifty-four patients of mean age 57.7 years +/- 18.7 (SD) had Kapandji fixation and immediate mobilisation according to the originator. All the patients had clinical and radiological review at about six weeks and at 3, 6, 12 and 24 months after the operation. Pain, range of movement and grip strength were tested clinically, and changes in dorsal tilt, radial tilt, ulnar variance, and radial shortening were assessed radiologically. Statistical analysis was applied to comparisons with the normal opposite wrist. Pain and reflex sympathetic dystrophy were more frequent after Kapandji fixation and early mobilisation, but the range of motion was better although this became statistically insignificant after six weeks. The radiological reduction was better soon after Kapandji fixation, but there was some loss of reduction and increased radial shortening during the first three postoperative months. The clinical result at two years was similar in both groups

We studied the biomechanical behaviour of three sliding fixation devices for trochanteric femoral fractures. These were a titanium alloy sideplate and lag screw, a titanium alloy sideplate and dome plunger with cement augmentation, and a stainless-steel sideplate and lag screw. We used 18 mildly osteoporotic cadaver femora, randomly assigned to one of the three fixation groups. Four displacement and two strain gauges were fixed to each specimen, and each femur was first tested intact (control), then as a two-part fracture and then as a four-part intertrochanteric fracture. A range of physiological loads was applied to determine load-bearing, load-sharing and head displacement. The four-part-fracture specimens were subsequently tested to failure to determine maximum fixation strengths and modes of failure. The dome-plunger group failed at a load 50% higher than that of the stainless-steel lag-screw group (p < 0.05) and at a load 20% higher than that of the titanium-alloy lag-screw group (NS). All 12 lag-screw specimens failed by cut-out through the femoral head or neck, but none of the dome-plunger group showed movement within the femoral head when tested to failure. Strain-gauge analysis showed that the dome plunger produced considerably less strain in the inferior neck and calcar region than either of the lag screws. Inferior displacement of the femoral head was greatest for the dome-plunger group, and was due to sliding of the plunger. The dome plunger with cement augmentation was able to support higher loads and did not fail by cut-out through the femoral head.(ABSTRACT TRUNCATED AT 250 WORDS)

1. A total of 120 Moore's arthroplasties in 111 patients were reviewed one to nine years after operation. 2. There was striking reduction in the severity of pain in 105 out of the 120 hips reviewed. Range of movement was improved in most patients but the degree of independence was improved less often. The reasons for this are discussed. 3. We draw the following conclusions regarding the place of Moore's arthroplasty. Firstly, it was a natural step in the evolution towards total hip replacement, an operation which promises to give more complete relief of symptoms and which seems likely to replace Moore's arthroplasty as the treatment of choice in osteoarthritis of the hip in the elderly. Secondly, Moore's arthroplasty is still a rational procedure for the treatment of degeneration if the acetabulum is not involved—for instance, in idiopathic avascular necrosis of the femoral head. Thirdly, it is certainly a valuable operation for some cases of recent fracture of the femoral neck. Avascular necrosis of the femoral head after trifin nailing can be satisfactorily treated by Moore's arthroplasty, particularly in the early stages before the acetabulum becomes involved. Finally, Moore's arthroplasty gave many fairly elderly patients considerable relief of pain at a time when nothing better was available. Much of the relief afforded has proved to be lasting, but deterioration sometimes occurred with time. In the few patients whose deterioration amounted to failure a definite cause for the failure was found. In the majority the deterioration was slight, and it seems likely that the operation will last most of these elderly patients for the rest of their lives

A review of fifty cases of idiopathic pseudocoxalgia (Legg-Calvé-Perthes disease) followed into adult life for periods of eleven to thirty years (average seventeen years) after diagnosis shows:. 1. In the whole series rather more than one-third of the patients developed hips which were normal or nearly normal. 2. An equal number had hips which could only have been considered "fair.". 3. About one quarter had hips which gave pain and which showed marked loss of movement and gross degenerative changes radiologically. Judged from the point of view of symptoms, the results were better than the foregoing would suggest. Three-quarters of the patients were fully active and free from pain but only two-fifths had hips which were radiologically good. It is possible that such apparently good results are unlikely to be permanent, and I hope, therefore, to continue this follow-up for another ten or fifteen years. It can, however, be concluded at this stage that an immediate good result is likely to be maintained at least until the age of twenty-five years, even though half of such patients will have radiologically abnormal hips. There is a characteristic pattern of deformation of the femoral head and neck in the adult resulting from this condition in childhood, based on the degree of flattening of the head and shortening of the neck. The end-results are better in adequately treated cases. Two cases are reported in which osteochondritis dissecans developed as a late complication

1. Three cases are reported of ischaemic necrosis of the anterior tibial muscles which were not due to injury. In two, ischaemia was the result of strenuous or unaccustomed exercise in young adults; in the third it was an incident in a systemic disturbance. All three cases were probably the result of spasm of a large segment of the anterior tibial artery. 2. The clinical features during the first few hours resemble those of tenosynovitis of the tibialis anterior; and after twelve to twenty-four hours those of cellulitis of the leg. Later there is "drop foot" due to muscle weakness, contracture limiting plantar-flexion movement, and woody hardness of the muscles in the middle third. 3. The morbid histology is similar to that of Volkmann's ischaemic contracture. 4. The possible explanations—primary arterial disease, arterial occlusion by pressure of the interosseous membrane, occlusion by tension within the fascial space, intraluminary occlusion by embolism or thrombosis, and fatigue arterial spasm, are discussed. 5. The vascular pattern of the anterior tibial muscles has been studied by experimental injections in cadavers. 6. It is concluded that the most likely cause is spasm of the anterior tibial artery due to muscle fatigue, aggravated by increased tension within the anterior fascial compartment due to reaction after strenuous exercise. 7. Treatment is outlined. Exploration of the anterior tibial artery within the first twelve hours is warranted, but late exploration may be dangerous. 8. Although not previously recognised, evidence is shown that regeneration of necrotic muscle is possible in the human being

1. Léri's pleonosteosis is characterised by broadening and deformity of the thumbs and great toes, flexion contracture of the interphalangeal joints, limited movement of other joints, and often a Mongoloid facies. Four such cases are described. 2. A review of the twenty reports in the literature, and the cases now described, shows that the deformities are due to capsular contracture rather than deformity of bone. 3. In one patient there was striking evidence of fibro-cartilaginous thickening of the anterior carpal ligaments. It is suggested that the primary pathological change in pleonosteosis may be in the joint capsules rather than in the epiphyses. 4. The patient with thickening of the anterior carpal ligaments had bilateral median palsy from carpal tunnel compression. 5. The causes of carpal tunnel compression of the median nerve are reviewed. Acute compression may be due not only to dislocation of the semilunar bone but to haemorrhage in the palm. Late compression by bone may occur twenty to fifty years after injury. Late compression without bone abnormality has been attributed to occupational stress, but it is suggested that pathological thickening of the anterior carpal ligament may be the cause. 6. The patient with pleonosteosis and bilateral median palsy had also bilateral Morton's metatarsalgia with large digital neuromata. 7. Plantar digital neuritis has already been shown to be an ischaemic nerve lesion preceded by degenerative changes in the digital artery. The significance of the fibrous tunnel through which the artery passes to reach the digital cleft is considered

Objectives

We studied subchondral intraosseous pressure (IOP) in an animal model during loading, and with vascular occlusion. We explored bone compartmentalization by saline injection.

We have studied the long-term outcome of 408 primary medial St George Sled unicompartmental arthroplasties of the knee and 531 primary Kinematic total knee arthroplasties using survivorship analysis. The operations were performed by a number of surgeons under the supervision of two consultants at one orthopaedic centre. Prospective clinical assessment was carried out before and at 2, 5, 8, 10, 12 and 15 years after operation. Failure was defined as follows: revision or removal of the implant; the presence of moderate or severe pain; or ‘worst-case’ with all patients lost to follow-up. Cumulative survival rates at ten years were calculated using life tables. The follow-up rate was 97%. At ten years, 25 medial sled arthroplasties and 20 Kinematic knee arthroplasties had been revised. With revision or removal as the survivorship endpoint at ten years there was a success rate of 87.5% for the medial sled and 89.6% for the Kinematic knee arthroplasty. When moderate or severe pain was included these rates became 79.4% for both arthroplasties. There was no statistically significant (p > 0.05) difference between the rates of survival for the two arthroplasties using either of the endpoint criteria. Good or excellent results were recorded for 77.9% of the medial sled knees and 75.1% for the Kinematic knees. The former had 93.8% of cases with a final range of movement in excess of 90° compared with 83.7% for the Kinematic knees (p < 0.01). We conclude that at a single orthopaedic centre in the UK, the St Georg Sled medial compartment arthroplasty for appropriate specific indications offers predictable survivorship at ten years which is comparable with that of the Kinematic total knee arthroplasty

Aims

The aim of this study was to report the initial results of the Exeter V40 stem, which became available in 2000.

Aims

The aim of this study was to evaluate the outcomes of a salvage procedure using a 95° angled blade plate for failed osteosynthesis of atypical subtrochanteric femoral fractures associated with the long-term use of bisphosphonates. These were compared with those for failed osteosynthesis of subtrochanteric fractures not associated with bisphosphonate treatment.