Ten patients underwent endoprosthetic replacement of the distal humerus for bone tumours over a period of 30 years. There were eight primary and two secondary tumours in four men and six women with a mean age of 47.5 years (15 to 76). The mean follow-up was eight years (9 months to 31 years). Four patients required further surgery, three having revision for aseptic loosening; two of these and one other later needing a rebushing. There were no cases of postoperative nerve palsy, infection, local recurrence or mechanical failure of the implant. Four patients died from their disease, all with the prosthesis functioning satisfactorily. At follow-up the mean flexion deformity of the elbow was 15° (0 to 35) and the mean range of flexion was 115° (110 to 135). The functional results showed a mean Toronto extremity salvage score of 73% of normal. Endoprosthetic replacement of the distal humerus and elbow is a satisfactory method of treating these rare tumours

In 21 children with myelomeningocele who underwent kyphectomy for congenital kyphosis of the lumbar spine, aortography revealed no case in which the aorta followed the spinal curvature. Many anomalies of the intercostal and segmental arteries were demonstrated which were only in part associated with deformities of the respective vertebral bodies. The kidneys, which were frequently malformed, often lay within the kyphosis and were therefore at risk of operative damage. We conclude that the aorta is not at risk and that aortography is not usually necessary before kyphectomy, except in patients who have undergone prior abdominal surgery. Non-invasive methods (ultrasound, CT or MRI) should be used to detect malpositions and malformations of the kidneys

We assessed 46 Syme’s amputees attending our prosthetic clinics in terms of the clinical and radiological condition of their stumps, their level of function and problems with the prosthesis. Twenty-five were compared with a matching group of 25 transtibial amputees in regard to activity, function and prosthetic behaviour. Function was similar in the two groups, but Syme’s amputees had a higher incidence of prosthetic failure. Overall, Syme’s amputees were pleased with their prostheses and their function. Childhood amputations were associated with fewer long-term problems in terms of function and stump problems. Syme’s amputation is indicated for congenital foot deformities, fibular hemimelia and severe injury to the foot as long as the heel pad remains viable

Aim

It has been suggested that the use of a pilot-hole may reduce the risk of fracture to the lateral cortex. Therefore the purpose of this study was to determine the effect of a pilot hole on the strains and occurrence of fractures at the lateral cortex during the opening of a high tibial osteotomy (HTO) and post-surgery loading.

We have treated 11 patients aged three days to 15 years with bladder exstrophy by horizontal osteotomies of the innominate bones. The operation was originally used for older patients with severe deformity or failed previous surgery but is now applied as a primary procedure in the first week of life. The osteotomies enable the complex malformations to be corrected in a single operation without turning the patient: the pubic bones can be brought together, the abdominal wall repaired and the bladder closed with reconstruction of the urethra and external genitalia. The early results have been very satisfactory in all cases with only minor complications; we felt that a preliminary report should be made, despite a mean follow-up of only seven months

We describe a simple, quick ultrasound screening test for CDH, and its use in a prospective study of babies with a 'high risk' factor, over one year from January 1987. From a birth population of 3,879, 812 hip scans were performed on 406 babies and 98 babies were abnormal. So far, there have been no late cases of CDH. Family history, breech malposition, and postural foot deformities were confirmed to be important risk factors, but babies with a simple click were equally at risk. Our early results indicate that a large proportion of the potential late cases are contained within our extended high-risk group

Forty comminuted or unstable fractures of the femoral shaft were treated by closed intramedullary reaming and locked nailing. Twenty-four fractures were severely comminuted, and the other 16, in the distal or proximal third of the shaft, were classified as unstable. At 12 to 30 months postoperatively all the fractures had healed. Three patients had lateral rotation deformity of 5 degrees to 10 degrees, three had shortening of 1 to 2 cm and two had lengthening of about 1 cm. There were no infections or delayed unions. Closed intramedullary locked nailing can provide stability in fractures of the femoral shaft, irrespective of the degree of comminution and the site of injury

We studied the possible role of melatonin deficiency in experimentally-induced scoliosis. A total of 90 chickens underwent pinealectomy on the third day after hatching: 30 were treated with serotonin, 30 with melatonin and 30 received no therapy (control group). Scoliosis developed in all the control group, in 22 of the serotonin group, and in only 6 of the melatonin group. The six melatonin-treated chickens with scoliosis had less severe spinal deformities than those in the serotonin-treated group. There were lower blood melatonin concentrations in chickens with scoliosis than in those without. Our findings suggest that melatonin deficiency contributes to the aetiology of this experimental scoliosis, probably by interfering with the normally symmetrical growth of the proprioceptive system involving the paraspinal muscles and the spine

Abnormalities of lung function in 92 children with idiopathic or congenital scoliosis are described. The changes are restrictive in type with reduction in vital capacity and total lung capacity but normal residual volume. In children whose curves had an early onset, the amount by which vital capacity was reduced depended on the severity of the deformity; in those whose curves began in adolescence this severity had little or no effect on vital capacity. Most adolescents with idiopathic curves had normal or near normal lung volumes and measurement of vital capacity proved to be a reliable screening test. We therefore advocate a simple approach to the pre-operative pulmonary investigation of scoliotic patients; only a few require full spirometry

We have studied the progression of healing in 103 unstable fractures of the tibia. In 76 patients we removed the external fixator once the stiffness had reached 15 Nm/° in the sagittal plane. Deformity at the site of the fracture subsequently occurred in four patients. In a further 27, we measured stiffness in several planes and removed the fixator only when the stiffness reached 15 Nm/° in each. We found that stiffness in two orthogonal planes may differ widely (maximum difference 9.0 Nm/°, mean 4.1 Nm/°). There were no failures in the second group. We advocate that fracture stiffness be measured in two orthogonal planes when assessing tibial healing and suggest that values above 15 Nm/° in two planes give an indication that it is safe to remove the fixator

Between 1980 and 1988, displacement bone-marrow transplantation was performed on 25 children with Hurler's syndrome (type-1 mucopolysaccharidosis). We describe the musculoskeletal development of 11 of the 12 surviving children and the orthopaedic procedures undertaken to treat progressive thoracolumbar kyphosis, hip subluxation and carpal tunnel syndrome. We found abnormal bone modelling, focal failures of ossification and an avascular disorder of the femoral head in every patient and offer an explanation for these phenomena. Increasing valgus deformity of the knees and progressive generalised myopathy caused loss of mobility as the children entered adolescence. The benefit of bone-marrow transplantation as a treatment for the skeletal disorders of Hurler's syndrome is limited by the poor penetration of the musculoskeletal tissues by the enzyme derived from the leucocytes

Seven patients treated in infancy by a lumbar theco-peritoneal shunt for idiopathic communicating hydrocephalus presented later in childhood after developing a characteristic orthopaedic syndrome. This included a severe, rigid and progressive lumbar hyperlordosis, severe bilateral restriction of straight leg raising and abnormalities of stance and gait. Four of the patients, who had severe hyperlordotic curves of over 90 degrees, required operations to correct their extreme deformity. The recommended method of correction is a three-stage procedure: first, anterior wedge resection osteotomies at several levels in the lumbar spine, then a period of "90-90" femoral traction, and finally a posterior fusion and stabilisation using Harrington instrumentation. The results were good, with few complications

Experience in the management of fourteen children with melorheostosis has been reviewed. The principal and presenting clinical features were unilateral soft-tissue contractures associated with inequality of limb length. In contrast to the disease in adults, pain occurred infrequently and was never intense. The average interval between the discovery of the clinical features and the correct diagnosis was six years. The distinctive radiographic feature in the child was an endosteal pattern of hyperostosis marked by streakiness of the long bones and spotting of the small. This differs from the usual subperiosteal or extracortical pattern of hyperostosis seen in adults. The surgical treatment of the contractures proved difficult and recurrence of the deformity was the rule. Distal ischaemia occurred when the chronically contracted and flexed joint was rapidly extended

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

A new cosmetic weight-relieving brace which utilises stainless steel and light alloy in its structure is described. A clinical assessment of thirty-six patients (four bilateral cases) has shown the Salford Cosmetic brace to be suitable for over 80 per cent of patients attending for assessment. Five patients rejected the brace, and the reasons are discussed. Contra-indications which emerged during the assessment included limb shortening of more than 5 centimetres; fixed equinus of more than 10 degrees; and fixed deformity of the knee of more than 10 degrees. The safety and durability of the brace, first demonstrated in laboratory tests, are confirmed. Further possible development is outlined

1. The results of treatment have been compared in two unselected series of patients with unstable fractures of the thoraco-lumbar spine accompanied by paraplegia. 2. One group had been treated by conservative or " postural" methods while the others had been subjected to open reduction and internal fixation with double plates. 3. No difference in the amount of neurological recovery could be detected between the two groups but while a number of conservatively treated patients had significant residual spinal deformity and subsequently developed serious pain, this did not occur in any of the patients treated by plating. 4. It is concluded that open reduction and internal fixation are indicated in displaced fractures in the interests of long-term spinal function

1. Nineteen patients with spina bifida, myelomeningocele or lipoma of the cauda equina have been reviewed. Convex pes valgus was found in twenty-five feet. All patients had a neuromuscular imbalance between the evertors and invertors of the foot. 2. Results of release procedures only and of those which combine release procedures with tendon transfers are compared; they show that there is no consistently satisfactory operation for correction of the deformity when it exists with neuromuscular imbalance. 3. An operation in which release procedures are combined with the transfer of the peroneus brevis to the tibialis posterior and of the tibialis anterior to the neck of the talus is described. It has given satisfactory results in two out of three patients with paralytic convex pes valgus

I. Five cases of dislocation of the head of the radius associated with fracture of the upper end of the ulna in children are reported. It is important that fractures of the upper end of the ulna, especially those with some varus deformity in children, should arouse suspicion of the possible co-existence of a dislocation of the head of the radius. 2. The association of the injury to the elbow with a fracture of the lower end of the radius and ulna in three of our cases indicates the necessity for keeping in mind the possibility of this combination. 3. Closed reduction seems to be the best method of treatment. 4. Our five cases were seen during a period ofonly three years. We therefore believe that this injury is not as unusual as appears from the literature

Based on the constancy with which the limbus is inverted into the joint in a typical congenital dislocation of the hip, a hypothesis is presented which suggests that the sequence of events leading to established dislocation is: 1) lateral rotation aided and abetted by anteversion; 2) extension of the hips causing subluxation; 3) dislocation and inversion of the limbus; 4) secondary changes in the upper end of the femur, pelvis and acetabulum which will also develop if the deformity does not progress beyond a subluxation. A pen picture is drawn showing how anteversion is either moulded away during growth to produce a normal hip, or persists with or without dislocation. The fate of the persistently inverted limbus is discussed and a line of treatment based on these findings is briefly considered