The case histories of two brothers with congenital defects of the tibia and neurofibromatosis are presented. This report of congenital pseudarthrosis of the tibia in siblings is believed to be the first in the English literature.

1. Seventy-six patients with fracture of the upper end of the femur were examined phlebographically for evidence of thrombosis. The patients were randomly divided into two groups : one was given phenindione post-operatively ; the other acted as a control.

2. Analysis of the select series showed that the incidence of venous thrombosis in the anticoagulation group (19 per cent) was significantly less than that in the control group (48 per cent).

3. However, analysis of the complete series failed to show that the incidence of venous thrombosis in the anticoagulation group was significantly less than in the control group.

4. The number of bleeding complications in the anticoagulation group (47 per cent) exceeded those in the control group (16 per cent). The only life-endangering haemorrhage occurred in a patient who had not received an anticoagulant for five months.

5. We were unable to show that the fracture significantly influenced the site or the incidence of venous thrombosis.

6. No correlation was found between the clinical and phlebographic diagnosis of venous thrombosis.

7. It is concluded that the early use of a prophylactic anticoagulant is an effective means of reducing the incidence of venous thrombosis in patients with a fracture about the hip.

1. One hundred patients with fractures of the upper end of the femur were investigated clinically and radiographically to ascertain the incidence and site of deep venous thrombosis during convalescence.

2. The technique of phlebography used has its own inherent dangers, but we believe that familiarity with the technique reduces the risk of complications.

3. The investigation revealed thrombi that were clinically unsuspected and indicates a need for further investigation of factors such as manipulation and retraction that may promote deep thrombosis.

4. The study has provided a control series for an investigation of the effect of prophylactic anticoagulants upon the incidence of deep venous thrombosis and pulmonary embolism after fractures about the hip.

A long-term follow-up of a patient with melorheostosis and arteriovenous aneurysms confined to the left side of the body is reported. The patient was earlier investigated and shown at the Royal Society of Medicine by Murray in 1951.

1. Thirty-seven hips with osteoarthritis underwent phlebography before intertrochanteric osteotomy. The results of this study were reported previously.

2. Thirty-two of the hips were studied and have had a clinical, radiological and phlebographic examination about one year after operation. Three of these were excluded because of technical failures.

3. Twenty-four hips had a normal pattern of venous drainage after operation; of these only two had normal patterns before operation and the rest had had many abnormalities of venous drainage. These hips had been completely or considerably relieved of pain at rest and on activity.

4. In the other five hips, although the venous drainage pattern was still abnormal, in only one was there significant deterioration in the venous pattern; in this group there was also some alleviation of rest pain.

5. The findings are discussed in relation to the pathology of osteoarthritis and the possible influences of intertrochanteric osteotomy.

6. The pain produced by the injection of radiopaque material into the femoral head was similar to the rest pain. This finding is discussed in relation to venous obstruction and congestion.

1. Clinical and histological features in ten patients with smooth muscle tumours of the limbs are described.

2. Severe pain and tenderness and the radiographic demonstration of calcification are useful pointers to the diagnosis.

3. Local recurrence of the tumour occurred in four patients despite apparently adequate excision. In three of these the tumours were shown histologically to be benign.

1. Bone changes in the haemoglobinopathies are caused by either (a) chronic haemolysis with marrow hyperplasia, or (b) infarction, when Hb S is present in the red cells in amounts sufficient to allow sickling (and therefore vascular occlusion) in vivo.

2. Marrow hyperplasia produces osteoporosis, widening of the medulla, and thinning of the cortex; it may lead to spontaneous fractures and disturbances of growth. Enlargement of the foramina of the nutrient arteries may be seen especially in the phalanges. Infarcts leading to aseptic necrosis occur in the long bones, and may become infected with Salmonella organisms. The range of radiological lesions caused by these processes is illustrated.

1. Septic arthritis of the hip in adults is not common and the diagnosis can be difficult. The value of diagnostic aspiration is emphasised.

2. Predisposing causes in fifty patients are analysed and the possible relationship to pelvic infection is discussed.

3. Loss of joint space is occasionally seen within one week of the onset of the infection.

4. A method of treatment is suggested and the value of decompression by arthrotomy is discussed.

1. The follow-up reports of ninety-one joints affected by rheumatoid arthritis and treated by synovectomy showed that seventy-three joints remained free of pain. Forty-nine out of ninety-one joints retained useful function after a period averaging three and a half years.

2. The average duration of the disease before admission was eight and a half years.

3. The joints causing most distress were selected for operation. Better results might have been obtained if these patients had received constitutional treatment, splintage and synovectomy earlier. Many of these patients had advanced disease which was continuing to advance at the time of their admission, in spite of previous treatment. Many accepted a trial of treatment in a long stay hospital as a last hope.

4. The return of forty-eight out of sixty-two patients to unassisted or nearly unassisted activity and the maintenance of this state in thirty-nine out of fifty-four shows that the success of the pilot scheme conducted in cooperation with Dr W. S. Tegner and Dr R. M. Mason of the London Hospital has been confirmed by further experience.

1. In two dogs, approximately one to two years and three to four months of age, an experimental comparison was made between the calcium accretion rate as defined by the Bauer-Carlsson-Lindquist equation, and the bone formation rate determined by double tetracycline labelling.

2. The overall calcium accretion rate was determined from the specific activity of the blood plasma, and the urinary and faecal excretion of isotope, following an intravenous tracer dose of Ca⁴⁵. A time of five days after injection was used for the calculation of accretion rates, but data for shorter times of calculation are included.

3. Local accretion rates were obtained for different parts of the skeleton by determining the specific activities of bone samples at the end of the experiment.

4. The amount of isotope the uptake of which was not related to new bone formation (the diffuse component) was determined autoradiographically.

5. Local values for appositional growth rate and bone formation rate were obtained, using sections of undecalcified bone specimens, by measuring the linear separation between two tetracycline bone markers and the area of new bone enclosed by them.

6. In the older dog, the measurements for cortical bone showed that the accretion rate was two to three times as great as the bone formation rate: the observed diffuse component was sufficient to account for the greater part of this difference. Measurement of the bone formation rate for cancellous bone presented difficulties, but the approximate values obtained suggested that the accretion rate and the bone formation rate were of about the same order for this tissue.

7. In the younger dog, the bone formation rate could be determined only in cortical bone: at the sites studied, the values for the accretion rate and the bone formation rate did not differ by more than 20 per cent. It is suggested that this is due partly to the low specific activity of the diffuse component in this young animal, and partly to the relatively large amounts of new bone formed during the period of the experiment.

8. Despite the important differences between the rates of calcium accretion and bone formation that were found to exist in regions where there was only a small amount of new bone formation, there was a strong correlation between the two rates. The value of the accretion rate as a parameter of bone metabolism is clear.

1. The conservative school of treatment of fractures of the tibia, which bases part of its criticism of internal fixation on the ultimate risk of amputation, does not often publish its own rates of amputation.

2. Statistics from a hospital that treats one-third of closed fractured tibiae and two-thirds of compound fractures by internal fixation are therefore put up as a basis for criticism.

3. Comparisons are made with the few available statistics in the literature of conservative treatment.

4. Almost all of the causes for secondary amputation are now curable and in recent years the number of limbs being saved is increasing.

We describe two siblings with congenital growth defects of the distal limb bones and their progress over four years. They bear some resemblances to a boy described in 1958 by Solonen and Sulamaa and to a father and his three sons described in 1944 by Nievergelt.

1. With the object of perfecting the design of footwear for feet anaesthetic from leprosy, pressures on the soles of feet during walking were measured with transducers sufficiently thin to be worn inside ordinary shoes.

2. It was found that anaesthetic feet without deformity or muscle imbalance did not produce significantly higher pressures than normal feet during barefoot walking on a flat surface. The pressure distribution under drop feet with active posterior tibial muscles differed from normal, with increased pressure under the lateral forefoot and decreased pressures elsewhere.

3. Loss of toes or function of the toes results in high, sharp pressure peaks under the anterior end of the foot during push-off. In deformed feet these pressures are usually concentrated at one or two small areas.

4. In anaesthetic feet the prevention of trophic ulceration largely depends on the even distribution of pressure over the sole of the foot.

5. Moulding by carefully placed arch supports or metatarsal bars effectively redistributes plantar pressure.

6. A shoe with a rigid sole pivoting on a rocker near the centre of the foot most effectively reduces pressures under the forefoot of shortened, deformed feet.

7. We recommend the use of insoles made of microcellular rubber (approximately 1 5 degrees shore).

8. The importance of studying each deformed foot for areas of high pressure before fitting shoes is stressed; a pressure-indicating footprint is satisfactory for this purpose.

1. Two patients are reported with progressive fibrosis of the vastus intermedius muscle causing limitation of flexion of the knee. The first patient, a girl of ten years who was one of binovular twins, noticed difficulty in walking at the age of five, the disability increasing with age. The other girl, aged three, was one of uniovular twins and displayed the abnormality as soon as she started walking.

2. The nature of the condition remains obscure.

3. Surgery is effective, and simple division of the affected muscle segment is recommended. A good range of passive flexion is obtained at once; the active range can be obtained thereafter by physiotherapy. Because this requires the patient's cooperation it is suggested that the best age for surgery is about five or six years.

1. Two of the three metals at present in use in orthopaedic surgery have been studied to assess their tendency to cause wound reactions.

2. Cobalt-chrome alloy proved to be the better, the incidence of obligatory plate removal being at most 3 per cent. Visible corrosion in this metal never occurred.

3. 18/8 Mo stainless steel proved to be the poorer, the incidence of obligatory plate removal being 20 per cent. Visible corrosion of the metal is estimated to have occurred in about 5 per cent of screws inserted.

4. Regardless of such accelerating factors as metallic transfer, 18/8 Mo steel may have to be accepted as inherently more susceptible to corrosion than is cobalt-chrome alloy.

5. The qualities of two other stainless steels also became evident. Previous work describing the very bad situation arising from the use of EMS was confirmed. By contrast, a steel that was in use before 1951 gave little trouble. This steel was probably FSL.

1. A case is described ofcomplete rupture ofthe second part of the axillary artery complicating anterior dislocation of the shoulder in a woman aged fifty years.

2. Interesting features were that the patient was comparatively young, that the rupture was a result of the dislocation and not of the reduction, that the axillary vein remained intact, and that a satisfactory circulation returned after ligation of the artery.

1. A series of fractures of the forearm has been treated by exceptionally rigid internal fixation with a special plate and screws.

2. The plate and screws are described.

3. The results of rigid fixation are found to be: i) reliability of union, and ii) good final function.

4. The lessons learned regarding the application of the plate and the after-treatment of the forearms are recounted.