Fifty patients with adolescent idiopathic scoliosis treated by posterior fusion and Harrington instrumentation augmented by a Cotrel bar or by sublaminal Luque wires were studied in a prospective trial to ascertain the need for postoperative bracing. Twenty-five patients wore a plaster brace postoperatively for six months, while 25 were managed without a brace. The mean loss of correction from the first standing postoperative radiograph to one obtained two years later was 7 degrees in the braced group, and 6.3 degrees in the unbraced group, the difference not being statistically significant. We conclude that postoperative bracing is unnecessary after augmented Harrington instrumentation

Plain radiographs show only two dimensions of a three-dimensional object. On anteroposterior and lateral radiographs an implant may appear to be safely within the head of the femur although surface penetration has occurred. We have attempted to identify this complication in the treatment of fractures of the femoral neck and have analysed the position of a screw or pin in the femoral head and neck on the basis of orthogonal frontal and lateral radiographs. A retrospective analysis of 60 cases of osteosynthesis of fractures of the femoral neck confirmed the risk of non-recognition of articular penetration or breaking of the cortex of the neck during surgery. Unrecognised screw penetration of the hip was observed in 8% and of the posterior part of the neck in 10%. The risk differs according to the type of fracture: it is greater in the coxa valga produced by Garden-I fractures of the femoral neck

Ten patients with 13 ankylosed elbows after burns are described. Six elbows, fixed in nearly full extension, had almost total functional disability; the other seven had varying amounts of deformity. In five of the 13 elbows there was a continuous bony mass with loss of the joint space; these were treated by a modified excision arthroplasty which restored good movement and useful function, though there was some lateral laxity. Six elbows had a posterior bony block; this was excised, which restored a useful arc of movement. The literature on bony ankylosis after burns is reviewed and the management of these cases in a developing country is described

We evaluated the nerve roots of the cauda equina by CT myelography in 36 patients aged from 11 to 19 years with lumbar disc herniation. On straight-leg-raising tests, six younger patients had isolated hamstring tightness with no sciatica (group A) and 30 had sciatic pain (group B). CT myelography showed that no patient in group A had associated nerve-root swelling, and that the roots were displaced posteriorly, but not compressed. In 21 of the group-B patients, swelling of the nerve roots was confirmed, with compression between the herniated disc and the superior articular process. Our findings suggest that hamstring tightness in these patients may be caused by a different mechanism from that which causes sciatic pain

Four infants between 2 and 13 weeks of age developed vertebral osteomyelitis. Their symptoms were different from those of children with discitis in that our patients were systemically ill, there was almost complete dissolution of involved vertebral bodies with either normal or nearly normal adjacent vertebral endplates, and three of the four children had recurrence of infection. The importance of long-term antibiotic treatment is emphasised. Years later the radiographic appearance of these children can be identical to congenital kyphosis with either anterior failure of segmentation or posterior hemivertebrae. The treatment should be the same as for congenital kyphosis with early bracing in extension and early fusion for progressive kyphosis

A series of 100 patients with pain in the leg was studied and the accuracy of electrical studies in the diagnosis of nerve root lesions was investigated before operation. The electrical studies which were performed on all the patients, included recordings of fibrillation potentials, H-reflex and ankle reflex latencies. This diagnosis technique was found to be more accurate than radiculography or clinical examination and did not give false evidence. Seventy patients were classed as having a lesion of the nerve root. Fifty of these patients were treated surgically. The operation revealed compression of the nerve root by osteophytes arising from degenerative and incompletely dislocated posterior facet joints in 43 patients

1. Twenty-two cases of synovial rupture of the knee have been studied. This condition may complicate any chronic synovitis of the knee in which a tense intra-articular effusion is subjected to increased tension during flexion and extension of the joint. 2. Two types of rupture have been seen; a herniation of the synovial membrane into the popliteal fossa and down the leg, and an acute synovial tear with extravasation of joint contents between the muscle planes of the calf. 3. The diagnosis of this condition, the differentiation of the types of rupture and their treatment are discussed. 4. The acute rupture usually responds to simple bed-rest; the large synovial herniations often need removal and repair of the posterior capsule

Early decompression in Pott's paraplegia gives encouraging results. It produces speedy recovery from paraplegia and ensures rapid healing of the lesion. Lateral extrapleural decompression without fusion for lesions of thoracic vertebrae is safe and satisfactory. It gives adequate exposure of the anterior and posterior parts of the vertebral bodies and of the theca, without endangering the stability of the spine. Age, sex and site of the lesion have no influence on the prognosis, whereas paraplegia of longer duration, paraplegia in flexion, and paraplegia presenting as a spinal cord tumour carry a bad prognosis. In early lesions there is reconstitution of vertebral bodies whereas in advanced lesions there is consolidation or bony fusion

We measured pressures in the anterior and deep posterior compartments continuously for up to 72 hours in 20 patients with closed fractures of the tibial shaft treated primarily in plaster casts. All were examined independently after periods of three to 14 months. Pressures above 40 mmHg occurred in seven (35%) and above 30 mmHg in 14 (70%). No patient had the symptoms of compartment syndrome during monitoring. Abnormalities at review did not correlate with the maximum consecutive time periods during which the compartment pressures were raised. Thus, in the absence of symptoms the monitored pressures did not relate to outcome. Routine monitoring in this type of patient is therefore of doubtful benefit

We report a case in which the popliteal artery was divided during upper tibial osteotomy performed with the knee in 90 degrees of flexion. This position is believed to allow it to fall safely back from the tibia, but we could find no published confirmation. We used duplex ultrasonography in ten healthy volunteers to measure the distance from the popliteal artery to the posterior surface of the tibia at various degrees of flexion of the knee. Our results showed that in 12 of 20 knees the popliteal artery was closer to the tibia in 90 degrees of knee flexion than in full extension. Surgeons performing upper tibial osteotomy should be aware that flexing the knee does not protect the popliteal artery from injury

We reviewed 33 children with tuberculosis of the knee treated during the period from 1979 to 1991. All were treated with triple chemotherapy, using rifampicin, isoniazid and pyrazinamide for nine months. No patient had a synovectomy; surgery was limited to open biopsy or salvage procedures such as posterior release and arthrodesis for late stages of the disease. The radiological appearance of the knee at presentation predicted the outcome. The 30 patients with stage-1 (normal) or stage-2 (osteomyelitic) disease had excellent or good results; the three with narrowed joint spaces in stage 3 or stage 4 (arthritic) had fair or poor results. Early active mobilisation, as against long-term immobilisation, seemed to have no effect on the outcome of stage-1 or stage-2 disease

To assess the stability of the hip after acetabular fracture, dynamic fluoroscopic stress views were taken of 41 acetabular fractures that met the criteria for non-operative management. These included roof arcs of 45°, a subchondral CT arc of 10 mm, displacement of less than 50% of the posterior wall, and congruence on the AP and Judet views of the hip. There were three unstable hips which were treated by open reduction and internal fixation. The remaining 38 fractures were treated non-operatively with early mobilisation and delayed weight-bearing. At a mean follow-up of 2.7 years, the results were good or excellent in 91% of the cases. Three fair results were ascribed to the patients’ other injuries. Dynamic stress views can identify subtle instability in patients who would normally be considered for non-operative treatment

Electromyographic and clinical studies were performed on patients undergoing total hip replacement by the modified direct lateral (29 hips), the direct lateral (29 hips) and the posterior approaches (21 hips). Assessments were made three months after operation. The Trendelenburg test was positive (Grade II) in eight cases operated upon by the direct lateral route, but in only one of each of the other two groups. Denervation occurred in only five of the 28 hips with abductor weakness without statistical difference between the groups. In the modified direct lateral group, radiological evidence of union of the trochanteric sliver was associated with significantly better abductor function than in those with malunion or non-union

Anterior tibial translation was measured in both knees using the radiological Lachman test and the lateral monopodal stance tests in 281 patients with unilateral anterior cruciate ligament (ACL) rupture. Measurements of translation in the medial compartment were more useful than those in the lateral compartment. Measurement of anterior tibial translation in the medial compartment using the radiological Lachman test showed ACL rupture in 92% of cases compared with 70% for the lateral monopodal stance test. In normal and in ACL-ruptured knees the monopodal stance test showed that every 10 degrees increase in posterior inclination of the tibial plateau was associated with a 6 mm increase in anterior tibial translation; the radiological Lachman test showed a 3 mm increase for every 10 degrees increase in tibial slope

Injuries to the sciatic nerve are an occasional complication of surgery to the hip and acetabulum, and traction is frequently the causative mechanism. In vitro and animal experiments have shown that increased tensile strain on peripheral nerves, when applied for prolonged periods, impairs nerve function. We have used video-extensometry to measure strain on the human sciatic nerve during total hip replacement (THR). Ten consecutive patients with a mean age of 72 years undergoing primary THR by the posterior approach were recruited, and strains in the sciatic nerve were measured in different combinations of flexion and extension of the hip and knee, before dislocation of the hip. Significant increases (p = 0.02) in strain in the sciatic nerve were observed in flexion of the hip and extension of the knee. The mean increase was 26% (19% to 30%). In animal studies increases of this magnitude have been shown to impair electrophysiological function in peripheral nerves. Our results suggest that excessive flexion of the hip and extension of the knee should be avoided during THR

Nuclear magnetic resonance imaging (MRI) was used to study the normal knee. As well as revealing bone quality, MRI provided useful information on intra-articular and extra-articular soft tissues. Midsagittal views gave clear images of the cruciate ligaments, and of the patellar and quadriceps tendons. Parasagittal views were the best for delineating the menisci which, like ligaments and tendons, are of low intensity; the semimembranosus tendon and its insertion to the proximal tibia were also seen clearly in these views. The cruciate ligaments and menisci, though visible in the coronal view also, were better seen in the sagittal view. Axial views provided information on the structure of the patella, its cartilage, the patellofemoral joint and posterior soft-tissue structures

A series of experiments showing how posture affects the lumbar spine is reviewed. Postures which flatten (that is, flex) the lumbar spine are compared with those that preserve the lumbar lordosis. Our review shows that flexed postures have several advantages: flexion improves the transport of metabolites in the intervertebral discs, reduces the stresses on the apophyseal joints and on the posterior half of the annulus fibrosus, and gives the spine a high compressive strength. Flexion also has disadvantages: it increases the stress on the anterior annulus and increases the hydrostatic pressure in the nucleus pulposus at low load levels. The disadvantages are not of much significance and we conclude that it is mechanically and nutritionally advantageous to flatten the lumbar spine when sitting and when lifting heavy weights

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

Six children with entrapment of the medial epicondyle in the elbow after closed reduction of a posterior dislocation were seen an average of 14 weeks after injury. The elbows were painful and the average range of flexion was 22 degrees. Two children had ulnar nerve involvement which recovered after operation. The epicondyle was removed from the joint and either reattached to the humerus or excised, and the muscles reattached. Two children had anterior transposition of the ulnar nerve, one for pre-operative hyperaesthesia, and the other to relieve tension on the nerve. At follow-up, at an average of 15 months after operation, flexion had increased fivefold, none of the children had pain and all were leading normal lives

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