We present a case of late dislocation of the hip in a 30-month-old girl. Her hip was clinically stable at birth and an ultrasound scan at six weeks was normal. She had no additional risk factors for developmental dysplasia. She underwent anterior open reduction with a femoral osteotomy

Achilles tenotomy is a recognised step in the Ponseti technique for the correction of idiopathic congenital talipes equinovarus in most percutaneous cases. Its use has been limited in part by concern that the subsequent natural history of the tendon is unknown. In a study of 11 tendons in eight infants, eight tendons were shown to be clinically intact and ten had ultrasonographic evidence of continuity three weeks after tenotomy. At six weeks after tenotomy all tendons had both clinical and ultrasonographic evidence of continuity

Aims . To investigate whether pre-operative functional mobility is a determinant of delayed inpatient recovery of activities (IRoA) after total knee arthroplasty (TKA) in three periods that coincided with changes in the clinical pathway. Patients and Methods. All patients (n = 682, 73% women, mean age 70 years, standard deviation 9) scheduled for TKA between 2009 and 2015 were pre-operatively screened for functional mobility by the Timed-up-and-Go test (TUG) and De Morton mobility index (DEMMI). The cut-off point for delayed IRoA was set on the day that 70% of the patients were recovered, according to the Modified Iowa Levels of Assistance Scale (mILAS) (a 5-item activity scale). In a multivariable logistic regression analysis, we added either the TUG or the DEMMI to a reference model including established determinants. Results. Both the TUG (Odds Ratio (OR) 1.10 per second, 95% confidence intervals (CI) 1.06 to 1.15) and the DEMMI (OR 0.96 per point on the 100-point scale, 95% CI 0.95 to 0.98) were statistically significant determinants of delayed IRoA in a model that also included age, BMI, ASA score and ISAR score. These associations did not depend on the time period during which the TKA took place, as assessed by tests for interaction. . Conclusion. Functional mobility, as assessed pre-operatively by the TUG and DEMMI, is an independent and stable determinant of delayed inpatient recovery of activities after TKA. Future research, focusing on improvement of pre-operative functional mobility through tailored physiotherapy intervention, should indicate whether such intervention enhances post-operative recovery among high-risk patients. Cite this article: Bone Joint J 2017;99-B:211–17

A consecutive series of 150 patients with clavicular fractures is presented. In 81% detailed information regarding the mechanism of the injury was available and, of these, 94% had fractured their clavicle from a direct blow on the shoulder; only 6% had fallen on the outstretched hand. This finding, at variance with commonly held views regarding the mechanism of this injury, was further investigated by biomechanical analysis of the forces involved in clavicular fractures. The biomechanical model supported the clinical findings

High myelomeningocele lesions do not preclude an acceptable level of functional walking provided that an integrated programme of surgical treatment and bracing is adopted. Clinical analysis of 100 patients with myelomeningocele shows that the development of the "swivel walker" and "hip guidance orthosis" has been associated with an improved level of function. Over 30 per cent of patients with thoracic lesions and 68 per cent of those with lumbar lesions achieved independent walking. For this reason the criteria used at present by paediatricians to govern the selection of infants for non-active treatment may require reconsideration

1. A case of bilateral extensordigitorum brevismanuscausingsymptomsisdescribed. A review of the literature has revealed fourteen previous cases in which the anomaly was recognised. 2. The phylogenetic and morphological significance of this atavistic structure is considered. 3. Observations are made on the clinical features of the condition. It usually presents in a young male manual worker who complains of pain and swelling on the dorsum of the hand after heavy work. There is a visible swelling with the physical characteristics of a small fleshy extensor muscle. 4. Various methods of treatment are discussed. If the symptoms warrant operation total ablation of the muscle is suggested

Ischaemia is a rare complication of injury to a limb but must be excluded in every case. Two distinct types occur: Type I, where a proximal arterial injury gives rise to ischaemia distally; and Type II, where a direct injury gives rise to ischaemia at the site of the injury. Whatever the nature of the insult, an ischaemic contracture only develops as a result of swelling of the soft tissues where these soft tissues are contained in un unyielding osteofascial compartment. This secondary ischaemia can only be relieved by a timely fasciotomy. The diagnosis of ischaemia in an injured limb and the indications to operate on it can usually be made on clinical grounds alone

From 1984 to 1988 we implanted 127 massive allografts irradiated with a dose of 25,000 grays. These were reviewed at a minimum follow-up of three years to determine the effect of irradiation on infection, the complications and the functional result. No bacteriological infection was seen in the 44 patients who had allografts for revision of joint arthroplasty or for a tumour with no adjuvant therapy. For the 83 patients who also had chemotherapy or radiotherapy or both for a bone tumour, the rate of infection was 13%. The major mechanical complications were nonunion in seven grafts (5.5%) and fracture in eight (6%). These rates do not differ greatly from those reported for non-irradiated grafts. Our results suggest that irradiation, which remains the most convenient and acceptable method of sterilisation, does not jeopardize the clinical results

We have developed a simple technique for demonstrating the sagittal profile of each rotated level of a scoliotic spine and used it to determine the patterns of lordosis and kyphosis in each of six clinical types of idiopathic scoliosis. The currently accepted classification of scoliosis is inaccurate and a modification is proposed. The three main types of scoliosis were shown to have sagittal profiles distinctly different from each other and from normal. Single structural curves had short lordotic sections at their apices, limited above and below by kyphosis. Double curves showed longer lordotic sections limited only by one area of kyphosis. Lordosis throughout the thoracic and lumbar spine was associated with triple curve patterns. The biomechanical effects of the abnormal sagittal profiles provide a simple explanation for the genesis and progression of the different types of scoliosis, and the recognition of the pattern of the sagittal abnormalities permits treatment to be designed on a sound anatomical basis for individual cases

Doubt remains as to the safest surgical approach to the prolapsed thoracic intervertebral disc. Laminectomy, lateral rhachotomy and the transthoracic approach all have their protagonists. Twenty-two patients from the National Hospital for Nervous Diseases, Queen Square, and Atkinson Morley's Hospital have been reviewed. Their clinical presentation is discussed and the ancillary aids to diagnosis assessed. The diagnostic value of disc space calcification is stressed, and the use of air myelography as an adjunct to positive contrast myelography is noted. Fifteen patients were subjected to laminectomy, and seven to lateral rhachotomy. Each group contained patients with a wide range of neurological deficit. Six of the patients who underwent laminectomy were improved, two were unchanged, six deteriorated and one died. Of the patients who had lateral rhachotomy, six were improved, one was unchanged and none deteriorated. The conclusion is drawn that lateral rhachotomy is a safer procedure

1. The arterial supply of the upper end of the femur has been studied in twenty-four children and twenty adults. 2. The arterial system was demonstrated by injection of radio-opaque material, with Spalteholz' method of clarification, and histological section of the neck and ligamentum teres. 3. The upper end of the femur is supplied by the nutrient artery of the shaft, the retinacular vessels of the capsule, and the foveolar artery of the ligamentum teres. 4. The retinacular vessels consist of three separate groups: postero-superior, posteroinferior, and anterior. These vessels are the chief supply to the epiphysis and femoral head at all ages. 5. The foveolar artery constitutes a small and subsidiary blood supply to the femoral epiphysis. In this series, it penetrated the cartilaginous or osseous head in 33 per cent. of young specimens and 70 per cent. of adult specimens. The foveolar vessels increase in size with age. 6. The site of the vascular pathology in various lesions of the femoral head is considered

Diurnal changes in the loads acting on the spine affect the water content and height of the intervertebral discs. We have reviewed the effects of these changes on spinal mechanics, and their possible clinical significance. Cadaveric lumbar spines subjected to periods of creep loading show a disc height change similar to the physiological change. As a result intervertebral discs bulge more, become stiffer in compression and more flexible in bending. Disc tissue becomes more elastic as its water content falls, and its affinity for water increases. Disc prolapse becomes more difficult. The neural arch and associated ligaments resist an increasing proportion of the compressive and bending stresses acting on the spine. Observations on living people show that these changes are not fully compensated for by modified muscle activity. We conclude that different spinal structures are more heavily loaded at different times of the day. Therefore, the time of onset of symptoms and signs, and any diurnal variation in their severity, may help us understand more about the pathophysiology of low back pain and sciatica

Forty-eight patients with achondroplasia and 24 with hypochondroplasia have been reviewed in order to clarify the differences between the two disorders and establish the height, body proportions and other clinical and radiological variations within each group. Some of the "classical" findings in achondroplasia are not always present, and hypochondroplasia at its most severe is indistinguishable from achondroplasia at its least severe. The frequency of spinal stenosis and neurological complications was established in an unselected group of 27 achondroplastic and 12 hypochondroplastic patients aged 10 years and over. Only three of the former were free of symptoms but only three developed serious complications (11 per cent). Measurement of radiographs of the lumbar canal did not in general correlate well with the severity of spinal stenosis symptoms, but it was found that the ratio of interpedicular distances at the first and fourth lumbar vertebrae had some value. Neurological complications were rare in patients with simple narrowing of the spinal canal or with persistence of a thoracolumbar kyphos but when these occurred together there was a high risk of serious neurological involvement

1. An analysis has been made of the clinical features and investigations in ninety-five cases of primary intraspinal tumours. 2. Loss of muscle power was the commonest symptom, and was often ignored until late in the course of the disease. 3. Two-thirds of the patients had no pain in the spinal region, although five of these had either extensive growths or radiographical evidence of bone erosion by tumour. 4. One-third of the patients had urinary symptoms, and two of them had acute retention initially attributed to prostatic obstruction. 5. In eighteen cases posture and gait were abnormal. The case histories of five of these patients are recorded, and they emphasise the importance of recognising lumbar spasm and hamstring tightness in young patients as signs of a cauda equina neoplasm. 6. All patients had some detectable sensory, motor, or reflex changes, and these were mostly bilateral. 7. Radiography, and cerebrospinal fluid manometry and analysis, were helpful in establishing the diagnosis. 8. Hysteria should not be diagnosed until all efforts have been made to prove otherwise

A retrospective series of 272 operatively proven bucket-handle tears of the meniscus has been studied to define the natural history of the tear and to assess the accuracy of arthrography as a diagnostic technique. A simple twist, or a sporting injury accounted for most tears in the 196 patients on whom information was sufficient to allow analysis. There was, however, either no known trauma or merely a history of crouching in 20 per cent of patients. These were distributed evenly throughout the age range. Most of the 272 patients presented either with a locked knee (43 per cent) or with a history of locking (37 per cent). Fifty per cent of those with a previous history of locking but who were clinically unlocked at the time of operation, had displaced bucket-handle tears, indicating that unlocking of the knee joint frequently represents anterior extension of the tear, rather than relocation of the displaced fragment of meniscus. Significant meniscal tears were identified in 77 per cent of the 187 arthogram reports that were studied. Most errors in diagnosis seemed to occur when the separated fragment was hidden in the intercondylar notch and the peripheral rim was misinterpreted as an intact meniscus

The clinical features of nine new patients with dysplasia epiphysialis hemimelica are reported, with a long-term follow-up on a further seven patients who were described in the earliest case reports of this disease. Each of these 16 patients had only one leg involved, but 12 had multiple epiphyses affected. The distal femur, distal tibia and talus were the commonest sites and most patients presented with painless swelling or deformity. Wasting of the muscles of the affected leg was a common finding, and was occasionally disproportionate to the degree of disuse. One patient had the unique combination of involvement of the lateral and medial halves of different epiphyses in the same limb and another had unusual metaphysial changes. Diagnosis was often delayed despite typical radiographic appearances. There was no evidence for a genetic component in the aetiology nor was any common environmental factor identified. Treatment by local excision was generally effective for lesions in the vicinity of the knee, but some patients with involvement of the talus required arthrodesis around the ankle. The long-term prognosis appears to be good and so far only two of these patients have developed premature osteoarthritis

I have tried to describe the functional attainments of amputees using conventional prostheses. I have outlined the work we have been doing on pneumatic arms for infants and children. I have discussed some of the practical problems in applying pneumatic and myo-electric systems to adults. The inescapable conclusion that one must reach is that two basic clinical requirements must be met before really significant advance is made in this field. Firstly, we must find a method of providing sensory information from the prosthesis. Secondly, we must find a way of utilising more control sites. So far we have only been able to make use of direct movements or myo-electric signals. In the high level bilateral subjects more controls are required than appear to be available. Capener has suggested, in more than one discussion that I can recall, the possibility of using the voice and I have no doubt that a subject could be trained to reserve certain frequencies for prosthetic controls. It may be that we will have to think along some such lines as this

Total hip replacement using porous-coated cobalt-chrome femoral implants designed for biological fixation has been evaluated in 307 patients after two years and in 89 patients after five years. Histological study of 11 retrieved specimens showed bone ingrowth in nine and fibrous tissue fixation in two. Fixation by bone ingrowth occurred in 93% of the cases in which a press fit of the stem at the isthmus was achieved, but in only 69% of those without a press fit. The clinical results at two years were excellent. The incidence of pain and limp was much lower when there was either a press fit of the stem or radiographic evidence of bone ingrowth. Factors such as age, sex, and the disease process did not influence the clinical results. Most cases showed only slight resorptive remodelling of the upper femur, but in a few cases with a larger, more rigid stem, more extensive bone loss occurred. The results after five years showed no deterioration with time. Fixation by the ingrowth of bone or of fibrous tissue both appeared to be stable, but bone ingrowth gave better clinical results

We have reviewed 13 operations on 11 patients using curettage and polymethylmethacrylate cement for giant-cell tumour of bone (GCT) to assess the value of radiology in the early detection of recurrence. There were four recurrences, the most specific radiological sign on plain radiography was lysis of 5 mm or more at the cement-bone interface. This preceded clinical signs by a mean of four months and was identified at a mean of 3.75 months after operation. There was not always a complete sclerotic margin around the cement, but when it was present, there was never evidence of recurrence. MRI was helpful in assessing cases with evidence of recurrence. Frequent surveillance with plain radiography should continue for one year after operation irrespective of clinical signs of recurrence. When the appearance of the plain radiographs suggests recurrence, MRI should be performed and followed by image-guided needle biopsy