1. The risk of injury to the sciatic nerve during closed ischio-femoral arthrodesis by nail and graft has been assessed on the basis of clinical evidence and of anatomical studies in the living and in cadavers. 2. The margin of safety for the nerve is nearly always small. 3. The risk of injury to the nerve is prohibitive when there is marked deformity or hypoplasia of the pelvis. The risk is also increased when the buttock is compressed against the table and, because of the technical difficulties that are entailed, when the hip is in marked flexion. The risk is probably greater in children than in adults. 4. In properly selected cases in which none of these adverse factors is present it is submitted that the risk of nerve injury can be eliminated by proper attention to surgical technique and by the observance of certain definite precautions. 5. When there is doubt in the surgeon's mind about his ability to complete the operation without injuring the nerve the closed technique should be abandoned in favour of the open posterior approach.
1. The unreliable results of the conventional cup arthroplasty are attributed to mechanical imperfections in the reconstructed joint. 2. If its reliability can be improved, there will remain a place for cup arthroplasty, which, in relatively young and active patients, offers advantages over prosthetic replacement arthroplasty. 3. A technique of concentric cup arthroplasty is described. The new joint is shaped with precision to exact dimensions and lined with a cup designed to ensure stability, concentric movement and a uniform clearance between the moving parts. 4. The results so far are encouraging and justify continued clinical trial.
1. The steps of the operation of spinal osteotomy, as carried out with the patient in the lateral posture, are described. 2. Details of post-operative management are given. 3. The major risks of the operation are discussed and precautions suggested.
One hundred and sixty-four cases of intramedullary nailing of the long bones have been studied with special reference to the difficulties and complications encountered. There was one death not attributable to the method. Two cases of pulmonal fat embolism and one case of thrombosis occurred, all in fractures of the femur. The lessons we have learned from our mistakes can be summarised as follows: 1 . The method requires technical experience and knowledge and is not suited to inexperienced surgeons or surgeons with little fracture material at their disposal. 2. Intramedullary nailing should only be used in fractures to which the method is suited. In general, comminuted fractures or fractures near a joint are unsuitable. 3. Open reduction is preferable to closed methods. 4. The nail should never be driven in with violence. It should be removed and replaced with a new one if difficulty is encountered when inserting it. 5. In fractures of the femur the nail should be driven in from the tip of the trochanter after careful determination of the direction. 6. The nail should be introduced only to the level of the fracture before exploring and reducing the fracture. 7. Distraction of the fragments must be avoided. 8. If the nail bends it should be replaced by a new one, at least in femoral fractures. 9. If union is delayed, the fracture should be explored and chip grafts of cancellous bone placed around it. 10. Improvised nails or nails which are not made of absolutely reliable material should never be used. 11 . Make sure that the nail is equipped with an extraction hole for removal.
The technique of the transfibular approach for arthrodesis of the ankle joint is described. The results of this operation in a series of thirty cases shows that the procedure is reliable if the technique is carried out faithfully. The two cases in which a first operation failed can both be explained by errors of technique or after-treatment.
A review of the pathology, mechanism, and operative treatment of recurrent dislocation of the shoulder, based on an analysis of 180 cases, with 159 operations, is presented. From this analysis the following conclusions have been made and appear to be substantiated: 1. The pathology comprises two important elements: ( 2. The frequency of the humeral head defect has been under-estimated in the past, because of the difficulty of demonstrating it, particularly when the defect is small. 3. Either type of lesion alone may predispose to recurrence of the dislocation. 4. Both types of lesion are often present in the same shoulder. When this is the case the tendency to redislocation is great. 5. The initial dislocation, which results in the development of one or both these persistent structural abnormalities, may be due to very different types of injury, the commonest of which is a fall on the outstretched hand. The factor common to all these injuries is a resultant force acting on the humeral head in the direction of the anterior glenoid margin. 6. In the treatment of recurrent dislocation of the shoulder joint the Nicola operation is unreliable, and it may be associated with a recurrence rate as high as 36 per cent. It is believed that continued instability after this operation is usually due to the presence of a defect of the humeral head. 7. Operative treatment should aim at repairing, or nullifying, the effects of both types of lesion. For anterior detachment of the labrum this involves either suturing the labrum back to the glenoid margin, or constructing some form of anterior buttress, fibrous or bony: for humeral head defects it necessitates some procedure designed to limit external rotation, thus preventing the defect from coming into engagement with the glenoid cavity. Such limitation of external rotation does not constitute a significant disability.
