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Volume 40-B, Issue 4 November 1958

"FORTY YEARS ON" Pages 615 - 617
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Norman Capener
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PARALYTIC CLAW HAND Pages 618 - 632
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Paul W. Brand
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1. The intrinsic paralysis that occurs in leprosy has been treated by the sublimis transfer of Stiles and Bunnell for the past nine years. Since 1951 300 hands have been operated upon, and 150 patients selected geographically have been followed up in this study.

2. The patients have been assessed by a standard method involving: 1) Measurement of range of movement of the interphalangeal joint (unassisted movement, assisted active movement and passive movement); 2) grasp index; and 3) photographs of each hand in six standard positions.

3. Assessment of the open hand—The Stiles-Bunnell procedure is effective in achieving a fully open hand: 73 per cent of the fingers scored good or excellent results. A defect in the operation is that it sometimes hyperextends the interphalangeal joint, producing an "intrinsic plus" hand.

4. Assessment of sequence of joint flexion—The Stiles-Bunnell operation restores satisfactory mechanism of closure of the hand in 93 per cent of cases—that is, the metacarpo-phalangeal joints flex before the interphalangeal joints.

5. The closedfist assessment—About 30 per cent of patients had some defect in the complete closure of the fist after operation. In 5 per cent of cases the fingers did not reach the palm after operation.

6. Complications—The "intrinsic plus" defect is commonest in the best and most mobile hands. This is a late complication which gets worse in succeeding years. It can be corrected by Littler's operation together with a profundus tenodesis in the middle segment of the finger. Lateral deviation of fingers due to radial-side attachment of the transferred tendon can be avoided by ulnar-side attachment of the tendon used for the index finger. Bowstringing of the sublimis stump in the flexor sheath may be avoided by division of the sublimis at it insertion. Weakness of grasp and pinch from loss of sublimis may be avoided by using only one or two sublimis tendons split into several strands. The index finger sublimis should be left in position.

7. It is concluded that the sublimis transfer of Stiles and Bunnell is a very powerful corrective of intrinsic paralysis of the fingers. Its chief defect is that it is too powerful and produces the opposite deformity. For this reason the use of this operation should be restricted to fingers in which there is some limitation of passive extension. For fully mobile fingers an operation should be selected which does not remove the sublimis from its normal position.


John Charnley H. G. Lowe
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1. An analysis of 171 cases of compression arthrodesis in the knee is presented.

2. A total success rate of 98·8 per cent was revealed.

3. The average time between operation and walking free of splintage was nine weeks.

4. When the compression was removed, after an average period of four weeks, 88·2 per cent of the knees already showed clinical union.


James H. Miller John White Thomas H. Norton
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1 . Criticisms are expressed of previous reports on the use of intra-articular injections in the treatment of osteoarthritis of the knee.

2. A series of 181 patients with primary osteoarthritis of the knee treated by certain intra-articular injections is reported. Three solutions in common use were studied; normal saline and mock injections served as controls.

3. Irrespective of the injection used, including the controls, no significant difference in the effects was demonstrated in the results.

4. The place of intra-articular injection therapy in osteoarthritis is discussed. Attention is drawn to the psychological implications.


Anatol Axer
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1 . An operation for strengthening the lateral abdominal muscles in children after poliomyelitis is described. It consists of transposition of the proximal part of the gluteus maximus, the tensor fasciae latae and the ilio-tibial band ("the pelvic deltoid" of Henry) to a chosen rib.

2. The results of this operation in eight consecutive cases of paralytic scoliosis, pelvic obliquity and thoraco-pelvic instability are assessed.

3. A "strong" motor allows the child to lift the pelvis against gravity, whereas with a "weak" motor the child is unable to do so efficiently. However, even a "weak" musculotendinous tendinous unit helps invariably in restoring the thoraco-pelvic stability, just as a weak "hamstring-into-patella" transplant stabilises the knee.

4. Those motors (gluteus maximus with or without tensor fasciae latae) that contract vigorously and move the free end of the ilio-tibial band for at least three centimetres on direct faradic stimulation with a bipolar electrode during the operation become ultimately strong and most efficient.

5. The unreliability of the clinical test of tensor fasciae latae in small children is discussed, and the advantage of using the gluteus maximus as the motor for the musculo-tendinous unit is emphasised.

6. Using the proximal half (or less) of the gluteus maximus for strengthening the lateral abdominal muscles does not seem to affect appreciably the strength of hip extension. This phenomenon may be explained with reasonable probability by the existence of a twofold insertion of that muscle.


R. A. Bremner A. M. Jelliffe
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1. Problems of management of a pathological fracture of a major long bone through a metastatic cancer deposit are outlined. The relatively short life expectancy of these patients is stressed.

2. The results of treatment of thirty-six consecutive fractures of this type by internal fixation and radiotherapy, and of similar treatment used "prophylactically" on seven occasions, are reviewed.

3. Four-fifths of the patients with lower limb fractures became ambulant with crutches and were able to return home.

4. "Prophylactic" internal fixation and radiotherapy appear to be helpful in selected cases.

5. The theoretical dangers and difficulties of the technique are discussed. They are easily surmountable and have probably been over-emphasised in the past.

6. It is concluded that this is the best method at present available for dealing with this difficult problem.


A. G. Quinlan W. J. W. Sharrard
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1. Five cases of postero-lateral dislocation of the knee with capsular interposition are described.

2. The mechanism of the injury is considered in the light of the case histories and the findings at operation.

3. The constant clinical findings associated with this injury are described.

4. Open reduction is recommended: with early operation the prognosis for function and stability is good.


Cedric Carter Rodney Sweetnam
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The family we record draws attention to an association between recurrent dislocation of the patella and joint laxity, which is not confined to the knee. This may pass unrecognised if specific inquiry is not made. In this and other families reported, the joint laxity is inherited, as though due to a dominant gene, but some only of those affected suffer recurrent dislocation of the patella. It is probable that there are other genetically determined causes of recurrent patellar dislocation. In three other families we have seen more than one subject of patellar dislocation, but none had lax ligaments, and two other families have been recorded with no mention of associated joint laxity.


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Lipmann Kessel George Bonney
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1. The etiology of hallux rigidus has been studied by an examination of ten adolescent and four adult patients.

2. Although osteochondritis dissecans of the metatarsal head has been seen in two cases, our evidence generally suggests that metatarsus primus elevatus is the important etiological factor in established hallux rigidus.

3. The common factor for the production of symptoms is the limitation of dorsiflexion of the first metatarso-phalangeal joint, just as the key to treatment is the existence of a good range of plantar-flexion of the joint.

4. The technique and results of the operation of phalangeal extension osteotomy for hallux rigidus are given.


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G. K. Rose
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1. The mechanical qualities of the peritalar joint, the calcaneo-contact joint, and their interreaction with the hip joint in the standing weight-bearing foot are considered.

2. The most efficient ways of correcting the pronated foot have been indicated.


J. C. Foster
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1. A series of 142 fractures of the trochanteric region treated by fixation with Vitallium nail-plates of the original McLaughlin pattern is described. The hospital mortality was 9 per cent. Disruption of the nail-plate junction occurred in 8 per cent of cases. This confirms McLaughlin and Garcia's (1955) view that this pattern of nail-plate should no longer be used.

2. Despite this, satisfactory functional results were achieved in 78 per cent of the survivors.

3. The new Model V McLaughlin nail-plate is described, and the stresses in nail-plates are considered. On theoretical grounds and laboratory tests the weakness at the nail-plate junction has been eliminated in the new model, and the strength of the appliance as a whole compares favourably with other types of nail-plate. Full clinical trial is therefore justified, and seventy-one patients have so far been operated on, with satisfactory early results.

4. Marked stiffness of the hip joint greatly increases angulatory and rotational stresses on the nail-plate, and a high incidence of disruption is to be expected in these cases.


R. A. Bremner W. D. Graham
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1. The results of treatment of 100 consecutive patients with pertrochanteric and basal fractures of the femur treated by early operative fixation with a McKee two-piece nail and plate are reviewed.

2. Technical failures are analysed and discussed.

3. The pattern of mortality is discussed and contrasted with that in a comparable series of patients treated conservatively.

4. It is concluded that early operative fixation is the method of choice in the management of these fractures, and that the McKee pin and plate is a satisfactory and reliable device for securing internal fixation.


J. E. Caughey
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1. The clinical features of hyperostosis cranii are briefly reviewed. In large series of cases the syndrome has been found to occur almost entirely in females.

2. In recent studies of dystrophia myotonica, it is apparent that hyperostosis cranii is one of the variable features of the disorder. This disease occurs equally among males and females and the hyperostosis cranii also is distributed equally among males and females.

3. Hyperostosis cranii also occurs in patients with Morgagni's syndrome, with acromegaly, and as "senile hyperostosis."

4. The etiology of hyperostosis is still a matter for speculation. More recent studies have focused attention on the endocrine system, and it seems probable, in view of the sex distribution in dystrophia myotonica, that the key to the problem may be found in this disorder.

5. In dystrophia myotonica the characteristic skull changes are hyperostosis cranii, a small pituitary fossa, excessive sinus formation and prognathism. These are acromegaloid changes. Gonadal atrophy is a common feature and endocrine study suggests that the endocrine defect is primarily a failure of the androgenic function of the adrenals and the testes.

6. In rodents and in humans ablation of the gonads leads to overactivity of gonadotrophic cells and, at times, of somatotrophic cells. Sometimes pituitary tumours develop.

7. Acromegaloid features may occur in eunuchs, and it is likely that the acromegaloid changes in dystrophia myotonica are of the same order from overactivity of growth hormone.

8. In animals excess of growth hormone produces thickening of the skull.

9. In dystrophia myotonica, acromegaly, and Morgagni's syndrome, it is suggested that hyperostosis cranii is an expression of unrestrained activity of growth hormone.


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W. J. Weston J. D. Reid J. H. Saunders
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1 . A case of parosteal osteoma with histologically low-grade sarcomatous areas is described.

2. Arteriography revealed abnormal arteries, the histological appearances of which are described.

3. Vascular shunts indicative of low-grade malignancy were also seen.

4. Reasons are given for accepting the view that this lesion is a tumour, originally benign, but liable to the development of low-grade malignancy.


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Ronald S. Cowie Joseph S. Barr H. Robert Dudley
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Jack Stevens Bernard Lennox
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A patient with Paget's sarcoma of the femur, alive and well seven years after amputation, is reported. Long survival in two previously reported cases is also mentioned.


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K. H. Pridie E. A. McVerry
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David Allbrook W. H. Kirkaldy-Willis
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The experiments were performed to answer three main questions. These and our answers may be summarised as follows.

What is the precise mechanism of healing of a raw bony surface in a joint? What cells are involved? Where do they originate?—In all the implant experiments and in the control series the fundamental mechanism of healing was similar.

1. A massive proliferation of fibroblasts occurred from the cut periosteum, from the cut joint capsule, and to a lesser extent from the medullary canal.

2. Fibroblasts grew centripetally in the first few weeks after operation, attempting to form a "fibroblast cap" to the cut bone end.

3. Fibroblasts of this cap near the cut bone spicules metamorphosed to become prechondroblasts, chondroblasts laying down cartilage matrix, and hypertrophied (alkaline phosphatase-secreting) chondrocytes lying in a calcified matrix.

4. This calcified cartilage matrix was invaded by dilated capillaries probably bearing osteoblasts which laid down perivascular (endochondral) bone.

5. Some of the cells of projecting bone spicules died and their matrix was eroded in the presence of many osteoclasts.

6. In the control experiments of simple excision of the radial head new bone was produced at the periphery only by processes (3) and (4). This sealed off the underlying peripheral cortical bone from the superficially placed peripheral articular surface of fibrocartilage. At about a year from operation the central portion of the articular surface was still formed of bare bone, or of bone spicules covered by a thin layer of irregularly arranged collagen fibres. The opposite capitular articular cartilage was badly eroded.

Does the introduction of a dead cartilage implant over the raw bone end affect in any way the final constitution of the new articular surface?—In the implant experiments the new bone produced by processes (3) and (4) formed, after about a year, a complete cortical plate which entirely sealed off the cut end of the radius and left a superficially placed articular covering of smooth fibrocartilage, closely resembling a normal joint surface. The opposite capitular articular surface was normal.

What is the final fate of such an implant?—Whale cartilage implants underwent replacement by fibroblasts and collagen fibres, and took about nine months to disappear.

The cartilage of fixed autotransplants and homotransplants underwent similar gradual replacement, and took about the same time in each case. The dead bone, implanted in association with the cartilage in both cases, acted as a nidus for hyaline cartilage production by chondrocytes derived from fibroblasts. This cartilage underwent endochondral ossification. This observation suggests that induction by non-cellular osseous material is a factor in chondrification and ossification.

All the implants functioned as temporary articular menisci or in some cases as temporary radial articular surfaces. They were always replaced by a permanent fibrocartilaginous meniscus, or a fibrocartilaginous articular surface. An implant did, in fact, always act as a temporary protecting cap and mould for the subjacent growth offibroblasts which was necessary for the production of a satisfactory new joint surface.


W. Waugh
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1. Serial radiographs of fifty-two normal children's feet, taken at six-monthly intervals between two and five years, have been reviewed.

2. Twenty-one naviculars have been injected post-mortem and the vascularisation of the growing bone investigated.

3. The records of sixty-two children with a diagnosis of Köhler's disease have been studied.

4. It is submitted that abnormal ossification results from compression of the bony nucleus at a critical phase during growth of a navicular bone whose appearance is delayed.

5. Symptoms in Köhler's disease are related to further compression which produces vascular changes in the bony nucleus. Consequent ischaemia is followed by hyperaemia which produces local pain, tenderness and swelling.

6. Two radiographic types of Köhler's disease are described and attributed to variations in the basic vascular pattern of the affected bone.

7. The usual complete recovery of the navicular is ascribed in part to the basic arrangement of numerous radially penetrating vessels.


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E. H. J. Smyth
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1. The structure and blood supply of the femoral head and neck, the mechanics of weight bearing, and the known effects of an inert foreign body are considered in relation to arthroplasty.

2. Some artificial hips are reviewed from the biomechanical standpoint.

3. From the information now available it is inferred that mechanical soundness and clinical success are not only co-related but interdependent; and that the mechanical problem of design offers most scope for further development at the present stage of our knowledge.

4. To this end six propositions are submitted.

5. A theoretical replacement arthroplasty, confined to the head and neck, in which breakdown of the component forces suggests that reciprocal use of both tensional and compressive loads might occur as in the natural femur, is described.


J. Hickman E. G. C. Clarke A. R. Jennings
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1. Radiological and histological observations of the tissue changes resulting from the implantation of various metals in the long bones of dogs are recorded.

2. Of the metals employed, tantalum, Vitallium, alloys "C" and "S" and F.M.B. steel were inert; silver and mild steel were reactive; F.S.T. steel occupied an intermediate position.

3. A correlation has been demonstrated between the anodic back E.M.F., the weight loss due to corrosion and the histological changes produced.


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Bernard Bloch
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1. The properties and behaviour of ethoxyline resins, which are already well known in industry, are discussed.

2. Experiments in the use of these compounds for the bonding of fractures of the long bones of sheep are described.

3. There has been no evidence of toxic reaction to the presence of the resin in the tissues.

4. Application of the method to fractures in man has been studied, and two such fractures have been bonded with promising early results.


IN MEMORIAM Pages 813 - 816
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L. W. Plewes
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L. W. Plewes
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J. G. Bonnin
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Roland Barnes
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Lipmann Kessel
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Gordon Gordon-Taylor
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H. Jackson Burrows
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H. Jackson Burrows
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J. Crawford Adams
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H. Jackson Burrows
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J. N. Aston
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David Trevor
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P. G. Walker
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J. E. Roberts
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C. H. Lack
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Janet Vaughan
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Robert I. Stirling
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Max Geiser
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Geoffrey Jefferson
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Geoffrey Jefferson
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Bryan McFarland
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J. N. Wilson
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J. N. Wilson
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K. I. Nissen
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J. G. Bonnin
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G. K. T. Roche
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C. Langton Hewer
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Philip Wiles
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L. W. Plewes
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Donal Brooks
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Donal Brooks
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A. L. Eyre-Brook
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Donal Brooks
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Gordon Gordon-Taylor
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BOOKS RECEIVED Pages 856 - 857
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