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I have attempted to call attention briefly to an operation that has proved to be of use in many patients with non-union of the neck of the femur and have tried to point out not only the indications but also the contra-indications, and to stress some of the precautions in the technique and after-care of the operation. This trochanteric reconstruction operation may help to solve some of the problems related to the ununited hip fracture.
A series of ten infants is reported, seven of whom showed evidence of osteomyelitis of the upper end of the femur; the remaining three did not, but presented with an acute subluxation of the hip in a febrile illness. Four sequelae among the seven more severe cases were: 1) destruction of the capital epiphysis with dislocation at the hip; 2) destruction of the capital epiphysis, the femoral neck remaining in the acetabulum; 3) destruction of the epiphysial plate with the femoral head, remaining in the acetabulum, connected to the femoral neck by a fibrous union; 4) recovery with coxa magna but no other deformity.
The streptococcus plays a greater part in this osteomyelitis of infancy than in osteomyelitis of older children, but various other organisms were identified. The organism should be sought by blood culture as well as from the local lesion.
Aspiration of the hip, treatment of the hip in abduction and the use of the appropriate antibiotic are recommended. If there is marked swelling and induration, freer release of the pus is strongly advised.
Controlled abduction osteotomy plays a useful part in stabilising the femoral neck in the acetabulum or in stabilising the femoral neck beneath the capital epiphysis, but may usefully be preceded by an arthrograph because late ossification of a detached head sometimes occurs.
1. A method is described for measuring blood flow to the head of the femur after fracture of the femoral neck, by estimation of the rate of uptake of radioactive phosphorus.
2. Of one hundred cases investigated the readings in fifteen were incomplete, and in seventeen were unreliable. Reasons are given for discarding the latter seventeen cases. After two years seven patients had died, leaving sixty-one available for analysis.
3. The results in sixty-one surviving patients with a follow-up of not less than two years are analysed. In twenty of these radioactivity was measured by bone sampling and in forty-one by direct readings with a needle counter.
4. The twenty-one intertrochanteric fractures studied were used as controls. In these the P32 ratio varied from 0·4 to 3·0. Union occurred in all patients and none developed avascular necrosis.
5. Of the forty patients with displaced fractures of the femoral neck twenty-eight showed a low P32 ratio. In twenty-three of these (82 per cent) the fracture united.
6. Twelve patients with fractures of the femoral neck showed a borderline or abnormal P32 ratio. In ten of these there was subsequent avascular necrosis or non-union.
7. The possible reasons for the discrepancy between expected and actual results are discussed.
8. Almost 40 per cent of the cases investigated had to be abandoned because of technical faults and in one-fifth of the remaining cases the expected results failed to agree with the clinical results. The method of investigation is therefore not of much practical value at the present time. Improvements in apparatus and technique might make the method more reliable and more useful.
1. The results of twenty-eight "hinge" arthroplasties of the knee are described.
2. Failure was most often due to breaking of the prosthesis.
3. The design of the prosthesis has been modified as a result of experience in cases of mechanical failure.
4. The results suggest that with the use of the modified hinge good results may be obtainable in three out of four cases.
1. Some of the factors responsible for vertebral growth have been discussed.
2. In kyphosis and scoliosis it is important to prevent progressive epiphysial damage.
3. In selected cases of progressive scoliosis, epiphysiodesis on the convex side will correct unequal growth.
4. The technique of spinal epiphysiodesis is described and the results that may be expected are discussed.
1. A medial approach is preferred for arthrodesis of the wrist in reconstructive surgery because there is no interference with the extensor tendons.
2. The value of pre-operative assessment by a trial period in plaster is mentioned.
3. The technique of operation is described.
4. In the absence of active pronation, screwing the ulna to the radius in 45 degrees of pronation is advised.
5. The necessity for securing haemostasis before closing the wound is emphasised.
6. Thirty-four cases are reviewed. The shortest follow-up was one year and the longest twelve years. The result was satisfactory in all cases. Most patients were discharged from hospital after the plaster had been changed two weeks after operation. Union occurred in about sixteen weeks.
Removal of a small, moderate or major part of the articular cartilage of the patella for chondromalacia has been successful in twenty-two knees out of twenty-eight. These knees are functionally at least as good as after a successful patellectomy, and their appearance is better.
Only one knee that was initially improved by operation deteriorated during a follow-up period of five to seven years.
Of the six unsuccessful results, four were in patients whose symptoms began during adolescence. Excision of articular cartilage therefore seems to be contra-indicated during adolescence and when there is reason to believe that the chondromalacia will be rapidly progressive.
Failure of excision of articular cartilage to relieve the symptoms within a few months is an indication for patellectomy.
Case histories are given of three patients, two of whom had stress fractures of the patella, and one had a similar condition due to stress.
1. Five cases of a sudden block to extension in the metacarpo-phalangeal joint of the middle finger, in middle-aged patients, are described.
2. A possible explanation is that the ulnar collateral ligament gets caught on an osteophyte on the metacarpal head.
1. Nine cases of haemangiopericytoma are described and the treatment is discussed.
2. Six of the patients had a recurrence of the tumour after local excision.
3. Four patients developed metastases and died. All had been treated by surgery and cobalt 60 beam radiation.
4. Five of the patients show no further disease. Of these, two received cobalt 60 beam radiation after surgical treatment.
1. Six children suffering from acute infections of the spine have been studied.
2. Clinical and radiographic features are described. Reasons are given for bearing the condition in mind when dealing with cases of pyrexia of unknown origin in children.
3. Treatment is broadly outlined.
4. Radiographic findings are discussed in relation to the pathology of the disease.
1. The indications for amputation of all the toes for severe toe deformity in rheumatoid arthritis, hallux valgus and pes cavus are discussed.
2. The results of forty-seven amputations in twenty-eight patients are analysed: 93 per cent were found to be very satisfied with the operation.
3. The technique of the operation and the subsequent management are described. The importance of retaining full-length shoes fitted with metatarsal insoles and toe blocks to preserve a good gait and balance is emphasised.
1. Twenty-five lower limbs, amputated above the knee for senile atherosclerosis with peripheral gangrene, have been investigated radiologically and histologically to determine the vascular patterns in ischaemic bone with particular reference to the tibia. These have been contrasted with the patterns found in non-atherosclerotic tubular bone.
2. The principal changes are the development of a diffuse vascularisation of compact and spongy bone; a widening of Haversian spaces which come to contain a variable number of sinusoidal blood vessels; and an increasing periosteal participation in cortical nutrition which is related to the severity and chronicity of the ischaemic process.
3. Views on the normal blood supply of long bones are discussed, and evidence is presented for regarding this as discrete and end-arterial in nature; in particular it is suggested that the normal cortex has a wholly medullary, centrifugal, arterial supply.
This paper describes a procedure of activating osteogenesis by the use of the "petal" technique. The osteogenetic effect of these "petals" has been established in experimentally produced fractures and pseudarthroses in rats by radiographical, biomechanical, mechanical and histological examinations.
The conventional concept of the osteogenetic activity of bone transplants is discussed.
The authors feel that this method will find its clinical application in the operative treatment of pseudarthroses and, in selected cases, of fractures that are known for their tendency to unite slowly.
The alkaline phosphatase activity of pre-osseous tibial cartilage of rachitic bone stored in the deep freeze for two weeks at -25 degrees centigrade was only slightly less than that of fresh controls from the same animals. The deep frozen pre-osseous tissue did not calcify in
Bones heated at 65 degrees centigrade will calcify
It appears unlikely that a relationship exists between alkaline phosphatase and the minimal system required for calcification of pre-osseous cartilage
