General remarks–Comparison of the two reviews shows that patients with good results return more readily for a review than those with poor results. In middle-aged patients with some disability for walking an attendance of 80 per cent at least is necessary in order to obtain a representative follow-up five to ten years after operation.

An outstanding feature of all the operations reviewed is the degree of lasting relief of pain. It is rare to find that a patient with severe hip pain before operation has pain of the same severity after any of these operations at least up to ten years afterwards, and probably for much longer. Generally speaking, although in advancing years stiffness of the hip is undoubtedly a handicap, it is preferable to instability, particularly if this is progressive. A patient can adapt himself to and accept a disability that is permanent and unaltering, but instability increasing in later years can be distressing mentally and incapacitating physically.

Cup arthroplasty–There is an element of unpredictability in the results, especially the late results, of cup arthroplasty. Movement decreases and there is a tendency for pain and instability to increase after four or five years. There is little to indicate which case will be successful although the results vary according to the condition for which operation is performed. The operation gives good results, on the whole, for osteoarthritis, particularly when the operation is done on one hip only. Stability is much more important when both hips are involved, and, unless this is good in at least one hip, the results of bilateral operations are poor. "Excellent" results are not obtained in rheumatoid arthritis but few results are "poor." Operations for congenital dislocation of the hip give the most disappointing results. In operations for ankylosing spondylitis there is a high incidence of stiffening of the hip, but many patients are greatly improved in comparison to their state before operation.

Displacement osteotomy–The hazard in displacement osteotomy is ankylosis, particularly when internal fixation is not used. Relief of pain and stability are well maintained. The results in general, and for pain in particular, are less good when internal fixation is used. Adduction of the upper fragment of the femur appears to be of value in the production of a good result. In the series examined it was less often achieved when internal fixation was the method of immobilisation. The best results were obtained in cases of congenital dislocation of the hip and there were few "poor" results in cases of congenital subluxation.

Excision of the head and neck of the femur and Batchelor's operation–Rehabilitation may take a long time, but the late results are more predictable than in the other operations reviewed. A "fair" result is more likely than an "excellent" one, but late "poor" results are few. Relief of pain is better after excision of the head and neck than after any other operation reviewed.

1. The results of repair of the sciatic nerve and of its main divisions have been analysed in a series of 118 cases, the patients having been under observation for three to eighteen years (average 11·7 years).

2. A result was satisfactory if there was some return of sensibility throughout the autonomous zone (the area of skin supplied exclusively by the damaged nerve) and if the more important muscles of the leg were capable of contraction against gravity and resistance.

3. When the whole of the sciatic nerve is damaged it is necessary to present the results separately for the lateral and medial popliteal divisions.

4. Of forty-seven cases of repair of the medial popliteal nerve 79 per cent showed useful motor and 62 per cent useful sensory recovery. In three out of four cases the correspondence between the degree of motor and of sensory recovery was fairly close.

5. Of seventy-two cases of repair of the lateral popliteal nerve 36 per cent showed useful motor and 74 per cent useful sensory recovery. The latter figure must be regarded with some reserve because sensory "recovery" in the lateral popliteal zone may be due to the ingrowth of nerve fibres from contiguous normally innervated skin. Thus it is not possible to correlate motor and sensory recovery.

6. In eighteen cases of repair of the posterior tibial nerve, there was useful sensory recovery in the sole in twelve. But although there was evidence of recovery in the plantar muscles in eleven cases it was functionally valueless.

7. In repair of the medial popliteal nerve the result was better if suture had been carried out early. In repair of the lateral popliteal nerve there was no evidence that delay was harmful; but the proportion of good results was so low (as judged by motor function alone, sensory recovery being often extraneous) that this exception to a general rule cannot be taken very seriously.

8. Gaps of up to twelve centimetres–estimated after resection of the damaged nerve ends–could be closed without difficulty by the usual technique, and the extent of the gap up to that limit had no influence on the prognosis. The closure of larger gaps, when the knee must be flexed beyond a right angle, is not compatible with good recovery because the post-operative stretching of the nerve causes serious intraneural damage.

9. Nerve grafting has given poor results in repair of the sciatic nerve.

1. We have described what happens to patients a number of years after injury of the sciatic nerve or of its divisions; there were 329 who had been under observation for periods ranging from three to eighteen years. The neurological recovery was recorded in every case and, more important, the behaviour of the limb as appreciated by the patient.

2. Although it was generally true that good neurological recovery and good function went together there were remarkable discrepancies. Isolated paralysis of the medial popliteal or of the lateral popliteal nerve was often compatible with good function, though patients with lateral popliteal paralysis usually needed toe-raising apparatus. Even total sciatic paralysis sometimes gave little trouble.

3. Of the various types of injury, clean wounds and traction lesions led to rather better than average return of function.

4. Some degree of pain was present in about half the cases, and over-response–exaggerated and painful response to an ordinary stimulus–was present in one-third of the cases.

5. Repair of the posterior tibial nerve was rarely worth while; no less than eight out of twelve patients with this type of injury exhibited over-response.

6. One-third of the patients showed vasomotor and trophic disorders: coldness of the affected limb, erythema, thinness or pigmentation of the skin, changes in the nails or oedema.

7. Pressure sores were the most serious consequence of sciatic nerve injury and at some time or other were present in 14 per cent of our patients. The cause was deformity rather than insensibility of the sole.

8. Of the various palliative operations Lambrinudi's tarsal arthrodesis gave such disappointing results that we doubt whether the operation is worth doing. Tenodesis, revived as a time-saving expedient during the war, was a failure. For lateral popliteal paralysis anterior transplantation of tibialis posterior is excellent.

9. Amputation was done in only ten cases. When it was performed for fixed deformity with secondary ulceration the result was satisfactory. When it was done because of pain there was no relief. Amputation is, therefore, avoidable provided that vigorous steps are taken to prevent or correct deformity; it should not be done for the relief of pain.

The hypothesis provides a theoretical justification for, and re-emphasises the practical importance of, close reduction and strict immobilisation in the treatment of fractures of the neck of the femur. It does not support the view that failure of union is caused by vascular damage at the time of the original injury. Unexpected failure of union after nailing is more likely caused by unrecognised imperfection of reduction and the acknowledged deficiencies of internal fixation.

Attempts to improve results by passing the sartorius muscle around the fracture (Adams 1956), or by attaching muscle or joint capsule to the proximal fragment, have failed, because such soft tissues are swept off by the acetabular rim when the hip is flexed or medially rotated.

Further work is required, both on the more detailed biochemistry of haemarthroses and on the practical and wider implications of the hypothesis.

Cases are reported of two men who sustained bilateral hip injuries while undergoing convulsive therapy and of one woman who sustained bilateral hip injuries during a uraemic convulsion. A further twenty-three previously unreported cases are analysed, sixteen of which were of simultaneous bilateral femoral neck fractures and five of which were simultaneous bilateral central dislocations of the hip. One other patient sustained his injuries in an epileptic fit. A review of the literature has revealed another thirty-five cases of bilateral hip injuries, most of them caused by convulsive therapy, but a few by accident, disease of the femoral neck, or epilepsy.

One case is included of a rare double injury, a femoral neck fracture on one side and a central dislocation on the other. I have found no previous reference to this combined injury.

Double hip injuries are very rare in relation to the large numbers of patients receiving convulsion therapy, but the change from pharmacological to electrical methods has not prevented their occurrence and at least fifteen are known to have occurred during the last six years.

A wide age range is represented, and many fractures of convulsive origin have occurred in fit, well nourished, adult men. Only a few have been found in more elderly and possibly osteoporotic patients.

All the "convulsive " injuries were sustained during unmodified treatment, and mention is made of the differences of opinion among psychiatrists about the use of anaesthesia and of relaxant drugs in convulsion therapy.

These are the most severe injuries complicating convulsion therapy, and the most difficult for the orthopaedic surgeon to treat.

1. The "frame" or traction method of reduction of congenital dislocation of the hip is, from the evidence collected in this hospital, both more effective and safer than the manipulative method of reduction. The traction method caused less frequent and less severe lesions of the femoral head than the manipulative method.

2. In cases in which closed reduction failed, open reduction was attempted; the quality of the results depended mainly on the time of operation, the best being in patients operated upon a few weeks after the initiation of the frame treatment.

3. Even with its improved results, still about 40 per cent of cases treated by the frame method showed insufficient reduction or structural changes of the femoral head.

4. Arthrography may help in indicating those cases in which open reduction is desirable.

1. A brief description is given of normal epiphysial growth of the human femur.

2. Some ways in which abnormality of the growth plates may affect the shape and length of the human femur are described.

3. The influence of the blood supply on growth is discussed with particular reference to the etiology and treatment of congenital coxa vara.

1. Epiphysial tilt commonly precedes slipping.

2. This tilt is due to a diminished or arrested growth from compression of the back of the epiphysial plate.

3. The stresses on the upper end of the femur are such that the upper femoral epiphysial plate is peculiarly liable to compression.

4. A primary abnormality of the cartilage of the epiphysial plate renders it susceptible to the effect of compression.

5. Because this abnormality is diffuse, deformities due to a similar pathology may be found elsewhere, notably in the spine.

Simple pinning to fix the epiphysis in those patients in whom the position is acceptable is a valuable surgical procedure. It is safe and gives good results. It eliminates the danger of further displacement, promotes fusion of the epiphysial plate and allows the patient to return to full activity within one month, thus avoiding joint stiffness, muscle atrophy, osteoporosis and interference with growth at other sites.

Fixation by small pins is preferable to the use of the trifin nail, the latter giving excessive trauma and predisposing to subtrochanteric fracture. Gentle replacement of the epiphysis, when loose, into an acceptable position is a valuable method of treatment. It is essential that replacement is not undertaken by force.

The problem of major displacement of the epiphysis which cannot be so replaced is unsolved. Conservative treatment in this group is useless and harmful. Intra-articular osteotomy can give good results in most cases but is risky and may cause stiffening of the hip. Subtrochanteric osteotomy does not give a good anatomical result but in most cases the function of the hip is satisfactory.

Slipping of the upper femoral epiphysis, however slight, should be regarded as a surgical emergency.

1. A series of eighty-one hips with slipped upper femoral epiphysis in sixty-three patients is reviewed.

2. The importance of early diagnosis is emphasised.

3. Conservative treatment is condemned.

4. In attempting reduction violent manipulation and strong traction must be avoided.

5. In cases of slight displacement pinning in the position of displacement gives the best results.

6. Three or four small pins are recommended for fixation.

7. When the amount of slip is 50 per cent or more of the diameter of the head gentle manipulation should be tried and, if successful, followed by fixation with three or four pins.

8. The hip with an irreducible slip of 50 per cent or more should be treated by pertrochanteric or subtrochanteric osteotomy.

1. A type of bony sclerosis is described, occurring in nine members of a Jamaican family and resembling the more benign form of Albers-Schönberg's disease. The parents were consanguineous. Three of the patients developed facial palsy at the same age, and one had bilateral optic atrophy and proptosis.

2. Although radiological changes occurred of all grades of severity, certain features often described in this condition were lacking. In one child the onset of radiological changes was observed at the age of eleven years.

3. Serum studies showed increased alkaline phosphatase activity.

4. These features are discussed in the light of present-day knowledge and theory of the pathology of Albers-Schönberg's disease.

1. A family of six generations, consisting of 114 members affected by epiphysial dysplasia of the lower extremities, is described.

2. Twenty-two males and twenty-three females were affected, while thirty-two males and thirty females were unaffected. Seven members of the family could not be traced.

3. Variations from Fairbank's description of dysplasia epiphysialis multiplex are discussed. In the family here reported the lower limbs only were affected and the severity of the disease was very variable.

4. Long term follow-up studies are presented.

A modified Lambrinudi arthrodesis is described which has given excellent results in forty-two out of the forty-four operations for the severest types of club foot.

1. The history of open operations on fractures of the calcaneum is reviewed.

2. A report is given of the results of treatment of comminuted and depressed fractures of the calcaneum by primary arthrodesis by a modified Gallie procedure.

3. Of twenty-nine patients, twenty-seven returned to full employment within an average of 6·4 months. Twenty-five of these returned to their previous jobs.

4. Poor tendo calcaneus function and lateral sub-malleolar pain were found to be closely allied; both complaints were absent in the usually successful case and occurred only where there had been some complication.

5. It is contended that subtalar arthrodesis is a successful method of treatment for this fracture, but that the operation should be performed soon after the injury in order that the deformity may be corrected.

1. A patient with Ollier's disease, who has been observed for fifty-four years, is described.

2. Repeated operations have been performed and the radiological appearances have been interpreted on several occasions as sarcomatous, but no evidence of malignant change has occurred.

A description is given of a direct approach to the lateral compartment of the knee with the joint fully flexed. This approach has been found useful for excision of cysts of the lateral cartilage, but is also applicable to excision of the lateral cartilage for tear.

Attention has been drawn to the variations found in the anatomy of the tendons of the abductor pollicis longus and extensor pollicis brevis muscles as they lie in the first extensor compartment of the wrist. Such variations involve reduplication of the abductor pollicis longus tendon and more rarely the extensor pollicis brevis tendon. An accessory tendon may occasionally lie in a separate osseo-fibrous canal. It is not unusual to find the abductor pollicis longus and extensor pollicis brevis tendons lying in separate compartments, because an accessory fibrous septum is subdividing the first extensor compartment into two parts. Furthermore, the extensor pollicis brevis tendon may also lie in its own separate fibrous canal in the depths and the more distal part of this common compartment.

Such variation could lead to two possible misinterpretations during the course of surgical decompression for de Quervain's disease and these misinterpretations could reasonably be linked with the failure rate for this particular operation.

1. The finding of the abductor pollicis longus and its accessory tendon in a single compartment (12 per cent of wrists in the series) after a limited surgical incision could be mistaken for the abductor pollicis longus and extensor pollicis brevis tendons. Such a mistake would lead to failure to decompress the extensor pollicis brevis.

2. A failure to identify the deeper-lying separate canal for the extensor pollicis brevis in the distal part of the compartment would again be responsible for failure to decompress the extensor pollicis brevis (14 per cent of wrists in this series).

1. Certain macroscopical and microscopical features of the tendo calcaneus of the rabbit are described and illustrated, and the vascularisation as revealed by Spalteholz clearing is presented.

2. The vessels of the epitenon are chiefly derived from proximal and distal sources.

3. The vessels of the paratenon are derived from the main arteries of the leg.

4. The two vascular systems are largely independent of each other except along one edge of the tendon by way of a mesotenon.

5. The paratenon, epitenon and mesotenon and the related vessels are comparable to those found in tendons with synovial sheaths. By inference and from evidence obtained by dissection on the living human subject it is suggested that the arrangements are similar in the human tendo calcaneus.

6. Considerable friction develops on movement between the surfaces of the paratenon and epitenon. This might be significant in pathological states of the human tendon.

Throughout this work data have been gathered favouring the concept that the metaphysial vascular arrangement is primarily related to the process of enchondral ossification, and has very limited, if any, responsibility for the nourishment of the growth cartilage.

The present evidence favours the suggestion that when the chondrocytes of the column have become too far separated from their source of nourishment (the epiphysial vessels) they and their surrounding matrix suffer changes which prepare them for the process of calcification. At least calcium and phosphate ions will be required for this to take place. The proximity of the vessel and also the fact that it is not isolated by a membrane at its very end suggests a profuse interchange of fluids with the surrounding area.

1. A series of experiments on adult rabbits was carried out in which a tendon was transplanted and embedded in a bony tunnel and traversed a joint after the manner of a tenodesis.

2. Histological observations were made on the reaction of surrounding bone and tendon at intervals over a period of 307 days.

3. The findings suggest that the buried tendon undergoes a process of progressive degeneration, and that host cells issuing from the adjacent bone marrow infiltrate and ultimately replace it by new tendon tissue.

4. The invading cells are believed to be derived, as a result of the provocative stimuli provided by the experiment, from primitive reticular cells of the haemopoietic tissue.

5. The tunnelled bone undergoes considerable remodelling and associated with this is the presence of a considerable number of osteoblasts and osteoclasts.