1. A series of 705 fractures of the tibia is reviewed, 674 of which were treated conservatively.

2. The factors most conducive to delayed or non-union are initial displacement, comminution, associated soft-tissue wound and infection. The extent to which these are combined in any fracture determines its "personality" and its inherent propensity for union.

3. Eight fracture types are differentiated based on the above "personality rating." The incidence of delayed union or non-union varies from 9 per cent in the most favourable type to 39 per cent in the least favourable. Infection raises the incidence to 60 per cent. Comparative statistics which fail to recognise these differences can be entirely misleading.

4. Continuous traction does not retard union.

5. The results of conservative treatment are analysed with regard to union, deformity, stiff joints and contractures and the conclusion is reached that no case has yet been made out for internal fixation as the method of choice in the treatment of this fracture.

1. The conservative school of treatment of fractures of the tibia, which bases part of its criticism of internal fixation on the ultimate risk of amputation, does not often publish its own rates of amputation.

2. Statistics from a hospital that treats one-third of closed fractured tibiae and two-thirds of compound fractures by internal fixation are therefore put up as a basis for criticism.

3. Comparisons are made with the few available statistics in the literature of conservative treatment.

4. Almost all of the causes for secondary amputation are now curable and in recent years the number of limbs being saved is increasing.

It seems right to draw the following conclusions from this study of the relative merits of early and delayed fixation for fractures of the femoral and tibial shafts.

1. In patients under the age of sixty years with femoral shaft fractures there seems to be a significant improvement in the speed and quality of union when internal fixation is delayed. In patients over the age of sixty years the results of delayed fixation are worse than those of early fixation, and in any case the dangers of prolonged recumbency make the latter method preferable.

2. Delaying fixation for tibial shaft fractures does not affect speed of union or functional result. However, the incidence of non-union in these fractures is reduced by over 50 per cent by delaying fixation. This is a good reason for delaying fixation of this fracture too.

Some possible reasons for the improved results after delayed fixation have been discussed.

1. Fifteen cases of bone transplantation for fibrous union of fractures of long bones are described, using boiled minced cancellous bone from cadavers. One transplant became infected but the infection responded to treatment.

2. In one patient with non-union of the shaft of the humerus, bony union was not obtained, but a good functional result obviated further treatment.

3. It is suggested that this relatively simple method of bone transplantation could be used more widely if its potentialities were appreciated more fully.

1. A simple method of internal fixation of adult forearm fractures which gives consistent good results is necessary because the closed method of treatment is of limited application.

2. Open reduction of fractures without rigid internal fixation gives a high proportion of non-union and poor results.

3. Rigid internal fixation with standard plates and screws has been shown to give a low incidence of non-union in this series.

4. A three and a half inch long plate with six screws is suitable for most fractures, but if there is moderate or severe comminution, or if there is a segmental fracture, longer plates and more screws should be used to provide sound fixation.

5. Severely comminuted fractures with large avascular bone fragments should have the addition of a bone graft at the time of the plating operation in order that union may be assured. Thin strips of iliac bone are preferred.

6. Rigid plating is considered to be the most satisfactory treatment for open fractures.

7. Immobilisation of the limb after operation is not necessary and is undesirable if the fixation is rigid.

8. The functional results of this treatment are good and seemingly better than those achieved by other methods.

9. Serious complications of the plating operation are few and avoidable.

1. The indications for and technique of posterior iliopsoas transplantation are described with particular reference to paralytic dislocation and subluxation of the hip in children.

2. Experience of 150 operations in ninety-five patients and of the long-term results of forty-one operations are given.

3. Reduction of the dislocation has been maintained in every case even when there was complete paralysis of all gluteal muscles.

4. All the children are able to walk without the aid of hip splintage.

1. The family history of, and associated congenital abnormalities in, patients with talipes equinovarus, talipes calcaneo-valgus and metatarsus varus living in Devonshire has been studied.

2. The chances of any individual having one of these deformities is approximately one per 1,000 in each case.

3. If one child in a family has the deformity, the chances of a second having it are one in thirty-five for talipes equinovarus and one in twenty for talipes calcaneo-valgus and metatarsus varus.

4. The male relatives of the female patients with talipes equinovarus are at particular risk.

5. It is suggested that the cause of club foot is partly genetic and partly environmental, from a factor acting on the foetus in the uterus.

6. The classification of associated congenital abnormalities leads to the suggestion that the genetic factor in talipes equinovarus and talipes calcaneo-valgus relates to defective formation of connective tissue.

1. A long-term follow-up of eighty-four patients with talipes equinovarus is reported.

2. A detailed examination was made to ascertain the nature of the residual deformity and assess the function of the deformed foot.

3. Radiographic technique in infants and adults is described.

4. Results showed that: 1) In many cases there was a dysplasia of the whole limb. 2) The dysplasia was no more marked in the patients treated in the early 1930's by multiple forceful under anaesthetic, than in the more recent patients treated by gentler means. 3) Nearly half the cases had only a false correction of the deformity in that the foot was "broken" at the talo-navicular level, leaving the heel in inversion, although the forefoot was plantigrade.

5. The posture of patients with laterally rotated hip joints is related to the fixed inverted heel.

6. Clinical assessment correlated with radiographic appearances shows clearly the near impossibility of a good foot resulting from a false correction.

1. The clinical and radiological results of seventy-one osteotomies for primary osteoarthritis of the hip performed with internal fixation have been examined two to eight years after operation. Advanced cases where osteotomy would have been purely a salvage procedure were excluded.

2. The hips were divided into two groups: one in a relatively early and the other in a later intermediate stage of the disease. The two criteria for inclusion in the "early" group were a) fiexion movement of 90 degrees or more, either with the patient conscious or completely relaxed under anaesthesia, and b) no collapse of bone seen in the radiograph.

3. The clinical results show that early osteotomy seldom fails to give relief of pain, which is closely correlated with improved function and a favourable assessment of the operation by the patient. A good range of flexion, not less than 70 degrees and frequently 90 degrees, is retained when the criteria mentioned above obtain.

4. The radiological assessment was based upon examination of the joint space, the cystic appearances and the degree of collapse of bone, if any, as seen in serial films. There was convincing evidence of regression indicating arrest of the arthritic process in 70 per cent of the "early" cases.

5. Regression after osteotomy appears to be a well-defined process which is more commonly observed and more complete when the osteotomy is performed sooner rather than at a later stage of the disease. With few exceptions a good radiological result is associated with a good clinical result.

6. Some of the possible causes of failure are discussed. Osteotomy is more likely to fail if delayed till stiffness is severe and collapse of bone has begun. Large cysts, rapid advance of the disease, and a valgus osteotomy in the presence of lateral subluxation may also prejudice the results.

7. This review offers good support for Nissen's suggestion that in primary osteoarthritis of the hip osteotomy should be performed early, while the joint is still mobile and capable of repair, in order to retain good function.

8. Relief from pain is not the only consideration in deciding when to operate; the prospects of arresting the disease and of stimulating a healing reaction in the disordered cancellous bone and articular cartilage by early osteotomy should always be kept in mind.

9. In many respects the findings of this review are complementary to those of Postel and Vaillant (1962) who reported excellent results from varus osteotomy of Pauwels' type in a series of cases of subluxation of the hip with pain but without frank secondary osteoarthritic change.

1. The cases of six Chinese children affected by so-called congenital fibrosis of the vastus intermedius muscle are described. The reasons for the choice of name are discussed.

2. Reasons for early operation are put forward: in young children simple division of the tendon of the vastus intermedius is adequate.

3. With increasing age severe changes in all the joint tissues occur, notably in the articular cartilage of the patella. These changes are likely to vitiate the result after operation.

4. The importance of getting as much flexion as possible in children of Asiatic race is stressed.

1. Contracture of parts of the quadriceps muscle is not uncommon and is often accompanied by tightness of the ilio-tibial tract. It is suggested that this may follow intramuscular injections.

2. Recurrent dislocation of the patella can be a consequence of this muscle contracture.

3. Division of the ilio-tibial tract and lengthening of the fibrotic elements of the quadriceps can prevent further dislocation and restore good function.

1. Six cases of quadriceps contracture in children are described. All were either premature or suffered severe illnesses soon after birth.

2. Some additional information is given about cases of the same condition previously published by other authors.

3. It is suggested that injections and infusions given to newborn babies are sometimes the cause of the condition.

4. Some of the therapeutic substances and measures which may be responsible are discussed. These include antibiotics, vitamin K preparations and "subcutaneous" fluid therapy.

1. The amount of orthopaedic surgery which is possible in patients with leprosy is immense. It is likely to decline with improved medical care as deformity rarely begins after the start of medical treatment. In spite of prolonged chemotherapy, skin smears often remain positive for more than five years and lifelong treatment may be necessary.

2. In Hong Kong the disease affects mainly those in the best working years of their lives and at an age when they should be best able to understand the benefits that treatment confers. Education of the public must be one of the main points of disease control. This education should extend to enable patients with anaesthetic extremities to learn the limitations that the disease places upon their activities. Thus they will be less liable to injure themselves and better able to prevent minor injuries from becoming serious. Ulceration only occurs in areas lacking protective sensation but, although bilateral anaesthesia is common, bilateral ulceration is not often seen.

3. In patients with diminished sensation or with paralysed muscle groups there is usually enlargement of the nerves but this may be difficult to detect.

4. Clawing of the fingers is best treated by standard surgical procedures but opposition transplant in the combined median and ulnar nerve paralysis of leprosy is less satisfactory. Any transplant must prevent hyperextension at the metacarpo-phalangeal joint and this is best done by providing a double insertion for the transplant. If the soft tissues between the first and second metacarpals are contracted it is better to perform osteotomy of the base of the first metacarpal bone rather than to perform the standard operation of soft-tissue release and skin grafting.

5. The value of tibialis posterior transplantation in drop-foot has been confirmed.

6. The problem of fitting an artificial limb to an anaesthetic stump has not been solved. It was often found that ulcers of the stump occurred even with well-fitting sockets and cooperative patients. If amputation above the foot is necessary it is usually wiser to try a through-knee amputation.

7. Return of power or sensation after the start of medical treatment is unusual but it is also unusual for these symptoms to be noted for the first time when the patient is taking sulphones. It would be worth while investigating the effects of decompression of the median nerve at the level of the wrist by dividing the carpal ligament in those patients developing symptoms and signs of impaired median nerve function. Nerve decompression should also be performed in patients showing tender, swollen nerves in acute lepromatous reactions where steroid therapy fails to bring improved function within six hours.

8. It is essential that surgical methods of limiting disability such as incision, decapsulation or transposition of nerves, which have received favourable comment in the past, should be repeated in a controlled series. Series, so far, have lacked reference to the natural history of the condition under medical treatment alone and have often lacked adequate follow-up.

9. Acute lepromatous reactions in the foot often subside with little bone destruction if the patient is rested in bed with the foot immobilised in plaster. If deformity occurs it may be corrected by triple arthrodesis or pantalar arthrodesis. Shortening of the limb may be necessary to prevent stretching the posterior tibial artery. The use of staples at operation greatly eases the task of maintaining the position. Surgery is not always contra-indicated in the presence of long-standing ulceration.

1. The use of acrylic cement in bonding femoral head prostheses to bone is described.

2. No sign of deterioration of the bond between the cement and bone has been seen in histological preparations up to three and a quarter years after operation, and no harmful effects have been recognised, or suspected, in 455 patients in whom it has been used.

3. The technique is considered justifiable in elderly patients where the medullary canal is large and the cortex of the femur is thin and brittle.

1. Sixteen patients with articular cartilage erosions after slight injury have been described, as have the results of their treatment.

2. The clinical features of this rarely diagnosed condition are discussed. Attention is drawn to "articular crepitus" and "synovial crepitus" as useful physical signs in establishing the diagnosis.

3. A radiographic sign of localised subarticular osteoporosis is reported and discussed.

4. The surgical treatment used was either shaving of the affected area of cartilage or a combination of shaving with drilling of the subchondral bone plate.

1. Strain or rupture of the anterior marginal attachments of the meniscus was observed in approximately 10 per cent of a group of patients operated upon for internal derangement.

2. In about half of these a tear of the body of the meniscus was found and it is probable that this tear may have been the cause of the symptoms. In the remainder no injury to the body of the meniscus was found.

3. Recognition may be difficult and delay in diagnosis may be the cause of degenerative joint changes.

4. The condition should be looked for at operation when the meniscus appears to be intact or when the only lesion appears to be an area of chondromalacia on the weight-bearing surface of the femoral condyle.

1. A family, in which ten members of the second and third generations had osteochondritis dissecans, is described.

2. It is probable that the disease also occurred in the first and fourth generations.

1. Exostosis bursata in a patient with hereditary multiple exostoses is described.

2. Fracture of the tip of the exostosis had occurred causing acute pain and haemorrhage into the bursa.

3. Although it appeared that it might be a pseudo-joint cavity the histological appearance indicated that it was a bursa caused by friction between the exostosis and the surrounding soft tissue.

1. A Nigerian patient with radiographic features of osteopathia striata, osteopoikilosis and melorheostosis is reported. Also radiographs of a patient from the Radiographic Museum of the Institute of Orthopaedics at the Royal National Orthopaedic Hospital are reproduced because they show a similar mixture of these conditions.

2. lt is probable that a common factor is present at some stage in the development of melorheostosis, osteopathia striata, osteopoikilosis and possibly osteopetrosis.

1. A method is described by which the relative water contents of adjacent microscopic regions of bone can be assessed.

2. The water content is correlated with the inorganic and organic contents in regions of different age.

3. The results suggest that the age increase in the mineralisation of bone occurs at the expense of both the organic and water fractions.

Dr J. Robert Close has been good enough to point out a misquotation from his article, "Some Applications of the Functional Anatomy of the Ankle Joint"(Journal of Bone and Joint Surgery, 1956, 38-A, 761) in a later contribution by Mr M. G. H. Smith entitled "Inferior Tibio-fibular Diastasis Treated by Cross-screwing (Journal of Bone and Joint Surgery, 1963, 45-B, 737). Dr Close, in referring to tibio-fibular diastasis and deltoid ligament rupture with low fractures of the fibula, wrote (p. 780), "Treating diastasis therefore frequently means treatment for the deltoid lesion. When one realises that a certain amount of spreading apart of the malleoli and a certain amount of rotation of the fibula about the tibia are anatomical requirements for normal ankle motion the necessity for later removal of such internal fixation becomes obvious. Screws thus placed have been known to break during normal walking after the fractures have healed." In his paper Mr M. G. H. Smith, making mention of tibio-fibular movement, wrote, "This small range of movement of the fibula at the inferior tibio-fibular joint caused Close (1956) to recommend that screws placed across the joint to maintain reduction of diastasis be removed before weight bearing and movement were commenced. He stated that screws had broken when left in position." Further abbreviation by editorial staff led to the statement actually printed p. (737): "Close (1956) recommended the removal of screws that had been placed across the joint to maintain reduction of diastasis before movement was allowed, because the screws broke when left in position." The inadvertent change in sense unfortunately escaped attention, and we very much regret that Mr Close was thus misquoted.