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Volume 47-B, Issue 1 February 1965

SURGICAL IMPLANTS Pages 3 - 8
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Norman Capener
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R. D. Leffert Herbert Seddon
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Over a period of twenty years a small number of patients, thirty-one, have been seen who suffered injuries of the infraclavicular brachial plexus as a direct result of skeletal injury in the region of the shoulder joint.

Except for isolated circumflex nerve injuries the prognosis is generally good whatever part of the plexus is damaged. The treatment is conservative and its two most important features are prevention of stiffness of joints and the control, by regular galvanic stimulation, of denervation atrophy of muscle during the often prolonged period before recovery becomes apparent.


Peter F. Williams
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1. Fifty operations of fragmentation and rodding in the long bones of patients with osteogenesis imperfecta are reported.

2. The technique of the operation is described and a modification of Sofield's original method is suggested.

3. The results and complications of treatment are described.


F. P. Dewar T. W. Barrington
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1. A method of treating chronic acromio-clavicular dislocation by transfer of the coracoid process to the clavicle is described.

2. This has been successful when other procedures have failed.

3. Three patients have been reviewed a long time after this operation and two others after a short time. All obtained a good result.


J. Debeyre D. Patte E. Elmelik
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1. The results of operation in sixty-three patients with rupture of the rotator cuff of the shoulder have been reviewed.

2. In seventeen patients the classical delto-pectoral route was found to give poor access and mediocre results.

3. In forty-six patients a superior approach along the supraspinatus fossa and through the divided acromion process was found to give excellent access and to permit lateral advancement of the supraspinatus muscle in order to enable wide gaps to be closed. With this improved surgical access the proportion of good results has been doubled.

4. It is suggested that when a case of rupture of the cuff, confirmed by arthrography, fails to respond to physiotherapy, operative repair should be undertaken.


AINHIJM Pages 43 - 51
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G. J. Cole
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1. An account of fifty-four patients suffering from ainhum is presented, and the clinical and pathological findings are discussed.

2. Etiology is considered, and a plan of treatment proposed.

3. Ainhum in Ibadan is a disease of all ages and both sexes.

4. Most patients have considerable pain.

5. It is due to a non-inflammatory change in the basal layer of the epidermis.

6. Surgical treatment has gratifying results.


S. G. Browne
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The distinctive clinical characteristics of ainhum conforming to classical descriptions, as seen in 100 patients in Central and West Africa, are briefly reviewed, special emphasis being laid on those features that serve to differentiate ainhum from other conditions that may in some respects resemble it.


J. Charnley J. Kettlewell
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1. The customary method of broaching and of knocking the prosthesis down into the neck of the femur produces an indeterminate interference fit.

2. The usual interference fit may suffer progressive breakdown under even small, steady loads. This results in a permanent relative movement between prosthesis and femur as the metal insert "beds " into the bone.

3. Modification of the usual practice by providing a clearance fit between prosthesis and femur and cementing of the metal into the bone provides a system which has been shown to be free of breakdown under steady loads up to about 450 pounds.

4. By cementing the prosthesis shaft into the femur permanent relative movement between the elements has been shown to be reduced from approximately four-hundredths of an inch per 100 pounds load to two ten-thousandths of an inch per 100 pounds load–that is, a reduction of 200 to 1.


P. R. Davis H. A. K. Rowland
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1. Radiography of the spines of thirty-three West African patients recently recovered or dead from tetanus revealed vertebral fractures in nineteen. These fractures occurred most frequently in the fourth to eighth thoracic vertebrae.

2. The spines of 111 Nigerians from the same area of West Africa were examined, measurement of the areas and shape of the vertebral bodies carried out, and the proportional incidence of articular shelves and laminar spicules was calculated.

3. The upper mid-thoracic vertebral bodies are relatively long and narrow and have but little greater cross-sectional area than those immediately above them; possessing no neural arch supports to sustain longitudinal compressive forces in flexion, they are at greatest hazard during tetanic spasms.

4. Analyses of these factors and of the clinical features, together with experimental observations drawn from the literature, are used to explain the prevalence of upper mid-thoracic vertebral fractures as a complication of tetanus in West Africans, and in particular the greater degree of compression and higher incidence found in children.

5. Vertebral fracture is not usually an important complication of tetanus; it causes little pain, does not prolong the illness, gives rise to no permanent disability and has no effect on the mortality.


David Stuart
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1. This clinical investigation compares the results with varying periods of immobilisation after the primary repair of extensor tendons over the metacarpo-phalangeal joints of the fingers.

2. One hundred and thirty-seven Bantu mine workers with such injuries were each splinted for either one day, ten days or three weeks, and the results were compared.

3. The results indicate that the optimum period of splintage is ten days.


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G. B. Smaill
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1. A five-year follow-up of forty-one patients who sustained Colles's fractures was made.

2. The objective results were not so satisfactory as the subjective, but overall there seems to be no reason to depart from the present methods of managing these injuries by manipulation and immobilisation in plaster.

3. Colles's belief that in time the patient would regain full painless function irrespective of how the fracture was treated seems to be vindicated.


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H. E. D. Griffiths C. Watts
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1. Attention is drawn to the incidence of hypersensitivity to para-aminosalicylic acid in the course of antituberculous treatment.

2. The clinical features are described with particular reference to hepatic complications.

3. Three cases are presented to illustrate the salient features of the condition.

4. The importance of early detection of the reaction, the giving of test doses and the technique of desensitisation of the patient to para-aminosalicylic acid are discussed.


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C. B. d'A. Fearn J. W. Goodfellow
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An isolated palsy of the anterior interosseous nerve of the forearm is described in a boy aged nine. It was cured by surgical division of a constricting fibrous band in the forearm.


COSTAL CHONDRITIS Pages 94 - 99
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R. A. Elson
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1. Two cases of costal chondritis are presented. The special features and treatment of this condition are described and the literature is reviewed.

2. Early diagnosis and energetic treatment of costal chondritis obviates serious morbidity.

3. Treatment with antibiotics is of value in curing the condition before cartilage necrosis has occurred and in controlling the spread of infection to neighbouring tissues.

4. Excision of all necrotic cartilage is essential for cure, if cartilage necrosis has occurred.

5. Secondary infection with organisms of low virulence, notably pseudomonas pyocyanea, is nowadays the commonest cause of chronicity.


J. A. E. Gleave
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1. This is a report on the production of sockets for above-knee prostheses utilising a composite laminate of synthetic and natural materials and using a principle of total stump contact with the socket, which before fitting is shaped to suit individual stump contours.

2. A new method of taking casts is described, as is the production of the socket, and observations on the use of the prosthesis over the last two and a half years are made.


E. P. Melmed
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1. This case is presented to illustrate two etiological factors in tendon rupture occurring in one patient.

2. The rupture of the long head of the biceps brachii muscle appears to have been of acute traumatic origin.

3. Bilateral simultaneous rupture of the calcaneal tendons is rare, but it seems probable that the cortico-steroid therapy was the etiological factor in this case.

4. It has been suggested that degeneration in the tendon is caused by ischaemia, secondary to hypertrophy of the tunica media and narrowing of the medium calibre blood vessels. Betamethazone could possibly have aggravated, or may even have caused these changes, and the periarteriolar changes found in the biopsy specimen would tend to support this theory.


TRAUMATIC FEMORAL BONE LOSS Pages 106 - 110
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J. R. Kirkup
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1. A motor-cyclist's temporary loss of ten inches (25 centimetres) of femoral shaft and its replacement are recorded.

2. The mechanism of injury is considered.

3. The management of extensive bone loss is discussed.

4. Attention is drawn to the importance of retained periosteum and its contribution to healing in such injuries.


John T. Scales
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B. J. S. Grogono J. Jowsey
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1. An unusual muscle anomaly found during an operation for a severe club foot is recorded.

2. This muscle fitted the description of the flexor accessoreus longus and may add support to the phylogenetic theories of development of the long flexor muscles suggested by Wood Jones.


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Grace M. Jeffree C. H. G. Price
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1. Alkaline and acid phosphatase, non-specific esterase and beta-glucuronidase have been estimated and demonstrated histochemically in a series of bone tumours and allied lesions, of which ten were osteogenic sarcomata, ten were giant-cell lesions, eleven were fibroblastic lesions and seven were tumours of cartilage.

2. Osteogenic sarcoma was found to be characterised by high levels of alkaline phosphatase, with rich staining for this enzyme in the tumour cells. Similar high levels of alkaline phosphatase were found in other bone-forming lesions, such as fibrous dysplasia, a giant-cell sarcoma with osteogenic matrix, and fracture callus.

3. Giant-cell lesions were characterised by high levels of acid phosphatase, and intense staining for this enzyme in the osteoclasts. These cells were also found to be rich in non-specific esterase (as shown by the alpha-naphthyl acetate method) and in beta-glucuronidase, but almost or entirely lacking in alkaline phosphatase. High levels of alkaline phosphatase were not found in giant-cell lesions except in relation to osteogenic matrix.

4. Fibroblastic tumours were characterised by moderate levels of all four enzymes, with little or no staining for phosphatases in the tumour cells; non-specific esterase was generally present in a proportion of the cells.

5. In certain lesions intermediate stages in the differentiation of fibroblasts to osteoblasts were found, notably in fibrous dysplasia, in which the biochemical change preceded the histological. In such lesions high total levels of alkaline phosphatase were found.

6. Cartilaginous tumours were characterised by low levels of all four enzymes, and little histochemical staining except in hypertrophied cells in areas of ossification.

7. It was found in general that the enzyme distributions in these neoplasms and other lesions reflected the findings in comparable reactive and growing normal tissues.


A. M. Parfitt
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1. The changes in serum calcium and phosphorus which occurred in forty-one patients with post-menopausal osteoporosis during treatment with stilboestrol were examined.

2. There was a fall of approximately 15 per cent in mean serum phosphorus and of approximately 3 per cent in mean serum calcium.

3. The fall in serum calcium is considered to furnish some evidence against the theory that the primary action of stilboestrol is a reduction in calcium excretion.


Jack Stevens Robert D. Ray
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1. The radiographs of paired living and dead rat tibiae, obtained in an experiment previously reported, have been examined by densitometry.

2. The dead bone became progressively less dense than the living bone as the duration of the implantation increased.

3. The change in density was related to the quantity, but not to the quality, of the bone tissue examined.


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E. Storey
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1. Stable strontium in large amount in the diet of rats initially inhibits calcification and induces rickets.

2. Changes later become atypical and a complex series of epiphysial plate defects develops: formation of localised osteoid wedges in the metaphysis; invagination of the epiphysial plate and sequestration of multiple cartilage nodules into the marrow cavity; and, in severely affected animals, localised loss of part or parts of the epiphysial plate with formation of large cartilage nodules in the metaphysis and epiphysis.

3. The appearance of cartilage nodules in the metaphysis in man has been shown to be associated with changes in the epiphysial plate, but much of the information is radiological and therefore incomplete, and detailed cellular changes are seldom available.

4. Some of the conditions mentioned, which have presented difficulty in interpretation, partly because of their rarity but also because of lack of knowledge of the fundamental processes concerned, are multiple exostoses and endochondromatoses, metaphysial dysostosis and osteochondritis.

5. Comparison of basic mechanisms revealed in this study with those supposed to occur in human cartilage dystrophies demonstrates that strontium rickets mimics some changes occurring in chronic renal rickets; that invagination of the epiphysial plate and cartilage nodule sequestration could account for the development of multiple exostoses and some endochondromatoses; and that localised endochondral defects in calcification can induce epiphysial changes resembling osteochondritis juvenilis, demonstrating that avascular necrosis is not necessarily the mechanism initiating epiphysial deformity.


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W. R. Lee J. H. Marshall H. A. Sissons
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1. In two dogs, approximately one to two years and three to four months of age, an experimental comparison was made between the calcium accretion rate as defined by the Bauer-Carlsson-Lindquist equation, and the bone formation rate determined by double tetracycline labelling.

2. The overall calcium accretion rate was determined from the specific activity of the blood plasma, and the urinary and faecal excretion of isotope, following an intravenous tracer dose of Ca45. A time of five days after injection was used for the calculation of accretion rates, but data for shorter times of calculation are included.

3. Local accretion rates were obtained for different parts of the skeleton by determining the specific activities of bone samples at the end of the experiment.

4. The amount of isotope the uptake of which was not related to new bone formation (the diffuse component) was determined autoradiographically.

5. Local values for appositional growth rate and bone formation rate were obtained, using sections of undecalcified bone specimens, by measuring the linear separation between two tetracycline bone markers and the area of new bone enclosed by them.

6. In the older dog, the measurements for cortical bone showed that the accretion rate was two to three times as great as the bone formation rate: the observed diffuse component was sufficient to account for the greater part of this difference. Measurement of the bone formation rate for cancellous bone presented difficulties, but the approximate values obtained suggested that the accretion rate and the bone formation rate were of about the same order for this tissue.

7. In the younger dog, the bone formation rate could be determined only in cortical bone: at the sites studied, the values for the accretion rate and the bone formation rate did not differ by more than 20 per cent. It is suggested that this is due partly to the low specific activity of the diffuse component in this young animal, and partly to the relatively large amounts of new bone formed during the period of the experiment.

8. Despite the important differences between the rates of calcium accretion and bone formation that were found to exist in regions where there was only a small amount of new bone formation, there was a strong correlation between the two rates. The value of the accretion rate as a parameter of bone metabolism is clear.


IN MEMORIAM Pages 181 - 182
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J. T.
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J. G. Bonnin
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Richard Battle
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G. C. Lloyd-Roberts
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V. Logue
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J. I. P. James
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Donal Brooks
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J. S. Batchelor
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J. G. Roberts
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J. G. Bonnin
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G. P. Arden
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