1. At the present stage of our experience, when 150 patients have been analysed over a period of five years, the conclusion has been reached that anterior interbody fusion in the lower lumbar spine is a procedure which should be added to our surgical armamentarium for use in selected cases.

2. Patients suffering from chronic intervertebral disc degeneration whose main symptoms are recurrent incapacitating backache derive the most benefit from this procedure.

3. When used as a salvage operation in patients who have had previous unsuccessful laminectomy or posterior fusion, good results can be expected.

4. In patients with spondylolisthesis anterior interbody fusion should be confined to cases in which the vertebral bodies have not slipped forward more than one-third.

1. Ten patients with neurological evidence of damage to the intrathecal sacral nerve roots of the cauda equina by verified lumbar disc prolapse are described.

2. The nature of the bladder paralysis has been investigated by cystometry and the findings contrasted with published opinions.

3. The prognosis of the bladder paralysis has been established by review up to six years after removal of the disc prolapse. No evidence of recovery of complete bladder paralysis has been found, but the consequences of persistent bladder paralysis have been much less severe than previous reports have stated. Reasons have been suggested for this.

4. Principles of recognition and management of bladder paralysis due to cauda equina lesions have been stated and methods suggested.

1. A direct approach to trimalleolar fractures is described.

2. It is considered that a direct view of the fractured joint surface is essential in operations on all trimalleolar fractures and that access must be planned accordingly.

3. Failure to get a perfectly congruous surface is likely to be followed by osteoarthritis.

1. Analysis of eighty-one patients with neurofibromatosis showed that sixty-two (76 per cent) had café-au-lait markings; 12 per cent had significant spinal deformity.

2. Thirty-three examples of spinal deformity in neurofibromatosis showed a wide variety of patterns and severity of the adult curve. There was no evidence that there was any recognisable pattern of scoliosis in neurofibromatosis. No evidence was discovered to suggest that any acquired local abnormality of bone contributed to the deformity.

3. Some of the severe deformities showed a pattern similar to that seen in the congenital sco1ioses, and this might be the link between the neurofibromatosis and the spinal deformity.

1. Orthopaedic treatment of joint deformities in thirteen patients with haemophilia is reviewed over a period of seven years.

2. Forms of treatment discussed include open operation, manipulation under general anaesthesia, continuous traction, splintage and physiotherapy. The amount of intravenous therapy required for each form of treatment is indicated.

3. In discussing prevention of joint deformity the histories of a further eighteen patients have been taken into account. It is concluded that initially painless haemarthroses provide the main threat to joint deformity in haemophilia.

4. The best preventive treatment is early immobilisation followed by prolonged splintage and physiotherapy; intravenous therapy with antihaemophilic factor plays a less important role here than in other forms of haemorrhage.

5. Evidence is presented that joint deformity in severe haemophilia can often be entirely avoided.

1. The case history of a haemophiliac in whom a large haematoma of the thigh was treated by amputation of the limb is described.

2. Examination of the available radiographs and of the histology led to the conclusion that the cyst was subperiosteal in origin.

3. Evidence is presented to support the hypothesis that haemophilic pseudotumours are always associated with subperiosteal haemorrhage, and that those haemophilic cysts which are confined to muscle have little or no effect on the adjacent bone.

1. Thirteen instances of compression of the lower trunk of the brachial plexus at the thoracic inlet are described.

2. In each case the cause of compression was an aponeurotic band passing from the seventh cervical transverse process to the first rib.

3. The symptoms, physical signs, radiological features and findings at operation are described.

4. Satisfactory results followed removal of the band.

5. The anatomical arrangements are compared with those of the "normal" thoracic outlet and with those obtaining in cases of "vascular" thoracic outlet syndrome.

1. A method of treatment of displaced supracondylar fractures of the humerus in children by manipulative reduction and fixation in plaster in full extension of the elbow and supination of the forearm is described.

2. The method is easy, safe and requires a short period of hospitalisation. The carrying angle at the elbow can only be recorded, controlled and maintained when the elbow is extended and the forearm is fully supinated. Thus cubitus varus can be avoided.

3. The results of treatment in seventy-two displaced fractures treated by this method are reported.

4. Treatment by other methods is reviewed.

1. Three cases of premature epiphysial closure at the knee complicating prolonged immobilisation for congenital dislocation of the hip are described.

2. The etiology of this complication is briefly discussed, and it is suggested that relative ischaemia of the epiphysial plates is the most likely cause.

1. Two cases of bilateral fracture of the first rib are reported. The fractures were situated near the neck of the first rib.

2. A possible mechanism responsible for the bilateral fracture of the first rib at this particular site has been suggested.

1. A thirty-two-year-old man has been under treatment for twelve years for primary hydatid disease of the body of the third lumbar vertebra.

2. The second lumbar vertebra became involved, as were the soft tissues over a wide area, but the spinal canal was not affected.

3. A hydatid cyst was found in the left lung.

4. Management included stabilisation of the spine by bone graft, desensitisation to hydatid antigen, removal of the diseased vertebral bodies, pedicles and processes, the use of saturated solution of sodium chloride as a scolicide and the dilation of secondary ureteral strictures.

5. The patient, although not cured, has been enabled to "live with his disease" to earn his living and enjoy tennis and swimming.

1. A case of hydatidosis of the innominate bone is described.

2. The disease was treated by local resection combined with instillation of supersaturated salt solution.

3. The disease appears to have been arrested and the functional result is good.

4. The lethal effect of supersaturated salt solution on the parasite is stressed.

5. The experience of other workers in the field of hydatid disease is described.

1. Resection of the shoulder for a malignant tumour involving the scapula which was too extensive for treatment by excision of the bone is described.

2. The procedure is suggested as an alternative to forequarter amputation in suitable instances.

1. Autografts, isografts and homografts of fibrocartilaginous callus were observed in the anterior chamber of the eye in rats. Proliferation of cartilage ceased, endochondral ossification followed, and the end-product was a new and complete ossicle with a cortex and a marrow cavity. The size and shape of the ossicle was determined by the size and shape of the sample of callus. Thus the callus in the eye performed the function of a cartilage model like that of the developing epiphysis or a healing fracture of a long bone.

2. Fibrocartilaginous callus, heavily labelled with ³H-thymidine, was transplanted to the eye twenty-four hours after the last injection, when there was little if any radioactive thymidine circulating in the blood. A few small chondrocytes with labelled nuclei persisted in the cores of new bone trabeculae, but the largest part of the labelled callus was resorbed and replaced by unlabelled new bone.

3. Homografts of labelled callus produced the same results as autografts at twenty-five days, but between twenty-five and forty-five days the donor cells were destroyed by the immune response of the host.

4. Isogenous transplants in host rats treated with ³H-thymidine between nine and thirteen days, when the callus was invaded by new blood vessels, produced many osteogenetic cells with labelled nuclei and made it possible to trace the origin of the new bone. The label appeared in the progenitor cells within twenty-four hours. While remaining thereafter in progenitor cells, it appeared also in osteoclasts (or chondroclasts) and osteoblasts in forty-eight to seventy-two hours, and in osteocytes in ninety-six to 120 hours. Chondrocytes did not proliferate and were not labelled in the eye.

5. Homogenous transplants in host rats treated with ³H-thymidine between five and one days before the operation also produced new bone, but contained no labelled osteoprogenitor or bone cells after twenty-five days in the eye. At forty-five days the donor tissue had been destroyed by the immune response of the host.

6. Devitalised callus was encapsulated in inflammatory connective tissue and scar. When the dead callus was absorbed by the capillaries of the host new bone formation by induction produced a scanty deposit as a delayed event in a few instances.

7. Irrespective of whether it originated in the donor or the host, a connective-tissue cell type that proliferated rapidly and became labelled with ³H-thymidine was identified as a progenitor cell. Differentiation and specialisation as osteoprogenitor cells occurred after the growth of blood vessels into the interior of the callus, and developed inside of excavation chambers in cartilage. Except that the interaction of the donor tissue and host cells leading to new bone formation by induction takes place in the interior of the excavation chamber, the biophysico-chemical mechanism is unknown.

In this study the direct relationship between the type of bone implant used, the vascular reaction caused to the host and the revascularisation of the implant has been studied. It was found that the best graft was that which was the most rapidly and permanently vascularised. Not only was the biological affinity between the graft and the bed important, but the structural facilities offered by the implant for the "penetration" by the host vessels were also of paramount importance. Thus small, fresh, cancellous bone grafts offered the best chance of rapid incorporation provided they were not crushed to the point of making vascular progress difficult. The findings from this investigation so strongly suggest that the rapid revascularisation of the bone grafts was because of an end-to-end anastomosis of the vessels of the host with those in the implant that it seems justified to consider that the best bone graft is that which is richest in vessels. Apart from a recent short paper by Graf (1960), we have not found this assertion before. It is this which seems to make the fresh, autogenous, cancellous implant so superior to all others.

We believe that any new material for bone grafts should be tested by the technique described here. The material which one day may replace fresh, autogenous, cancellous implants will have to show the same readiness to vascular penetration, vascular osteogenesis and vascular permanency that at present is exhibited only by the cancellous autograft.

1. The development of sclerosis of the femoral head after fracture of the femoral neck has been investigated by a combined microradiographic and histological examination of twenty femoral heads removed during arthroplasty of the hip done at varying intervals after fracture.

2. Mineralisation of the bone did not differ from the normal.

3. There was a direct correlation between the density of the femoral head as judged radiologically and the width of the trabeculae. In cases of sclerosis of the femoral head the trabeculae were broader than normal and histological examination showed that this was caused by apposition of new bone upon the necrotic trabeculae.

4. Although sclerosis is a result of necrosis, it is at the same time a definite sign that revascularisation and restitution are going on.

1. A case of essential osteolysis is presented, occurring in a young man of eighteen with no known family history and developing progressively from early childhood. The condition was radiologically evident in the elbows, hands and feet, and was accompanied by atrophy of the cancellous bone of the epiphyses of the shoulders and knees. It was also associated with certain abnormalities of the skull and vertebrae. The patient died from a nephropathy of late onset.

2. Examination of the left foot revealed on the radiologically "lysed" bony extremities a very slow process of erosion affecting essentially the epiphysial and metaphysial cortical bone, of a non-inflammatory nature and accompanied by disappearance of the hyaline cartilage. The extremities not radiologically "lysed" showed signs of erosion that were histologically similar but not macroscopically evident; they were accompanied by regressive changes in the hyaline cartilage.

3. There were no signs of renal osteodystrophy or of Sudeck's dystrophy.

4. Post-mortem tests revealed an increase in the seromucoids and failed to reveal the presence of proline in the serum or of proline and hydroxyproline in the urine.

5. The authors discuss the place of this condition among osteolyses in general.

It has been shown by mechanical analysis that by using cement to bond the stem of a femoral head prosthesis to bone two advantages are obtained when the conditions are compared with conventional methods.

1. "Fretting" between the implant and the living bone is eliminated. This source of persistent relative movement is probably the most important starting point for the progressive loosening of weight-bearing implants.

2. When cement is used the bond with the bone is exposed to stresses which are of an order three hundred times less than the shear strength of bone. The conventional prostheses expose the bond to compressive stresses which are near to the failure limits of the compressive strength of bone, especially in elderly patients with atrophic cortical bone in the femoral neck.