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1. The clinical features, diagnosis and treatment of osteomalacia are discussed in relation to thirty-seven recently recognised cases. It is suggested that this disease is not uncommon in elderly women, among whom it is liable to be confused with senile osteoporosis. Osteomalacia may be distinguished by, firstly, the history, in which persistent skeletal pain of long duration and muscular weakness are typical of osteomalacia, but not of osteoporosis in which transient episodes of pain usually associated with a fracture are more characteristic. There is a high incidence of previous gastric surgery in the osteomalacia patients. Secondly, the physical examination shows skeletal tenderness in osteomalacia but this is not a particular feature of osteoporosis. A shuffling "penguin gait" suggests osteomalacia. Thirdly, the biochemistry shows a low plasma calcium and phosphate, and raised alkaline phosphatase levels commonly in osteomalacia but these are usually normal in osteoporosis. Reduced twenty-four-hour urinary calcium is characteristic of osteomalacia but not of osteoporosis. Fourthly, radiology will show diminished bone density which is common to both diseases, but if the changes are more marked in the peripheral bones than in the axial skeleton osteomalacia is suggested; the opposite is typical of osteoporosis. Skeletal deformity without fracture suggests osteomalacia, as do stress fractures and greenstick fractures in the elderly. Looser's zones are diagnostic of osteomalacia in which they are the most important radiological feature. Finally, histology will show the presence of excess osteoid tissue in undecalcified sections of bone in osteomalacia. This may be the earliest and most sensitive index of the disease and biopsy is indicated in all doubtful cases.
2. The etiology is discussed and it is suggested that a dietary deficiency of vitamin D, limited exposure to sunlight and mild degrees of malabsorption may all be important either alone or in combination. No satisfactory explanation is offered for the predominant female incidence.
3. A practical method of treatment is given and the dangers of uncontrolled administration of vitamin D indicated.
4. Treatment of osteomalacia is rapidly and consistently successful, and well justifies a thorough screening of all elderly patients presenting with weakness, skeletal pain, pathological fractures or with diminished radiographic density of bone.
1. The case notes of 140 patients with a total of 297 severed long flexor tendons in the thumb and fingers have been analysed.
2. Fifty-seven patients in whom tendon reconstructive surgery was performed have been examined and the results have been recorded by three methods.
3. Methods of assessing finger and tendon function are reviewed and discussed. Accuracy and precision in tendon repair should be followed by an accurate and precise evaluation of tendon, joint and finger function.
4. A method of assessing the function is described. This is expressed as a percentage of the function of the uninjured contralateral finger.
1. Multiple barbed sutures made from nylon are described and the theoretical advantages with the use of the nylon are outlined.
2. Methods of joining tendon stumps using the multiple barbed sutures are illustrated and
3. Preliminary
4. The multiple barbed suture is an experimental suture for certain compact tendons capable of giving a neat and relatively atraumatic junction. It requires further study and development. It does not appear to make tendon repair technically easier, nor does it alter the indications for operation or management.
1. The modifications of standard Z-plasty technique that are necessary for its successful use in hand surgery are discussed with particular reference to the limiting factors imposed by the anatomical characteristics of the hand.
2. The use of the Z-plasty in Dupuytren's contracture and contracted scars is discussed.
1. One hundred and eight osteotomies were reviewed with regard to union, and fourteen were found to be ununited. In only one was non-union detected clinically; the others required radiographic demonstration. Tomographs were particularly helpful in confirming non-union.
2. Nine patients with non-union had pain, equal to or worse than before operation. The pain could not be distinguished from that of osteoarthritis of the hip.
3. Six of the patients with non-union needed an operation. Five had cancellous bone grafts followed by union in all except one.
4. The causes of non-union are reviewed. This complication was found to be less frequent in patients above sixty with stiff hips and bony collapse on the radiograph. Horizontal osteotomy with a displacement of not more than one-third of the diameter of the shaft reduced the incidence of non-union. The variable-angle nail-plate provided the best fixation. Traction provided no benefit and increased the incidence of non-union. Weight bearing is best avoided for eight weeks.
1. The rate of non-union of 100 intertrochanteric osteotomies of the McMurray type, with internal fixation, is reported. One in five was not united one year after operation. The criteria of union are discussed.
2. The patient's disability in twelve ununited osteotomies has been assessed, and related to the mobility of the osteotomy.
3. The factors which prejudice union have been analysed. The principal cause of non-union appeared to be the varus angulation strain on a varus osteotomy displaced medially more than half the diameter of the bone. Obliquity inwards and upwards of the osteotomy was a contributory factor. The types of internal fixation used, the use of external splintage and the period of protected weight bearing with crutches did not appear to be related to the rate of union.
4. It is concluded that marked inward displacement of the osteotomy, combined with either obliquity of the osteotomy or a varus position, prejudices union; that the use of this technique is unfounded in principle and not supported empirically; and that displacement should be eschewed to avoid this complication of intertrochanteric osteotomy in the treatment of osteoarthritis of the hip.
1. Fibrous union of an osteotomy occurred in only 3 per cent of osteotomies done during a four-year period.
2. Delayed union sometimes gives rise to pain on bearing weight while union is in progress, and non-union is usually associated with disabling pain.
3. The most significant factors predisposing to delayed or fibrous union are inefficient fixation and excessive displacement. A high or very oblique osteotomy may also have an adverse effect upon the rate of bony union.
1. It is suggested that abruptness of the condylar ridges on the femur plays a major role in the etiology of chondromalacia patellae. The medial condylar ridge is always abrupt in these cases, and indeed in many knees with no evidence of chondromalacia patellae. The lateral condylar ridge is rarely abrupt.
2. The short-term results of forty operations for reduction of femoral ridges in thirty-eight patients, with preservation of the patella in thirty-two cases, are satisfactory.
1. An account of experiences in seventy-five cases with a new method of treatment of low back pain and sciatica caused by intervertebral disc lesions has been presented. The method is based on the fact that chymopapain, a proteolytic enzyme, can break down displaced intervertebral disc material without deleterious effects upon adjacent tissues.
2. Chymopapain was injected into intervertebral discs by the postero-lateral or preferably the lateral approach. Two milligrams per disc constitute an effective dose. The enzyme was administered to seventy-five patients who were potential candidates for laminectomy. These patients were followed for four to thirty months and results were graded as "good" (76 per cent), "fair" (15 per cent) and "poor" (9 per cent).
3. Although untoward reactions have been encountered, none of these has been attributable to chymopapain.
4. Our investigations have convinced us that enzymatic dissolution of a lumbar intervertebral disc lesion is a safe, effective method of relieving sciatica and low back pain in selected cases.
1. The clinical features in nineteen patients with structural defects of the pars interarticularis are compared with the findings in twenty-two patients with degenerative changes in the lumbar spine, and are shown to be essentially the same.
2. It is suggested that both structural defects and degenerative changes give rise to mechanical instability of the lumbar spine. This puts an increased load on the posterior vertebral soft tissues and gives rise to a characteristic picture, the features of which are described.
3. The signs and symptoms of root compression may be superimposed on this picture, and when this is the case, decompression of the nerve roots should be undertaken in addition to spinal fusion, which is suggested as the logical treatment.
4. After fusion, with decompression when indicated, 50 per cent of the patients were completely relieved of their symptoms and 87 per cent derived worthwhile benefit.
1. Nineteen patients with articular synovial chondromatosis are reviewed.
2. The etiology, diagnosis and management of the condition are discussed.
3. It is concluded that extensive synovectomy is not justified; simple removal of loose bodies is the treatment of choice.
1. During the past twenty-five years there have been admitted to this orthopaedic service twelve children or adolescents having a close relative who previously or subsequently developed slipped upper femoral epiphysis. This represents an incidence of approximately 7 per cent.
2. There is some evidence that the incidence is considerably higher.
3. In addition to those with close relations also with slipped epiphysis, two patients had parents with osteoarthritis of the hip.
4. I believe, therefore, that in slipped upper femoral epiphysis there is evidence of a genetic defect. This is probably due to a recessive gene of low penetrance. The frequency in this region is high because the north-east of Scotland has very definite geographical boundaries and the rural, agricultural population, from which the majority of these cases were drawn, has formed until recently a stable community likely to show a greater than average incidence.
The case is reported of a fracture-dislocation of the shoulder, treated by an operation based upon a principle advanced by Moore in 1948. An excellent radiological and functional result was observed five and a half years after the injury.
1. A long term review of arthrodesis in the management of hallux valgus and rigidus is presented.
2. This is briefly compared with Keller's operation.
3. Eighty-five per cent of patients had a satisfactory result.
4. The reasons for failure and the errors in operative technique are discussed.
1. The technique and results of arthroplasty of the metatarso-phalangeal joints for the grossly deformed forefoot are described.
2. The early results are very encouraging.
3. Attention is drawn to some of the complicating problems in rheumatoid arthritis, particularly the hazard of arteritis.
1. The long-term results of thirty-two naviculo-cuneiform fusions for flat foot have been reviewed sixteen to nineteen years after operation.
2. The initial encouraging results of the operation have not been maintained.
1. A study has been made of the blood supply of the human patella. There are two main systems, one penetrating the middle third of the anterior surface and the other entering the lower pole of the bone behind the patellar ligament.
2. The relationship between these findings and the complication of avascular necrosis of the upper fragment of the patella after fracture is discussed. Forty-one cases of necrosis after operation have been studied and notes made on the pathological, clinical and radiological evolution of the condition. Whatever the severity of the ischaemic necrosis the prognosis was not substantially affected and good function was observed in all knees six months after injury.
3. The surgical implications of the vascular anatomy are discussed. It is pointed out that surgical intervention may damage the blood vessels entering the anterior surface of the bone and that circumferential repair of patellar fractures may strangle the vessels in their peripatellar course.
4. If removal of one-half of the patella after a transverse fracture is indicated, vascular studies indicate that the upper fragment should be removed.
1. Clinical studies in humans have indicated that a delay of one to three weeks in the open reduction of a fracture decreases the incidence of delayed union and non-union.
2. Studies in cats indicate that a delay of two weeks before open reduction causes a different repair mechanism from that following immediate operation.
3. Repair after delayed operation is characterised by increased periosteal new bone formation and more rapid endochondral bone formation. After immediate operation periosteal new bone is slow to develop; much more fibrous tissue and cartilage develop, followed by slow endochondral bone formation.
