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Volume 55-B, Issue 2 May 1973

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L. Solomon
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1. It is well known that the administration of corticosteroids may result in necrosis and progressive destruction of the femoral head. Identical changes have been found in chronic alcoholics, in South African negroes suffering from iron-overload osteoporosis and in patients with arthritis of the hip treated with non-steroid anti-inflammatory and analgesic preparations. The term "drug-induced arthropathy" is used to describe the common pathological lesion.

2. Seventy-two patients with this complication have been investigated and forty-two femoral heads were available for detailed study. The characteristic change is subchondral fragmentation and osteonecrosis, followed later by reactive bone formation and the typical increased radiographic density.

3. The frequent occurrence of fat occupying the Haversian canals in the affected femoral heads has not been adequately explained and its relationship to the destructive arthropathy remains obscure. The findings presented here do not support the theory that fat emboli are responsible for the subchondral bone changes.

4. More credence is given to the theory of subchondral microfracture in osteoporotic bone. The destructive arthropathy invariably follows the administration of some anti-inflammatory or analgesic preparation. It is postulated that a state of diminished sensibility predisposes to microtrauma in osteoporotic bone resulting in subarticular collapse of the femoral head.


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A. K. Jeffery
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1. Osteogenesis in the osteoarthritic femoral head has been examined with radioactive 32P and tetracycline bone markers.

2. In advanced osteoarthritis considerable osteogenic activity was observed, particularly in osteophytes, around cysts and in some areas of bone sclerosis.

3. Two forms of osteogenesis were seen: a form of enchondral ossification, and apposition of new bone to existing bone trabeculae.

4. The findings support previous studies suggesting that rapid turnover of bone tissues occurs in advanced osteoarthritis.


S. Bulos
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1. Of 456 patients with features of herniated intervertebral disc eight were under twenty years of age.

2. Differences in the pattern of clinical presentation of the herniated disc syndrome in adults and in adolescents are discussed.

3. Whereas in the adult conservative treatment is usually successful, this is not so in the adolescent, in whom the symptoms and signs tend to persist for many months.

4. It is suggested that in the adolescent conservative treatment should not be prolonged despite the absence of neurological deficit; operation should be undertaken early after confirmation of the diagnosis by myelography.


J. P. Alexander
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1. The knee-chest position offers the surgeon excellent conditions for operations on lumbar intervertebral discs.

2. Hypotension on resumption of the prone or supine position is common: it is influenced by the anaesthetic technique, the physical state of the patient, the operation time and the extent of surgical bleeding.

3. The hypotension is thought to be due to poor perfusion of the lower limbs while the patient is in the knee-chest position.


Isidor Kessler
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1. A review of seventeen patients who underwent silicone arthroplasty of the trapezio-metacarpal joint by prosthetic replacement of the base of the first metacarpal is reported.

2. Eighteen operations were performed and observed for periods varying from two to five years.

3. The technique of operation and the criteria for the assessment of results are discussed.


Robert E. Carroll Norman A. Hill
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1. A technique of arthrodesis of the trapezio-metacarpal joint of the thumb is described. Primary fusion was achieved in thirty-six of thirty-nine cases.

2. Compensatory movement at the adjacent joints permits a good range of thumb movement.

3. Trapezio-metacarpal arthrodesis is the operation of choice for patients under fifty with isolated osteoarthritis of this joint. It is also useful for stabilising the thumb in patients with paralysis of the thumb when adequate muscles for transfer are not available.


M. H. Young
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1. The late consequences of stable fractures of the thoracic and lumbar spine have been assessed in a series of workmen. The incidence of symptoms has been recorded and an attempt made to assess the degree of associated incapacity.

2. It has been found that most patients continue to have some symptoms attributable to the back injury and that approximately one in five of the patients who attended for review was partially or completely incapacitated as a consequence of such symptoms.

3. The persistence of symptoms was found to be unrelated to the severity of fracture, to its level, to the presence of radiological evidence of degenerative change, or to the age of the patient.

4. Persistent symptoms were found more commonly in those patients who had received more treatment. The implications of this observation are discussed.


H. B. S. Kemp D. L. Johns J. McAlister J. N. Godlee
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1. An ancillary diagnostic technique using Fluorine-l8 or Strontium-87m is described, and has assisted in the correct diagnosis of fifty-two patients admitted with the provisional diagnosis of infective spondylitis.

2. The technique is of particular value in the assessment of reactivation of chronic spinal infections and in the differential diagnosis of atypical lesions.


Niels Olaf Christensen
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1. The Küntscher method of intramedullary reaming and nail fixation was applied to thirty-five cases of non-union of the lower extremity, twenty femurs and fifteen tibias. A bone graft was generally not used.

2. Most of the patients were allowed to bear weight and to exercise the joints within a few days of the operation. Additional measures such as pre-operative surgery for infection or distraction of shortening were used in some cases.

3. The pseudarthrosis healed in all cases, even when infection was present. The nails were generally not removed until after healing had occurred.

4. It is concluded that the Küntscher method gives remarkably rapid consolidation and restoration of function even in difficult cases of non-union of shaft fracture, particularly of the femur.


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Sadhan Kumar Mukherjee Andrew B. Young
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1. Ten consecutive fractures of the dome of the talus are reported. Six were lateral, three medial and one anterior.

2. The injury is most commonly seen in the second and third decades of life, and with the exception of the rare anterior dome fracture, results from an inversion injury of the ankle. The possibility of a dome fracture associated with strain of the lateral ligament of the ankle joint should therefore always be borne in mind.

3. Antero-posterior views in neutral and in plantar fiexion are helpful in diagnosing medial dome fractures. Lateral fractures are best seen in an antero-posterior view taken in neutral flexion with 10 degrees inward rotation of the limb.

4. A large dome fracture with displacement should be accurately reduced by open operation in order to preserve congruity of the joint surface.

5. A small fracture with no displacement may be treated conservatively until radiographically it appears united.

6. A small fracture with marked displacement is best treated by early excision of the fragment to prevent further damage to the ankle joint.


G. C. Lloyd-Roberts
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1. Attention is drawn to the progressive disability caused by irreparable defects of the ulna in growing children.

2. Cross-union between the radius and the ulna resolves some of these problems and contributes greater stability and power to the hand.


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Leslie Klenerman M. V. Merrick
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1. A case of anterior sacral meningocele is described in members of a family consisting of a woman, her father and his brother.

2. This is the first recorded case of this anomaly in members of the same family of different sex, and only the second recorded case of occurrence in the same family.


FORCES UNDER THE FOOT Pages 335 - 344
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J. R. R. Stott W. C. Hutton I. A. F. Stokes
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1. A method is described for measurement of the vertical load carried by different areas of the foot while walking barefoot. The results of tests on fourteen subjects, seven with some foot abnormality, are reported.

2. The results show that the load carried by the normal midfoot is low. Measurements in this area could be useful in the quantitative assessment of some foot abnormalities.

3. Considerable variation between individuals is seen in the distribution of vertical load across the forefoot. The metatarsal bones do not necessarily carry loads in proportion to their size.


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T. A. Parsons
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1. Five cases are reported in which snapping of the scapula was caused by subscapular exostosis. In the four cases in which the exostosis was excised, symptoms were relieved without loss of scapular movement.

2. Antero-posterior views of the scapula do not always show the exostosis, and oblique views are recommended.

3. Winging of the scapula may be caused by a subscapular mass, with a neurologically intact subscapularis muscle.

4. Apart from subscapular exostoses, snapping of the scapula may be caused by exostoses or abnormal angles on the ribs, by Luschka's tubercle, or by an abnormal forward curve of the superior angle of the scapula.


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S. Sybrandy A. A. de la Fuente
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1. A case is described of three giant-cell tumours, the first in 1966 in the lower left femur, the second in 1968 in the upper right femur, the third later in 1968 in the upper left femur.

2. None of the tumours could be described as frankly malignant.

3. Despite a lapse of four years it is still not possible to decide whether the first tumour had metastasised or whether all three arose independently by multifocal origin.


J. McLauchlan
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1. A case of solitary myeloma of the clavicle is reported. The patient remained well, without signs of dissemination, twenty-four years after excision of the clavicle.

2. Solitary myeloma is rare; the diagnosis depends upon thorough investigation and prolonged follow-up.


R. A. Dickson F. Paice J. S. Calnan
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1. A new piece of equipment, the quantitative colour television image analyser, has been introduced as providing a superior method for measuring bone density.

2. This method produces not only a numerical result but also a pattern of density distribution in the form of a seven colour contour map.

3. The changes in twenty rheumatoid hands at an interval of one year have been measured. The metacarpals and proximal phalanges always lose bone, but the metacarpo-phalangeal joint may gain in density if the disease process is far advanced. Some areas can lose 50 per cent of bone in one year.


D. M. Chaplin
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1. The normal vascular anatomy of flexor tendons and extensor tendons in the hind limb of the rabbit is outlined. A marked difference between a tendon in a sheath and a tendon with a paratenon is shown, the latter having a much better blood supply.

2. The vascular reaction in flexor tendon divided within a sheath is shown.

3. The revascularisation of free grafts is illustrated and the differences between tendon with sheath and tendon with paratenon are detailed.

4. Experiments are reported to show that the microcirculation within a "vascular" tendon can support a pedicle graft in the rabbit. Such pedicle grafts are shown to be inferior to free grafts of "avascular" tendon, but the vascularity within the pedicle tendon graft may be modified by "blocking" the surface with silastic tubing.

5. The implications of this work on tendon grafting are discussed, together with a review of additional experimental work in related fields.


GÖRan Lundborg BjÖRn Rydevik
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1. Stretching of the tibial nerve cut 2 centimetres above the ankle has been the subject of an experimental study in rabbits.

2. The effects on intraneural microcirculation, on vascular permeability, and on the barrier function of the perineurium have been analysed with the aim of determining the extent to which a divided nerve can be stretched without interfering with the process of repair.

3. The results obtained may prove valuable for understanding basic mechanisms and for establishing certain important limitations when end-to-end suture of a nerve trunk is performed under some degree of tension in man.


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R. Salama R. Geoffrey Burwell I. R. Dickson
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1. This paper reports a histological study of the fate of sheep and calf cancellous bone grafts impregnated with autologous red marrow of Wistar rats and implanted intramuscularly as composite xenograft-autografts for two to twelve weeks. It also includes some biochemical estimations of certain types of sheep and calf bone used to prepare these composite grafts.

2. Only one of 223 devitalised bone xenografts implanted without autologous marrow formed new bone; in contrast 216 of 223 transplanted with marrow formed new bone.

3. The new bone formed by the composite grafts is derived from the autologous marrow. There was no evidence for an inductive effect upon the marrow of the various types of xenograft bone studied as described previously for allograft bone (Burwell 1966).

4. The highest score of new bone formation was found in composite grafts based on fully deproteinised sheep iliac bone prepared at Oswestry. Statistically this score was significantly higher than those registered by composite grafts prepared from intact (frozen and freeze-dried), decalcified (frozen and freeze-dried) and Kiel sheep bone, and by Kiel and Oswestry calf bone (Table II).

5. The histological evidence reported suggests that the high score with the sheep Oswestry composite grafts is because Oswestry bone is feebly immunogenic, if at all; and that such feeble or absent immunogenicity permits more marrow cells to differentiate into osteoblasts and lay down new bone without impediment.

6. The lower scores of new bone formation in most of the undeproteinised composite grafts of sheep origin–intact frozen, intact freeze-dried and Kiel–are attributed to residual immunogenicity within the organic material of the donor bone, because each type evoked the formation of mature plasma cells.

7. The Kiel bone grafts appeared to evoke less of a plasma cell reaction and may be less immunogenic than the intact and decalcified bone xenografts.

8. The sheep Oswestry CXA's formed significantly more new bone than did the calf Oswestry CXA's. This difference may be due to the different physical properties of the bone obtained from old sheep compared with the bone obtained from a young calf.


IN MEMORIAM Pages 418 - 420
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H. B. L. J. G. G. R. L.
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John Chalmers
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R. Drury
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Dennis Stoker
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W. J. W. Sharrard
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Praktische Anatomie Pages 446 - 447
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J. G. Bonnin
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Air Instrument Surgery Pages 447 - 448
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Gordon Hadfield
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C. W. Manning
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P. S. London
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