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1. Two hundred young Korean patients with a diagnosis of tuberculosis of the spine were allocated at random to in-patient rest in bed (IP) for six months followed by out-patient treatment, or to ambulatory out-patient treatment (OP) from the start. A second random allocation was made to chemotherapy with streptomycin for three months and PAS plus isoniazid for eighteen months (SPH), or to PAS plus isoniazid for eighteen months (PH). For various reasons twenty-nine patients had to be excluded from the study. The main analyses of this report therefore concern 171 patients, namely, forty IP/SPH, forty-six IP/PH, forty-two OP/SPH and forty three OP/PH. The comparisons made are
2. The clinical and radiographic condition of the four groups on admission was similar. Many patients had extensive lesions.
3. Two in-patients died, probably from miliary tuberculosis, but neither had evidence of residual activity of the spinal lesion.
4. For the eighty-six in-patients the mean stay in hospital was 199 days and five were later readmitted. Of the eighty-five out-patients twenty-one (fourteen SPH, seven PH) were admitted to hospital in the first six months for complications of the spinal disease, for other medical conditions, or for domestic or geographical reasons; after the first six months eight more were admitted.
5. Three in-patients and five out-patients received chemotherapy beyond eighteen months for abscess or for paraparesis.
6. An abscess or sinus was either present initially or developed during treatment in 76 per cent of the in-patients and 72 per cent of the out-patients. Complete resolution occurred in most of the patients, some abscesses being aspirated. At three years 11 per cent of the in-patients and 5 per cent of the out-patients still had residual abscesses or sinuses.
7. On admission the mean total vertebral loss was 1·79 in the in-patients and 1·33 in the out-patients, and increased over the three-year period by 0·15 and 0·31 respectively.
8. The mean angulation of the spine at the start of treatment was 37 degrees for the in-patients and 27 degrees for the out-patients, the mean increase over the three-year period being 8 and 18 degrees respectively.
9. On admission six in-patients and four out-patients had incomplete motor paraplegia. This resolved completely within nine months in eight patients, as did the one cauda equina lesion. Only two patients (both out-patients) developed paraparesis during the course of the study; both recovered.
10. At eighteen months 66 per cent of the in-patients and 58 per cent of the out-patients had responded favourably. The corresponding percentages at thirty-six months were 84 and 88.
11. There was little difference in behaviour between the SPH and the PH series; at thirty-six months 82 per cent of eighty SPH and 90 per cent of eighty-eight PH patients had a favourable response.
12. A multiple regression analysis failed to identify any factor of clearly prognostic importance on admission.
1. Pyogenic infection of the intervertebral disc in fifteen patients is described.
2. The importance of certain radiological signs in establishing the diagnosis is discussed.
3. Delayed diagnosis is believed to be responsible for the high incidence of paraplegia in this condition.
4. The place of operation in the management of this lesion is considered.
1. The results of treatment of 117 tuberculous and fourteen other types of infection of the spine in adults by anterior fusion and chemotherapy have been reviewed.
2. It is suggested that anterior fusion is justified because:
1. An anatomical study of the bony structure of the pars interarticularis of the fourth and fifth lumbar vertebrae has been made in specimens from seven cadavers aged seventeen to sixty-seven.
2. Layers of cortical bone have been described antero-laterally and postero-medially which are thickest in the narrowest region of the pars.
3. In one specimen from a seventeen-year-old male, a healing fracture was found in the antero-lateral layer of cortical bone in the right neural arch of the fourth lumbar vertebra.
4. The stresses to which the pars is subject consist primarily of shear forces applied to the articular processes. The significance of these stresses to the etiology of spondylolysis is discussed.
1. The relation of oxygen intake and walking speed has been investigated in a sixty-two-year-old patient before and after unilateral hip replacement for osteoarthritis.
2. Before operation walking speed was reduced to three to five kilometres per hour and stride length to 73 centimetres. Oxygen intake was 0·9-l·2 litres per minute and net energy cost 49 kilocalories per kilometre.
3. Nine months after operation the patient could walk at up to 8 kilometres per hour with a stride of 115 centimetres, oxygen intake of 2·4 litres per minute and net energy cost of 34 kilocalories per kilometre. Most of this improvement took place within three months of operation.
4. The oxygen intake of walking at ordinary speeds after full recovery was comparable with that of control subjects aged twenty-seven to twenty-nine years. In very fast walking, however, the oxygen intake was higher than that of the controls, whose oxygen intake was 1·95 litres per minute at 8 kilometres per hour.
5. The use of a stick or crutches did not reduce the oxygen intake in slow walking. However, crutches enabled the subject to walk at over 8 kilometres per hour with oxygen intake of 2·4 litres per minute (85 per cent of maximum oxygen intake).
1. A predictable pattern of degeneration occurs on both the femoral head and the acetabulum and this pattern is age dependent.
2. The degenerative areas on the femoral head are related to habitual non-use.
3. The hip is shown to be anatomically incongruent, and the dome of the acetabulum, a predictable area of degeneration, is shown also to be an area of habitual non-use.
4. The possible relationships between age-dependent degenerative changes and senile degenerative joint disease is discussed and the importance of changing geometry stressed.
1. Currently available total replacement hip and knee prostheses were tested in a machine enabling flexion-extension movements to be applied whilst the prostheses were surrounded with Ringer's solution or other liquid and loaded within the physiological range.
2. Prostheses of which both components were made in cobalt-chromium-molybdenum alloy produced visible quantities of alloy particles, whose sizes ranged down to about 0·1 microns, and cobalt and molybdenum ions in solution.
3. No metallic or plastic particles were detected during tests on a hip prosthesis made of stainless steel and high density polyethylene.
4. The frictional moments in cobalt-chromium-molybdenum hip prostheses were higher than in stainless steel-polyethylene hip prostheses, by a factor of at least 2 to 1.
5. It is accepted that the conditions of these tests were probably more severe than in life, but the difference is held to be one of degree and not one of kind.
6. The particulate alloy debris, when injected in massive doses into the muscles of rats, gave an incidence of malignant tumours which was comparable to that already established for pure cobalt powder, whereas particles of several other metals, tested in the same way, gave no tumours.
7. It is argued that the particles which are known to be produced in at least some patients using cobalt-chromium-molybdenum total replacement joint prostheses constitute a risk of tumour formation which is certainly small, possibly negligible, but not accurately calculable at present.
8. The results of these tests, particularly the differences in frictional moment and in the production of particulate debris, suggest a preference for high density polyethylene as one component of a total joint replacement prosthesis.
1. An initial series of 100 consecutive cases of trochanteric fracture treated by the Küntscher technique of condylo-cephalic nailing with the aid of an image intensifier has been reviewed.
2. The advantages of this simple method over internal fixation by open reduction and insertion of some kind of nail and plate are discussed.
1. Dissection of forty-four developing human hip joints has shown that while the embryonic acetabulum is a deeply set cavity which almost totally encloses the head it gradually becomes more shallow as birth approaches. During the same period the femoral head becomes less globular and at the end of foetal life is almost hemispherical. The cover afforded to the femoral head by the acetabulum also becomes decreased.
2. After birth these trends reverse: the acetabulum becomes deeper again and the femoral head more globular. This process continues throughout childhood.
3. The findings provide a possible explanation for the increased liability to dislocation of the infantile hip.
1. The results of synovectomy of the knee in eighty-five patients with rheumatoid arthritis are presented.
2. When reviewed between five and nine years after operation 55 per cent of 122 knees still had improvement in pain.
3. Only 31 per cent of knees lost movement.
4. Recurrence of symptoms in nearly all cases was related to the recurrence of active rheumatoid synovitis.
5. Recurrence of symptoms was a little less likely when the generalised disease improved, when the Rose-Waaler test was negative, when only one knee was involved and when the operation had been carried out within three years of the onset of disease in that knee.
1. An anatomical study of congenital club foot in various stages of foetal development is presented, and the literature is reviewed.
2. The most striking finding was deformity of the talus and in particular a change in its angle of declination.
3. That deformity was present in feet whose deformity could not be corrected by gentle manipulation; it was absent in feet whose deformity could be so corrected.
4. Abnormality of the tendon and insertion of the tibialis posterior muscle was found in most cases.
5. Speculations are advanced concerning the nature and cause of the talar deformity.
1. Thirty-three children with thirty-eight feet affected by a cavo-varus deformity and treated by calcaneal osteotomy with concomitant stripping of plantar muscles were reviewed two to ten years after operation.
2. Out of twenty-six patients who were over eleven years old at the time of the review, fourteen (with eighteen feet) did not need any further treatment. In three other patients the deformity had recurred to a slight degree but did not warrant tarsal reconstruction. In the remaining nine patients the recurrence was marked and necessitated tarsal reconstruction.
3. The combined procedure is of value when there is progressive deformity in children too young for tarsal reconstruction.
1. Seventy-three congenital club feet in fifty-one children have been reviewed between the ages of four and fourteen years to determine the incidence of residual adduction ofthe forefoot.
2. A radiological method of measuring metatarsus varus, based on the naviculo-metatarsal angle, is described.
3. On clinical examination 52 per cent of the feet had residual adduction of the forefoot, and metatarsus varus was present in 74 per cent of these.
4. There was no residual adduction in 48 per cent but only 45 per cent of these showed normal radiographic features. In the remainder various forms of spurious correction were seen.
5. For early treatment, detachment of the origin of the abductor hallucis muscle is recommended at the time of extended posterior release, with tenotomy of the tendon of insertion as an additional measure.
1. Osmium tetroxide and nitrogen mustard were injected into normal adult rabbit joints. Within one week widespread chondrocyte necrosis had occurred as evidenced by electron microscopic examination and radioactive proline uptake autoradiography.
2. Initially, the cartilage matrix was intact but three to seven months later the cartilage surface began to disintegrate.
3. These studies indicate that osmium tetroxide and nitrogen mustard are unsuitable agents for chemical synovectomy.
4. They also indicate that there may be a long latent period between cartilage cell death and cartilage destruction, and that the evaluation of any agent for chemical synovectomy must take this into consideration.
1. Analysis of the static and dynamic conditions in spastic cerebral palsy leads to the conclusion that contractures of the hip, knee and ankle should be released from above downwards, and that the full benefit is obtained only when all contractures have been corrected.
2. Only when these joints are mobilised by removal of the significant contractures is the spastic patient able, despite other handicaps, to sit, stand and walk with the least hindrance and the least cosmetic fault.
3. In our Danish experience, inadequate or poor results from the orthopaedic surgery of cerebral palsy are mainly due to the fact that patients with contractures are operated on too little and too late, or not in the correct sequence.
1. It has been shown in fifty normal feet that the perpendicular static plantar pressures rise by about 35 per cent between the ages of five years and maturity.
2. It is very likely that similar increases in plantar pressures occur between two and five years of age.
3. The plantar pressures in seventy-eight feet of children with spina bifida were with a few exceptions substantially higher than those of normal children of the same age. It is likely that this is so, at least in part, because the feet of children with spina bifida are smaller than normal.
4. This increase in perpendicular static pressure during growth must be relevant in the production of trophic foot ulceration.
5. The existence and importance of "flail deformity" as a factor producing areas of increased pressure and ulceration in anaesthetic feet is postulated.
1. The possibilities in the treatment of the elbow in arthrogryposis are discussed.
2. The role of tricepsplasty to gain movement, and of triceps transfer to obtain power are outlined and the results obtained in the surgical treatment of twenty-three elbows are analysed.
1. A case is reported of a benign osteoblastoma of the body of the second thoracic vertebra causing paraplegia in a woman aged twenty-six.
2. The tumour was resected, apparently entirely, through a costo-transversectomy approach, and the paraplegia resolved almost completely.
3. Five and a half years later symptoms recurred, due to a recurrence in the form of a large, partly calcified tumour in the left upper thorax which was resected
4. The considerable histological differences between the original tumour and the recurrence are discussed.
1. A case of chondroblastoma occurring in the upper tibial epiphysis of the right leg of a girl aged fourteen is reported.
2. Because the tumour recurred the leg was amputated.
3. Pulmonary metastases appeared two years after amputation.
1. Two cases of primary skeletal haemangiopericytoma treated by ablative surgery, one in combination with radiotherapy, are reported.
2. A discussion of the management of these tumours includes surgical excision, radiotherapy, a combination of both or a combination of radiotherapy with chemotherapeutic agents.
3. Because of the unpredictable behaviour of these tumours it seems necessary to include ablative surgery if cure is to be expected.
1. Two patients with multicentric extra-abdominal desmoid tumours are reported. Multicentric foci have not been described previously.
2. Both cases conform to the usual clinical, macroscopic and microscopic criteria of desmoid tumours in all other regards.
3. Their occurrence in a single limb bud suggests a congenital propensity and leads to the advocacy of radical surgery in such cases.
1. Four cases are described of multiple bony changes in the feet of members of a West Indian family.
2. The basic process is believed to be avascular necrosis of bone. The inheritance appears to be X-linked recessive.
The purpose of this paper has been to stimulate interest in amputation surgery, prosthetics and orthotics, and to illustrate the excellent work done in only some of the centres within the British Isles and to enlist the assistance of all orthopaedic surgeons in improving the orthotic equipment of their patients.
We also need the interest and the practical involvement of one orthopaedic surgeon in amputation work and prosthetics in almost every large hospital, particularly in the centres where it is to be expected that limb-fitting units will be installed and fully integrated within the hospital service. It is necessary to say "almost every large hospital", because in some the vascular surgeon will lead the amputation and prosthetic team. This is a worthwhile special interest for the orthopaedic surgeon. The need presents itself not only for the geriatric patient with limb ischaemia and for those who lose a limb from trauma, but also for the quite considerable number of children who are congenitally without a limb or part of a limb.
Orthopaedic surgery embraces a wide field, and in the larger centres the best work will result from a voluntary restriction in the field of operation of individual surgeons, many being involved in trauma and fractures, all being involved in adult orthopaedic surgery, some with a special interest and considerable time in children's orthopaedic surgery, or hand surgery, or the surgery of rheumatoid arthritis patient; and to this list one would hope might be added amputation surgery and the prosthetic rehabilitation of these patients. I will be well satisfied if I have succeeded in stimulating a renewed interest in this oldest branch of orthopaedic surgery.
