This abridged account of a report to the British Medical Research Council describes a long-term investigation of 1,503 subcapital fractures of the femur, almost all of which were treated by reduction and internal fixation. With three exceptions, union occurred in all Garden Stage I and Stage II fractures and in 67% of Stage III and Stage IV fractures, of which only 14-5% were united at six months. In women, late segmental collapse was seen after union had occurred in 16% of Stage I and in 27-6% of Stage III and Stage IV fractures. Delay of up to one week before operation had no significant effect on the incidence of non-union or of late segmental collapse. The incidence of union followed by late segmental collapse was higher in women with normal bone density than in those with osteoporosis. Smith-Petersen nailing was found to be the least effective form of fixation in displaced fractures. The age and physical state of the patient, the accuracy of reduction, and the security of fixation had the greatest influence on union.

Subtrochanteric osteotomy has been reported to interrupt the destructive phase of coxa plana and speed up the rate of healing. The aim of this investigation was to test the validity of these statements. The material comprised twenty-five patients treated by osteotomy and thirty-three patients treated by support in a Thomas's splint. For every patient the extent of the radiological changes was estimated and plotted against time as a percentage of the normal epiphysial volume. The graph so obtained represents the rate of destruction and re-ossification, as well as the maximum involvement of the epiphysis. The curves for each group of patients were superimposed in a graph with all the minima coincident in time. The two patterns of curves are closely similar. It was confirmed statistically that the rates of destruction and re-ossification did not differ between the two groups. The results afford no evidence that osteotomy interrupts the disease or speeds up healing.

We have considered the reasons for securing containment of the femoral head in Perthes' disease and have reviewed briefly the methods used. The present investigation describes the outcome in a controlled series of forty-eight hips treated by containment by femoral varus-rotation osteotomy in selected patients. In assessing the results we have emphasised that controls are essential, and for this purpose we have used two comparable groups, one untreated and the other treated by methods other than containment. The same factors were considered in assessment--namely age, duration, group, and the presence or absence of "at risk" signs. The results were graded similarly as good, fair and poor in all groups. We have concluded that containment by femoral osteotomy is the treatment of choice in patients with "at risk" signs provided that severe deformity has not already occurred. There is no evidence that treatment of any kind favourably influences the course of the disorder in the remainder. Although this is predominantly a radiological study some clinical features are discussed.

Skeletal age was estimated by examination of radiographs of the carpus in 182 children suffering from Perthes' disease after the reliability of the Greulich and Pyle Atlas had been checked for a control group of British children. A striking tendency to delayed skeletal maturation was shown in the children with Perthes' disease. This trait was also found in ninety-three unaffected siblings of the patients. The velocity of skeletal ageing as the disease progressed was estimated. In some patients the carpal skeleton failed to mature at all for periods of up to three years and the term "skeletal standstill" is applied to this phenomenon. The significance of these findings is discussed and it is suggested that the maturation defect may have aetiological significance.

Three patients were reviewed seven, eight and fourteen years after delayed open reduction of traumatic posterior dislocation of the hip. The delay between injury and operation varied from twenty-eight to ninety-three days. At the time of review symptoms were minimal or absent, and in all cases the injured hip was clinically normal. Radiological examination showed loss of articular cartilage in one hip and trabecular changes in the bone of all three. On the basis of these three results the traditional pessimism about prognosis in such cases may not be justified.

The results of excision arthroplasty on forty hips in thirty-two patients have been studied by personal review. The mean follow-up was ten years and the results were graded in the Lazansky system. The outcome was fairly predictable, most patients achieving a fair to good result. The patients were satisfied with the operation in unilateral cases as a secondary operation, but it was generally unsatisfactory as a primary procedure or when performed bilaterally. Pain relief was satisfactory, and previously infected hips achieved sound wound and bone healing. Half could walk with no aid or one stick. No correlation could be found between the radiological appearances and the quality of the result.

The clinical features of eight patients with myositis ossificans progressiva are described and the effects of treatment with the diphosphonate EHDP, together with surgical removal of ectopic bone, are assessed. Early correct diagnosis remains unusual, mainly because the significance of the short great toes is unrecognised, and because myositis may be mistaken for bruising, sarcoma or mumps. The diphosphonate disodium etidronate (EDHP) was given to all patients in an attempt to suppress calcification of new lesions; in five of them ectopic bone was removed during the treatment. EHDP sometimes delayed the mineralisation of newly formed bone matrix after surgical removal but this delay could not be predicted. The variable effect of EHDP may depend particularly on the amount absorbed and on the activity of new bone formation.

One hundred and three patients with scoliosis treated by posterior fusion and Harrington instrumentation are reviewed. The fusion technique described does not require added bone. Walking in a localiser plaster is encouraged as soon as the wound is healed, usually two weeks after operation. The results compare satisfactorily with others published. It is concluded that added bone is not necessary unless neural arch defects are present, and that early walking is advantageous and without risk to the correction.

This paper describes a simple method for the recording of rib deformity in idiopathic scoliosis. The relationships have been recorded between the measured rib hump and rib depression deformities and 1) the rotation of the vertebral bodies (as measured by the method of Nash and Moe on the standing radiograph); 2) the degree of lateral curvature (as measured by the method of Cobb on the standing radiograph); and 3) the rib-vertebra angles and their differences (as described by Mehta). No clear linear relationships were found. Many examples of irregular relationship were recorded, for example, marked spinal rotation with minimal rib hump. The response of the rib deformities to treatment by Milwaukee brace in fifty-two patients is described; the hump is little changed but the depression on the opposite side may be considerably reduced. Harrington instrumentation may have a similar effect.

The results of treatment of injuries of the thoracic and thoraco-lumbar spine with neurological involvement have been reviewed in a retrospective study of 115 patients, of whom eighty-nine received conservative and twenty-six surgical treatment. Operation was reserved, in general, for patients with irreducible dislocations and incomplete neurological lesions, open reduction and internal fixation being the commonest procedure. Only three patients required a delayed spinal fusion for suspected instability after a period of conservative treatment. On the other hand, ten patients, eight of whom had been treated surgically, were left with severe chronic spinal pain. Of the patients treated conservatively, 35% showed significant neurological improvement compared to 38% of those treated surgically, but the latter group contained a much higher proportion of incomplete lesions with a far better prognosis. It is concluded that the place for early operation might be still further restricted.

In a series of seventeen patients with unilateral osteoarthritis of the hip a scintiscanning follow-up study was made before and after total hip replacement for the assessment of the normal course of the 87mSr-scintiscan. In another series of twenty-eight patients with total hip replacement a photoscan was made as a supplement for the diagnosis of loosening of one or both components of a total hip implant. In most of these cases it proved to be a useful method, especially when clinical and raidological examination was inconclusive. It is concluded that up to six months after operation increased osteoblastic activity exists; the scintiscan became normal after that time. 87mSr scintiscanning offers a safe and simple technique for the assessment of the success and stability of total hip arthroplasty. It is also a useful aid for the early detection of loosening and infection. The procedure can help in the differential diagnosis of complaints after total hip replacement.

Spasm or contracture of the gastrocnemius muscle is predominantly responsible for the equinus deformity of the foot in cerebral palsy. Its release is therefore logical in the treatment of all cases which do not respond to conservative measures. The authors have demonstrated, by the use of metal markers and radiographic control at operation, that adequate release cannot be achieved by severance of the calcaneal tendon alone, and that in order to ensure relaxation of the gastrocnemius muscle, the operation of choice is gastrocnemius recession by the method of Strayer, coupled with lengthening of the calcaneal tendon to deal with such degree of the deformity as may be attributable to shortening of the soleus. A survey of 100 limbs treated by this method revealed a recurrence rate of equinus of 9% and a degree of calcaneus deformity resulting in inadequate push-off in 3% of cases after an average follow-up period of six years.

Twenty-two patients with cysts of the lateral meniscus have been treated by operation. A modified operative procedure is described whereby the meniscus is inspected for a concomitant tear. A tear of the meniscus was found in ten patients and these were treated by meniscectomy. The remaining twelve cases were treated by excision of the cyst only. The rehabilitation period was considerably less in these patients. Recurrence of the cyst did not occur. The rationale for local excision is based on the similarity between the cyst of a meniscus and a simple ganglion, and also on the desirability of preserving the meniscus.

Hindfoot (subtalar) movement and disability after fracture of the tibial shaft have been studied. One hundred patients with soundly healed fractures of the tibial shaft treated by immobilisation in a long leg plaster cast were examined at least one year after the fracture had healed. Subtalar movement was accurately measured by a special technique and the patients were questioned specifically about any disability associated with their hindfoot. Subtalar movement was limited to some degree in 72% of patients. Forty-three per cent of patients complained of symptoms related to their subtalar joint and 12% found these symptoms troublesome.

Biochemical changes in the articular cartilage of the knees of mature dogs, one with natural and four with surgically induced osteoarthritis, have been investigated. The four dogs were killed three, six, nine and forty-eight weeks after division of the right anterior cruciate ligament, the left knees serving as controls. The cartilage of the joints operated on was thicker and more hydrated than the control cartilage; the proteoglycans were more easily extracted and had higher galactosamine/glucosamine molar ratios. The proportion of proteoglycans firmly associated with collagen, and hence not extractable, diminished before fibrillation was demonstrable by indian ink staining of the surface. These biochemical changes were present throughout the entire cartilage of the joints operated on of the dogs killed more than three weeks later, and of the dog with natural osteoarthritis. The results suggest that in response to altered mechanical stresses the chondrocytes synthesise proteoglycans that contain more chondroitin sulphate relative to keratin sulphate than normally, as in immature articular cartilage.

A case of the Jansen type of metaphysial dysostosis, followed for fifteen years from childhood to the age of nineteen, is reported. Radiographs taken at five years revealed the characteristic metaphysial changes in all the tubular bones, especially those of the hands and feet. The acetabular and glenoid areas, the costochondral junctions and the sternal ends of the clavicles were also involved. Radiographs taken at nineteen years, however, showed only marked deformities, which shows that the involvement of the metaphyses can regress by the end of growth. Biopsy of the lower end of radius at the age of twelve revealed changes in the growth plate or physis, especially in the zone of resting cartilage. This finding suggests that cellular function in this zone is disturbed by some unknown mechanism. Hence, the term physial dysostosis may be more accurate than metaphysial dysostosis.

In a preliminary experiment the paired radii and femora of dogs were tested for bone mineral mass and mechanical properties including the load at break, the ultimate bending strength and the modulus of elasticity; symmetry was observed for most of the parameters determined. The influence of the elasticity of materials used for the internal splintage of bone and its relationship to bone remodeling were then investigated for stainless steel and plastic plates applied to the femora of dogs. A significant decrease in bone mineral mass per centimetre length of bone and in mechanical properties was demonstrated for the femora plated with steel, and microradiography showed that this was due to massive endosteal resorption. A model for determining the influence of protection from stress in bone is presented.

Infection of the intervertebral space is a rare complication of operation on the disc (Ford and Key 1955). It occurred in five cases in a series of 650 operations for lumbar disc protrusion done by two of the authors of this paper--an incidence of 0-8%. Symptoms began between seven and twelve days after operation. After initial relief of the original sciatic pain, the patients developed severe back pain and muscle cramps in the legs. Straight-leg raising became much more limited than before operation. The erythrocyte sedimentation rate was raised in all cases. The diagnosis was confirmed by rescreening the Myodil, when an indentation was seen opposite the intervertebral space from which the disc had been excised. Early removal of infected material from the disc space resulted in complete relief of pain and cure of the infection.

An experimental model was designed to find a theoretical solution to the clinical problem of congenital tibial pseudarthrosis in children. The osteogenic properties of periosteum having been accepted, paired pedicled flaps of periosteum were raised from the subcutaneous surface of the tibia, tubed and anastomosed in a series of young dogs. In the last twenty-four consecutive cases the rate of complete ossification in these tubes rose to one in three. In the later stages of the work, in addition to the construction of periosteal tube grafts, pseudarthroses were induced in the middle third of each canine tibia in order to see if hypertrophy would occur under the stress of weight-bearing. It was found that in each of twenty-four specimens some hypertrophy occurred in the ossified periosteal tube grafts, and in three of the specimens this hypertrophy was associated with complete ossification of the graft that by-passed the pseudarthrosis.

Spontaneous correction of deformity is produced by bone remodelling during the period of growth. The purpose of this experimental study was to find out in which phase and to what extent asymmetrical epiphysial growth participated in the correction of an experimentally produced deformity. Transverse wedge osteotomy was performed in the legs of twenty growing mongrel dogs, the fragments being fixed with bent AO-plates. From radiographs taken at intervals of two weeks the epiphysial and axial angles were measured. Nine dogs were given tetracycline ten to twenty days before death and the cut surfaces were photographed in reflected ultra-violet light. It was found that epiphysial growth played an important role in the remodelling process. This factor accounted for roughly half of the total correction and averaged 12-5 degrees during the observation time of 160 days. The greatest correction occurred during the first weeks. Correction of the epiphysial angle took place with acceleration of growth.