The aims of this survey were to establish the familial incidence of Perthes' disease, to note any associated developmental anomalies and to collect information on preceding trauma or synovitis, on the pregnancy and birth, and on various sociological factors. Height and weight measurements were obtained for 217 patients, and comparisons made with those of their parents, unaffected sibs and (local) controls. Results showed an extremely low frequency of Perthes' disease among relatives, with no obvious pattern of inheritance. As genetic factors were not apparent, environmental and sociological causes were sought. The disease occurred particularly in children who were third-born or later in the family, and had older than average parents. Many came from low-income families and one in ten had been a breech birth, shown other malposition or had had a version late in pregnancy. Many children were already undersized at the time of developing Perthes' disease and remained short than average throughout life. Neither their parents nor sibs were shorter than normal, indicating that the patients' short stature was not familial. The child who is going to develop Perthes' disease is already constitutionally and socially at a disadvantage, and during the perinatal period and the first few years of life is perhaps more susceptible to trauma than is a normal child.

The results obtained in a consecutive series of thirty-seven Pemberton operations for congenital dislocation or subluxation of the hip are reported. Over the period under review, 1967 to 1973, it was the only type of acetabuloplasty employed at Winford. Unless the mandatory concentric reduction could be obtained with ease, preliminary open reduction was favoured, especially in cases of primary care. Femoral rotation osteotomy was added for marked anteversion. The programme was designed to be complete inside fourteen weeks, and was so for eighteen hips. Secondary acetabuloplasty was performed on hips with instability or dislocation persisting despite previous treatment. The operations were performed from eighteen months to thirteen years of age. One initial failure required a repeat operation which was successful, but one severely dysplastic hip remained so. The average follow-up was six years.

Drawing upon a total experience of 450 hips affected by established congenital dislocation or subluxation, the author presents the long-term results in 177 hips treated for the first time between the ages of nine months and three and a half years, in support of his contention that surgical endeavour should in the first place be directed towards the limbus and upper end of femur rather than the acetabulum. The 144 patients, all treated on lines previously described in this journal (Scott 1953; Somerville 1953a, b; Somerville and Scott 1957), have now been followed up annually for between ten and twenty-five years, both hips receiving equal scrutiny. In brief, the routine has consisted of arthrography, excision of any limbus shown to be inverted, reduction by traction in abduction, and rotation osteotomy of 70 degrees. The addition of 10 to 15 degrees of varus was found beneficial and has become routine. Some hips required secondary procedures, and regret is expressed that these were not carried out sooner. The upper age at which recovery of the acetabulum may occur was found to be much higher than generally supposed, with a critical period between eleven and fourteen. The main conclusion is that in the great majority of cases first seen in this particular age group, improvement of the mechanics of the joint, especially by attention to the upper end of femur, leads to satisfactory development of the acetabulum and good functional results, at least up to early adult life.

An operative technique for correction of the severe kyphosis that may develop in cases of myelomeningocele is described. It includes excision of the apical vertebrae, correction of the full length of the kyphotic segment and of rigid compensatory curves, and extensive fusion aided by internal fixation with longitudinal threaded wires. The technique evolved during the management of eleven children. Of these, in the first two the internal fixation employed was inadequate; two others died; and in the remainder good correction was maintained up to the time of review one to six years later.

Children with congenital focal deficiency of the proximal femur present many problems that are but rarely encountered by the individual surgeon who is thus unable to accumulate a wide experience. This paper reviews the literature and analyses the treatment of twenty-three cases at the Royal Children's Hospital, Melbourne, with the object of producing a rational plan of treatment. The management of instability of the hip, malrotation, inadequate proximal musculature and leg length inequality are separately considered for five grades of deficiency. Milder forms are amenable to subtrochanteric osteotomy to correct varus deformity. Exploration and grafting of the pseudarthrosis is indicated where progressive deformity develops. In the more severe deficiency, conservative management of the proximal bony defect provides a better result with an operation only rarely indicated. The gross leg length inequality may be most successfully overcome by Syme's amputation with subsequent fusion of the knee to create an above-knee amputee with an end-bearing stump allowing ready fitting of a prosthesis.

The "osteopetrosis" section of the Fairbank Collection in the Radiology Museum of the Royal National Orthopaedic Hospital contains radiographs and case notes of twenty-two patients. This material has been reviewed in terms of modern concepts in an attempt to obtain a long-term follow-up and a firm diagnosis in each individual. Nine patients proved to have the classical autosomal dominant form of osteopetrosis, four had the malignant autosomal recessive type, craniometaphyseal dysplasia was present in two kindreds and isolated individuals had pyknodysostosis, atypical craniodiaphyseal dysplasia and craniosclerosis with osteopathia striata. As these conditions differ greatly in their clinical and genetic prognoses, diagnostic categorisation is of practical importance.

Two cases of unusual snapping at the elbow are described. In both, the medial head of the triceps was found to be separated from the main muscle belly. During flexion of the elbow, the medial head dislocated over the medial epicondyle, producing a characteristic snapping phenomenon. Both cases were of long standing and had been asymptomatic for years. The first clinical symptoms were those of an ulnar neuropathy. In order to restore the normal position of the medial head of the triceps, its tendon was detached from the olecranon, passed under the central tendon and interlaced to it. The ulnar nerve was left in the epicondylar groove in one case and transposed anteriorly in the other. At the end of the procedure flexion of the elbow was unobstructed and the snapping phenomenon had disappeared.

Osteomalacia may be a contributory factor in some patients in the development of fractures of the femoral neck and complicate the subsequent management. The level of serum alkaline phosphatase is often valuable in the diagnosis of metabolic bone disease but rises after any uncomplicated fracture, and since such a rise may limit the diagnostic usefulness of this measurement in detecting osteomalacia its extent was assessed in 106 patients. In the majority serum levels were normal on admission, rising after seven to nine days to reach a maximum within a month after fracture. Elevated levels on admission were found in patients with osteomalacia, liver damage or where there had been a delay of several weeks between injury and admission. In a small number of patients normal levels on admission subsequently reached very high values, usually in association with comminution or instability of the fracture. Elevated levels persisted for six to twelve weeks after fracture, the major influence upon the level at this time being the maximum value achieved rather than the presence of osteomalacia. If patients are to be screened for osteomalacia, the alkaline phosphatase must be measured within the first week after a fracture to avoid the distorting influences of the fracture itself.

Forty-eight men and three women were reviewed an average of thirty-one months after pes anserinus transposition for chronic anteromedial rotational instability of the knee. Their ages ranged from eighteen to forty-two years (average twenty-five years). All but four of the injuries occurred during sport. The interval between injury and operation averaged thirty months. During this time twenty-three patients had had other operations of which eighteen were for excision of menisci. A further sixteen patients required excision of one or both menisci at the time of pes anserinus transposition. After operation large haematomata had to be expressed from four wounds. One patient had a pulmonary embolism All made a complete recovery. Worthwhile improvement of stability during activity was found in forty-two of the fifty-one knees. Pre-existing degeneration of articular cartilage associated with severe instability of long duration was the main cause of failure. Good motivation was important for success. Four grades of disability are described according to the severity of symptoms. It was found that a successful operation gave approximately one grade of improvement on this scale. Arthroscopy is recommended to identify torn menisci and degenerative changes before pes anserinus transposition is undertaken. An important advantage of this operation is its simplicity. When more elaborate ligamentous reconstructions are necessary for severe instability, pes anserinus transposition can be usefully added to complete the repair.

The Insall-Salvati method of determining the position of the patella by radiography was employed in fifty-one patients with chondromalacia patellae that had been proved at arthrotomy. There was no definite relationship between chondromalacia patellae and patella alta. There was, however, a highly significant statistical difference between the ratio of the length of the patella to that of the patellar tendon in normal men and women.

Four methods of surgical treatment of chondromalacia patellae have been evaluated after periods ranging from two to thirty years (average seven years), to discover the success rate, complications and indications for each. A total of 140 operations had been performed in 98 patients. Overall, satisfactory results were achieved in 25 per cent after forty shavings of the patellar cartilage, 35 per cent after twenty cartilage excisions and drilling of the subchondral bone, 60 per cent after twenty medial transfers of the patellar tendon and 77 per cent after sixty patellectomies. Thirty-four primary patellectomies gave 82 per cent satisfactory results compared with 62 per cent after twenty-six patellectomies performed after a previously unsuccessful operation. The results were worst in patients below twenty years of age especially women and in those with Grade IV changes in the patellar cartilage. Weakness of the quadriceps after any procedure predisposed to an unsatisfactory result. Extensive late radiological degenerative changes in the knee were not seen. On the basis of the results in this report, patellar tendon transfer is recommended in adolescents and athletes with Grade I, II or III changes in the patellar cartilage. In adults over twenty years of age with Grade I and II changes cartilage excision and drilling is satisfactory. In adults with Grade III and adults or adolescents with Grade IV changes patellectomy is the treatment of choice.

The clinical, radiological and pathological features of hallux rigidus affecting nine toes (in seven patients) are described. Characteristic chondral and osteochondral lesions are seen to occur at a specific site on the metatarsal head, and account for the limitation of dorsiflexion but relatively unrestricted plantarflexion typical of hallux rigidus. Radiologically these lesions are often missed because they are mainly cartilaginous and are later obscured by secondary degenerative changes. Histological evidence indicates a traumatic aetiology and a mechanism of injury is suggested.

Various prostheses for total replacement of the first metatarsophalangeal joint for painful hallux valgus and hallux rigidus are briefly discussed. Altogether, the results of eighty-six replacements in sixty-nine patients have been recorded after an average interval of two years. In seventy-eight operations a Silastic* prosthesis as designed by Swanson for the replacement of metacarpophalangeal joints was used, with no case of fracture or deep infection up to date. Overall, the assessment of pain showed that 98 per cent of operations gave either complete or considerable relief. For hallux valgus, the objective assessment showed excellent or good results in 79 per cent, fair in 16 per cent and poor in 5 per cent. For hallux rigidus the corresponding figures were 86, 14 and 0. The technique of replacement described promises to be most satisfactory, especially for hallux rigidus. In selected cases of hallux valgus, a basal osteotomy of the first metatarsal should be added.

Children with flail feet who have control of their hips and knees are able to walk but are unable to stand still and find it difficult to walk slowly. These problems have been overcome in fifty-three children with flail feet due to myelomeningocele by fitting them with below-knee orthoses which provide maximum stability and yet allow normal walking. The biomechanical principles and the development of the orthoses are discussed.

Sixty-six deformities of the foot and ankle in forty-two patients with arthrogryposis multiplex congenita were reviewd. Pes equinovarus proved particularly difficult to treat as there was a tendency for the deformity to recur because of the thick and rigid capsule. Intracapsular procedures were more successful than those done adjacent to the joint. Wide capsulotomy or talectomy were the best procedures under the age of three years and triple arthordesis was most successful for the older child.

The clinical and radiological features in three cases of cystic angiomatosis of bone are reported. Although these features are generally diagnostic except from histiocytosis X, the definitive diagnosis must be established by a pathological study, preferably of a segment of an involved rib or fibula. The prognosis varies according to the type of clinical presentation-in particular upon whether the lesions are solely skeletal or whether there is extraskeletal visceral involvement. Whereas these last cases may often prove fatal, those with only skeletal involvement have a favourable prognosis: indeed, the cystic bone lesions may regress without any treatment, as occurred in some cases reported in the literature and in two of our three cases.

When aseptic failure of the bond between the cement and the prosthesis of a total joint replacement occurs, complete removal of the cement has been advocated before the insertion of a new prosthesis. The present study questions this practice. Both laboratory tests on variously prepared specimens of cement and clinical experiences demonstrate that recementing over old cement is a practical alternative if the technique employed includes the removal of blood from the old cement surface, rasping of this surface and the early application of fresh cement.

The beneficial effect upon osteogenesis of imprenating bone grafts with autologous red marrow is well documented. The experimental findings reported in a previous paper suggested that prepared xenograft bone might provide a good medium for osteogenesis by marrow cells. This paper is a preliminary report of the first clinical attempt to use xenografts of bone combined with autologous red marrow. Kiel bone, which was found the most suitable, was impregnated with marrow aspirated from the iliac crest and, apart from one case of infection, gave excellent results in twenty-eight patients under conditions covering a wide range of indications for bone grafting. Further trials should allow a more valid assessment.

Demineralised homologous bone-matrix implant was used to bridge a large circumferential osteoperiosteal gap in the diaphysis of the ulna of rabbits. Periodic observations of the graft were made clinically, radiologically, histologically and by tetracycline fluorescence up to forty-two weeks. By the twelfth week after operation 81 per cent of the animals revealed bone formation in the implant and complete bridging of the gap. The new bone was laid on the surface and in the substance of the matrix, suggesting that the inductive principle was acting locally. The bone, once formed, remodelled to the texture of a mature tubular bone and did not undergo absorption during a long follow-up period. Demineralise bone-matrix proved to be a highly osteoinductive and readily osteoconductive material. The graft did not evoke any appreciable local foreign-body or immunogenic reaction. The high degree of success in bridging massive bone defects justifies further serious studies and hopes for a useful substitute for massive autologous bone grafts.

One hundred and eighty-three conservative amputations of some part of the foot in 161 patients with gangrene from diabetes or arteriosclerosis have been studied retrospectively. They constituted 48 per cent of all amputations in one orthopaedic service over a period of twelve years, during which the minimal feasible procedure was always chosen. Sixty per cent healed soundly, but in over a third of these cases at least one revision to a higher level on the foot had been required. Factors that significantly influenced the outcome of the initial operation were the level of amputation, the age of the patient, the interval between the onset of gangrene and operation, anaemia and pyrexia.