One hundred and twenty-five patients with 194 feet affected by congenital talipes equinovarus were treated by the senior author during the period 1959 to 1980. Of these, 70 patients presented either at birth or in the early neonatal period, and 55 were seen later, having been referred from other centres. Seventy-five patients were subsequently reviewed by two of us; the remaining 50 were assessed from records and research files. Patients seen within four weeks of birth were termed "early", the remainder "late". Of the early group of 70 patients, 44 (with 68 affected feet) were reviewed and 26 (with 41 affected feet) were assessed from records. Excellent or good results were achieved in 94 per cent of feet treated conservatively and in 82 per cent of feet which required pantalar release. Of the 55 late referrals 32 patients (with 55 affected feet) were reviewed and 23 (with 30 affected feet) were assessed from records. Satisfactory results were slightly less frequent, but were achieved in 75 per cent of cases. There was no statistical correlation between early soft-tissue release and a good final outcome, but there was a positive statistical correlation between good clinical results and a high talocalcaneal index. Osseous correction (a laterally based wedge tarsectomy or a triple arthrodesis) was necessary at a later date in four feet (four per cent) of those who presented early and in 13 feet (15 per cent) of late referrals.

One hundred and twenty-nine unselected club feet were classified at birth into three grades of severity; 123 were followed up. The results of primary treatment were analysed and it is shown that the bad feet did worst. Serial splinting in plasters achieved lasting correction in nine in ten mild club feet, in half of the moderately deformed, but in only one in ten of the severely affected. Surgical correction succeeded in two out of three of the resistant feet, but had to be repeated in the others.

A modified form of the collateral operation originally described by Dillwyn Evans has been used in severe relapsed club feet to correct the sagittally breached or bean-shaped foot. Forty-five feet in 37 patients were followed up for an average of nine years and nine months. Previous operations had been performed on 42 feet. Thirty out of 45 feet were considered satisfactory at review when evaluated by a simple, functional system of scoring. The majority of the feet were stiff but relatively free of pain and able to fit into normal shoes. The collateral operation was considered successful in 42 feet if the patient's ability to take part in any desired sporting and recreational activities was taken as the criterion for success.

Between 1959 and 1974 the late Dillwyn Evans treated severe symptomatic flat feet by elongating the os calcis. The long-term follow-up of 20 of these patients with a total of 23 feet is presented 7 to 20 years after the operation. At review 17 of the 23 feet showed very good or good results and it was concluded that this is a useful procedure for severe cases of flat feet which appears to stand the test of time.

The clinical features, management and outcome of 178 early bleeding episodes into the musculature of the thigh and lower limb of 37 severe haemophiliacs are reported. Ninety-five per cent of all bleeds were treated in under three hours from onset of symptoms and the mean time to complete restoration of function was 3.5 days. The most frequent site of bleeding was the quadriceps (44 per cent) followed by the calf (35 per cent), anterior tibial compartment (seven per cent), adductors of the thigh (seven per cent), hamstrings (six per cent) and sartorius (one per cent). Bleeds of the quadriceps took longest to resolve (mean, four days), significantly longer than bleeds of the calf muscle (3.1 days). The first symptom in 66 per cent of bleeds was pain on movement. When the quadriceps was involved, this rapidly progressed to pain at rest. There was a significant prolongation of recovery time when bleeds of this muscle group were treated more than two hours after the onset of symptoms. Bleeds of the calf muscle required less transfusions and no prolongation in recovery time occurred in bleeds treated up to three hours from the onset of symptoms. The results of this study contrast markedly with earlier reports based on later presentations.

The relationship between meniscal tearing and degenerative joint disease was studied by macroscopic examination of 115 knees at necropsy. The incidence of meniscal pathology was 57 per cent. There was no overall difference in the severity and distribution of tibiofemoral degeneration, whether the meniscus was torn or normal. We found little evidence that degenerative meniscal tears cause osteoarthritis or vice versa.

Arthrodesis after the removal of a knee prosthesis is often hampered by the small area of contact of the bony surfaces and by pre-existing infection. Conventional systems of external fixation and compression frequently fail to achieve stability but the addition of the Wagner leg-lengthening apparatus applied anteriorly and adjusted to give compression ensures rigid external fixation. Four knees in four patients were treated using this technique; the treatment followed the removal of infected prostheses in three knees and painful fibrous ankylosis after the removal of the prosthesis in the other. All obtained a sound arthrodesis.

Ten patients are reported who had sustained a partial rupture of the anterior cruciate ligament in a twisting injury of the knee. Nine of the 10 patients presented with a small effusion and pseudo-locking of the knee which was thought to be due to muscular spasm to prevent further ligamentous injury. The patients were examined clinically, under anaesthesia and by arthroscopy and the signs were found to be remarkably similar to those in patients with a tear of the medial meniscus. The mechanism of injury leading to partial rupture of the anterior cruciate ligament is discussed.

Most patients with dominantly inherited osteogenesis imperfecta have blue sclerae and relatively mild symptoms. However, in a small group of families the patients have normal sclerae and this disorder has been classified as Type 4 osteogenesis imperfecta. This paper reports the clinical and radiographical features of 48 patients from 16 families with Type 4 osteogenesis imperfecta and compares the findings with those of the classical disorder with blue sclerae (Type 1 osteogenesis imperfecta). The two types are similar in usually causing a mild disease but with a wide range of severity, and in both types the rate of fracture declines in adolescence. There are, however, some significant differences apart from the colour of the sclerae. In Type 4 the first fracture more commonly occurs at birth, dentinogenesis imperfecta is more frequent than in Type 1 and bruising and nose-bleeds are less common. As in Type 1, the radiographic appearances of the bones may be normal. It is important that Type 4 osteogenesis imperfecta should be recognised because of the need for competent genetic counselling, because the management may be different from that appropriate for Type 1 and because it may be mistaken for idiopathic juvenile osteoporosis or child abuse.

A modification of a previously reported one-stage technique for reduction and stabilisation of severe spondylolisthesis using a posterior route is described. Reduction is obtained by inserting Harrington rods to lift L5 vertically out of the pelvis and two double-threaded screws to pull it backwards. After reduction the rods are taken away and stabilisation achieved by means of screws and a sacral bar. With this modified technique lumbar vertebrae above L5 are never immobilised, compared with the previous method where the retention of the Harrington rods resulted in more lumbar vertebrae being immobilised than was necessary for fusion. Bone is resected from the sacrum and the fifth lumbar vertebra to avoid too much tension on the nerve roots. Bone grafts are not needed and lumbosacral fusion is achieved within six months due to close contact between the raw bone of the vertebral bodies. Three patients have been treated with this modified technique; there was no reslip, neither during the period when the metallic fixation was in situ nor after its removal.

The long-term results of 17 patients who had had fusion in situ for severe lumbosacral spondylolisthesis are reported. The average follow-up was 14 years with a range of 7 to 20 years. The average age at operation was 16 years. At follow-up seven patients had occasional backache but only one patient had changed his job and no patient had lost any time off work in the previous year. Nine patients felt that their deformity had been improved and all but one patient still rated the results as excellent up to 20 years after the operation. Although all the patients had persistent foreshortening of the trunk only two patients were aware of any cosmetic deformity. There had been no significant increase in forward slip since the previous follow-up examination five years after the operation. There were no late complications nor significant degenerative changes in the lumbar spine. It is concluded that although fusion in situ does little to improve cosmesis very few patients complain about their appearance and that it is a safe and reliable method of treatment for severe spondylolisthesis which has stood the test of time.

Six patients, aged between 3 and 51 years, with tuberculosis of the upper cervical spine were studied. Prominent features of the disease included pain and stiffness, paralysis, swelling of the retropharyngeal soft tissue, osteolytic erosions, and atlanto-axial subluxation. Cure was obtained with antibiotics, transoral decompression and C1-2 fusion.

Eight patients suffering from various forms of idiopathic dystonia are described whose initial referral was for an orthopaedic opinion. The diagnoses of these patients, who were seen over a two-year period, comprised dystonia musculorum deformans, dystonia of the foot, spasmodic torticollis and occupational cramps. Although various musculoskeletal sequelae often occur, the primary underlying neurological cause of these unusual conditions is emphasised.

In comparison with monofilament wire, multifilament cable was found to be a more suitable material for fixation of the greater trochanter. It is versatile, easy to work with and has superior mechanical properties. The "trochanter cable-grip system" was developed to exploit the use of multifilament cable as a means of reattaching the greater trochanter and experimental studies have yielded excellent results. This system was subjected to clinical trials for over four years in 321 hips and, at its present state of development, the incidence of detachment has been reduced to 1.5 per cent and that of cable breakage to 3.1 per cent.

A kindred of 15 affected individuals in five generations is described with autosomal dominant inheritance of bilateral five-fingered hand. Some of them had additional pre-axial polydactyly of the fingers or toes and some had partial or complete absence of the tibia. The range of expression of the gene is variable and genetic advice to these families must take account of the whole spectrum of defects. The function of both upper and lower limbs was improved by surgery. A distinction is drawn between the five-fingered hand shown in this family and the different deformity of a four-fingered hand with a triphalangeal thumb.

We describe two boys with bilateral deformity of the upper end of the radius. The condition appears to predispose to non-traumatic posterior dislocation of the radial head and is associated with posterior bowing of the upper end of the ulna. This problem has not been previously described.

The long-term effect of stainless steel and titanium alloy plates on structural remodelling and bone mass of osteotomised canine femora was studied and the effects of early and late removal of plates were compared in 27 adult Beagles. Radiological, histological, histomorphometric and tetracycline fluorescence studies led to three conclusions. First, the continuous (60 weeks) presence of plates, irrespective of their composition, delays remodelling and leads to a reduction of bone mass. This loss is significantly greater under stainless steel plates. Secondly, the removal of plates at eight weeks leads during the 52 ensuing weeks to a marked and widespread structural remodelling and to a return to normal bone mass, irrespective of the type of plate used. However, remodelling is more intense after titanium alloy plates have been used; it is not complete 60 weeks after osteotomy. Thirdly, removal of plates at 40 weeks activates remodelling during the ensuing 20 weeks to a lesser degree and to a more limited extent than early plate removal. The clinical significance of this study is that less rigid but stable internal fixation permits the radiological assessment of healing and thus the determination of the optimal moment for removal of the plates. It also reduces the degree of bone loss should the plate be left in situ for any reason.

Biochemical and histochemical studies have indicated that there is specific cellular activity in the region of the calcification front of articular cartilage implying that a regulation process takes place there. Using scanning and transmission electron microscopy and light microscopy to examine tissue sections of both undecalcified and decalcified articular cartilage in the region of the calcification front, we have looked at its morphology with particular reference to its cellular control. Our observations show that physiological calcification is an active process under cellular control and is related to the presence of extracellular membrane-bound matrix vesicles.

The transcutaneous oxygen pressure (tcPO2) was measured by a polarographic technique in the legs of 161 volunteers and compared with the levels found in 62 patients with ischaemic skin due to peripheral vascular disease. The results show that the tcPO2 was related to the degree of ischaemia and, in many cases, was a more accurate guide to the viability of the skin than clinical assessment. Measurement of the transcutaneous oxygen pressure in the leg at the site of amputation in 24 patients with peripheral vascular disease showed that a preoperative level greater than 40 millimetres of mercury at an electrode temperature of 44 degrees Celsius was necessary for the skin of the stump to heal. The technique is simple, non-invasive and reliable. The tcPO2 accurately reflects the physiological and pathological changes in the circulation of the skin. It has potential in many fields of surgery where careful assessment of the viability of the skin is necessary.