Forty patients with tuberculosis of the lower cervical spine (second to seventh cervical vertebrae) have been reviewed. Pain and stiffness were important and dominant symptoms. Two types of disease were recognised. In children under 10 years old involvement was extensive and diffuse with the formation of large abscesses. In patients over 10 the disease was localised and produced less pus, but was associated with a much higher incidence of Pott's paraplegia. The overall incidence of cord compression was 42.5 per cent (17 out of 40); 13 of the 16 patients with the "adult" type of disease had this complication. The commonest method of treatment was with antituberculous drugs, anterior excision of diseased bone and grafting. This regime rapidly relieved pain, compressive respiratory symptoms due to abscesses and Pott's paraplegia. It also corrected kyphotic deformities from an average of 25.5 degrees to 5.4 degrees.

A case of rotatory dislocation of both atlanto-axial joints is presented. A review of the literature reveals two other cases, both in children. This would appear to be the first report in an adult, who survived and made a full recovery.

A clinical, cadaveric, biomechanical and radiological investigation of the pathogenesis of idiopathic scoliosis indicates that biplanar asymmetry is the essential lesion. Many normal children have coronal plane asymmetry (an inconsequential lateral curvature of the spine), and certainly all have vertebral body asymmetry in the transverse plane, but when median plane asymmetry (flattening or more usually reversal of the normal thoracic kyphosis at the apex of the scoliosis) is superimposed during growth, a progressive idiopathic scoliosis occurs. Idiopathic kyphoscoliosis cannot and does not exist, from the mildest cases in the community to the most severe cases in pathology museums. Median plane asymmetry is crucial for progression and the lateral profile of the spine must be carefully scrutinised. Increased anterior vertebral height at the apex of the curve with posterior end-plate irregularity characterises the median plane asymmetry and suggests that idiopathic scoliosis is the reverse of Scheuermann's disease.

The behaviour pattern of the scoliosis associated with osteoid osteoma or osteoblastoma of the spine is described. In patients presenting with symptoms at or around skeletal maturity, the scoliosis is postural. Excision of the lesion ensures complete resolution of the curve. In the growing child, however, an initial postural scoliosis may develop vertebral rotation with structural characteristics. The magnitude of the curve and the associated vertebral rotation is dependent on the time interval between the onset of symptoms and the surgical treatment. Although removal of the lesion usually results in regression of the curve, a prolonged delay in treatment may result in a progressive structural scoliosis. A possible mechanism for the behaviour of the scoliosis is discussed.

The clinical presentation and treatment of 18 cases of osteoid osteoma or osteoblastoma of the spine are described, with an average follow-up of 4.2 years (range three months to 11.5 years). The average delay between the onset of symptoms and definitive diagnosis was 19 months. All patients presented with marked spinal stiffness and a painful scoliosis. The lesion was situated in the pedicle in the 15 patients with involvement of the thoracolumbar spine. A surgical approach allowing direct access to the pedicle without entering the spinal canal or jeopardising spinal stability is described. Surgical treatment afforded immediate relief of pain and an early return of full spinal mobility.

Experimental evidence has accumulated in recent years to suggest that scoliosis can be caused by asymmetrical spinal muscle weakness due to sensorineural loss, though this suggestion has not achieved universal acceptance. The evidence is supported by histopathological observations on cases of clinical idiopathic scoliosis. A study is presented in which cynomolgus monkeys had one, two or three dorsal spinal nerve roots cut. Scoliosis developed, convex to the damaged side; its severity was dependent on the number of nerve roots cut. Section of the first lumbar dorsal spinal nerve root had a marked tendency to cause scoliosis. The study supports the view that scoliosis may be caused by asymmetrical paraspinal muscle weakness acting through loss of proprioception.

A new approach to the hip joint is described in which the integrity of the gluteus medius is preserved. It provides good exposure of the hip while causing the least disturbance to the abductor mechanism.

A new method of treating large bony defects of the proximal femur is described. The defect is filled with a large vascular-pedicled bone graft from the iliac crest. The graft, being nourished by the deep circumflex iliac vessels, remains viable and therefore induces rapid healing of the bone. This method of bony replacement encourages adequate excision of potentially malignant bone lesions and provides sufficient mechanical support to allow early walking. Six clinical cases are presented to illustrate its application.

A patient who presented with a malignant fibrous histiocytoma in the proximal femur after a total hip replacement is reported. The arthroplasty was of the Charnley-Muller type with detachment of the greater trochanter; polymethylmethacrylate cement was used. The possible tumour-forming effect of implant materials is discussed and the literature reviewed.

It is not uncommon to observe bone cement in the pelvis on radiographs after total hip replacement, a finding which is generally considered to be benign. This paper reviews some catastrophic late complications from intrapelvic methylmethacrylate. We also describe a case of progressive, unbearable dyspareunia beginning three years after total hip replacement. A possible explanation of the pathophysiology is suggested. Recommendations for prevention, diagnosis, and treatment of these late complications are offered.

Two patients are described, each with a fracture-dislocation of the hip combined with a fracture of the neck of the same femur. Open reduction combined with internal fixation was performed in both cases. Eight years later one patient had developed avascular necrosis of the femoral head; no signs of avascular necrosis or associated arthritis have appeared in the other patient after four years. A plea is made for considering this more conservative type of operation for these serious injuries before resorting to total hip replacement.

In 22 patients with femoral neck fractures 99mTc-MDP scintimetry was performed before operation and again shortly after operation; in 17 of these patients the investigation was repeated after four months. Six patients with increased uptake in the femoral head before operation and eight with decreased uptake had similar results at the first postoperative investigation. Of eight patients with an intermediate uptake before operation, two showed increased and six decreased femoral head uptake after operation. It is concluded that for the patients in the group with intermediate femoral head uptake before operation, the operative procedure probably influenced the postoperative blood supply of the femoral head.

One hundred and three sequential Stanmore knee replacements were reviewed retrospectively on two occasions with a maximal follow-up period of nine years three months. This knee prosthesis, which is hinged, was successful in alleviating pain, stabilising an unstable knee and modestly increasing the arc of flexion. Walking capacity was increased and flexion contractures were reduced. There were seven cases of infection and four of fracture around the prosthesis. All these proved difficult to treat and two knees with both fracture and infection needed amputation. Eight knees were revised for aseptic loosening and a further 14 were found to have radiological signs of loosening. The results have been analysed by the methods advocated by Tew and Waugh and give a cumulative success rate of 80 per cent at seven years, provided success is judged solely by whether the prosthesis is still in situ. The role of the Stanmore knee as a primary arthroplasty is discussed.

A simple method of treatment for ingrowing toenail by radical excision of the affected nailfold is described. The results in a prospective series of 50 patients are presented. This procedure, first described in 1872, does not destroy the nail, which heals to give an excellent cosmetic result. The recurrence rate after 18 months was 20 per cent, which compares favourably with procedures in which the nailbed is ablated. This method is proposed as an alternative to more complex procedures, especially when a cosmetic result is desired.

The results of 10 patients with severe rigid drop-foot corrected by the Lambrinudi triple arthrodesis were studied. The average amount of correction was 47 degrees, as evaluated from standing radiographs taken before and after operation. Radiological features of osteoarthritis and of flattening of the talus were common, but the feet were painless when reviewed at an average of 70 months later. A satisfactory range of movement was obtained at the ankle joint.

Dorsiflexion has been studied in three normal feet and in three feet with talipes equinovarus to determine the anatomical features which might contribute to the failure of operative treatment to correct the deformity. In the normal feet the movement of dorsiflexion was found to be essentially rotatory in nature and not simply hinging; as dorsiflexion proceeds the fibula moves forwards relative to the os calcis and the calcaneal tendon. In the club feet a posterolateral tether was found; this prevented fibular movement and blocked dorsiflexion. As a result of this study a posterior and lateral release is advocated for the operative correction of the hindfoot in a child with a club foot deformity, particularly under the age of a year.

The condition known as delta phalanx (or longitudinally bracketed epiphysis) is a rare congenital anomaly first described in 1964. The deformity consists of a triangular bone with an epiphysis running along the shortened side of the phalanx in a proximal to distal direction, making longitudinal growth of the digit impossible. Isolated hallux varus congenitus due to a delta phalanx of the proximal phalanges of both great toes is extremely rare: there have been only three such cases reported, two of which were in one family--the only report of a familial occurrence of this deformity. This present report details the occurrence of isolated bilateral hallux varus congenitus in four members of one family, a father and his three eldest children. All three children show bilateral delta phalanx of the proximal phalanges of both great toes. There are associated thumb nail anomalies, but no suggestion of polydactylism.

Five cases are presented of bilateral simultaneous rupture of the quadriceps tendon and the English literature of six isolated case reports is reviewed. All the patients were men, and most were over 50 years old. The injury often happens in elderly people and there is diagnostic confusion with other causes of inability to use the legs, notably with mild strokes. In three of our five cases there was a delay in diagnosis. The cardinal features are diffuse swelling around the knee, a visible or palpable suprapatellar defect and the inability to lift the straight leg despite a functioning quadriceps and normal activity in all other muscle groups in the leg. In all our patients operative repair was undertaken, followed by six weeks immobilisation in plaster and subsequent physiotherapy. Even late repair was associated with successful rehabilitation of the patient and a return to useful function.

All tibial shaft fractures treated at one hospital during a five-year period were studied in a prospective trial. Ninety-one displaced fractures in adults were treated using a conservative policy that included early bone grafting when indicated. Sound bony union was obtained in all cases. Those that healed primarily took on average 16.3 weeks whereas the 24 per cent that required bone grafts took 35.1 weeks. The number of complications, most of which were minor, was considered acceptable. It is concluded that provided early bone grafting is performed when necessary, a basically conservative policy of treatment is satisfactory; bony union of all displaced tibial fractures is achieved in a reasonable period of time.

Eight cases of unstable fractures caused by sharp heavy weapons such as swords or machetes are presented. A modern approach to these injuries is described against the historical background.

Eighteen patients with acute compartment syndromes below the knee were treated with four-compartment fasciotomies using the double-incision technique. Pre-operative tissue pressure measurements ranged from 28 to 47 mmHg. If fasciotomy was performed within 24 hours of the onset of clinical symptoms and signs, a good result was almost always achieved. It is recommended that tibial fractures complicated with a compartment syndrome should be treated with some form of operative stabilisation of the fracture at the time of surgical fasciotomies.

Ten cases of post-traumatic recurrent dislocation of the peroneal tendons were operated on between 1974 and 1982. In all cases the disturbed superior peroneal retinaculum was reconstructed by transposition of the calcaneofibular ligament to the lateral side of the peroneal tendons. The calcaneal insertion of the calcaneofibular ligament was mobilised with a small bone block and reinserted in its bed after the transposition. After an average follow-up of four years all the results were satisfactory.

In four children with primary subacute osteomyelitis of the talus seen one to five months from the onset of symptoms, the only constant complaints were of pain and a limp. All four were treated by curettage, immobilisation in plaster and appropriate antibiotics. All the bony cavities were healed within eight months of the operation and there were no growth disturbances nor any abnormalities of the adjacent joints.

Four-part fractures of the upper end of the humerus are uncommon injuries and there is still dispute about the best form of management. A retrospective study of 32 patients with these injuries has shown that non-operative management is frequently followed by persistent pain, stiffness and dysfunction of the shoulder. A prospective study of 49 patients with this injury presenting at the Bristol Royal Infirmary has shown that reconstruction of the upper end of the humerus with insertion of a Neer prosthesis will usually restore comfort and function. Whichever regimen is employed, disability is prolonged and dedicated physiotherapy is essential in their management.

The effects of synovectomy and excision of the radial head in 40 elbows affected by rheumatoid arthritis have been assessed. In contrast with many reports indicating minimal side-effects of this procedure, a common pattern of deterioration from what was often a satisfactory initial result has been demonstrated. A biomechanical theory of one of the factors responsible for failure has been put forward and the importance of conserving or replacing the radial head emphasised.

A new and simple operative technique has been developed to provide rigid internal fixation for all types of fractures of the scaphoid. This involves the use of a double-threaded bone screw which provides such good fixation that, after operation, a plaster cast is rarely required and most patients are able to return to work within a few weeks. A classification of scaphoid fractures is proposed. The indications for operation included not only acute unstable fractures, but also fractures with delayed healing and those with established non-union; screw fixation was combined with bone grafting to treat non-union. In a prospective trial, 158 operations using this technique were carried out between 1977 and 1981. The rate of union was 100 per cent for acute fractures and 83 per cent overall. This method of treatment appears to offer significant advantages over conventional techniques in the management of the fractured scaphoid.

A simple technique for screw fixation of the carpal scaphoid in cases of delayed union and non-union is described. The results obtained in 32 patients treated by this method are reported. The average follow-up was three years ranging from 10 months to 12 years. Union was obtained in 28 patients. The causes of failure to unite are discussed and the advantages of the reported method over other techniques such as bone grafting are stressed.

A case of Dupuytren's contracture is described, in which, both clinically and histologically, knuckle pad lesions involved the extensor tendons. Surgical excision of the Dupuytren's tissue from the dorsal aspect of the proximal interphalangeal joints, freeing of the lateral extensor slips and posterior capsulotomy resulted in marked functional improvement.

Carbon-fibre and polyester-fibre implants of comparable dimensions were used to replace the calcaneal tendon in 30 sheep. The neotendon produced in proximity to the polyester fibres was denser, more collagenous and more closely adherent than that in the carbon-based neotendon. Fragmentation of the carbon caused continuing cellular reaction which was associated with a poor collagen response.