Structural scoliosis occurs more commonly in patients with juvenile chronic arthritis than in the normal population. We have reviewed 32 patients with both juvenile arthritis and a scoliosis and suggest that structural curves may arise from postural curves associated with asymmetrical involvement of lower limb joints.

A prospective study to investigate changes in the rib hump or rib deformity after correction of the lateral curvature in adolescent idiopathic scoliosis is reported. The operative treatment for 47 patients was by a Harrington distraction rod and posterior fusion. Before operation and at follow-up, measurements of the Cobb angle, of vertebral rotation, and of the rib deformity were taken. Despite operative correction of the lateral curve, there was a progression of the rib deformity in 64% of the cases after four years. Correction of the lateral curve may thus have no effect on vertebral rotation and cannot be guaranteed to effect a permanent reduction of the rib hump.

Twelve adult patients with confirmed tuberculosis of the atlanto-axial spine are presented and a classification proposed. Stage I has minimal ligamentous or bone destruction and no displacement of C1 on C2; the suggested treatment is transoral biopsy and decompression followed by an orthosis. Stage II has ligamentous disruption and minimal bone destruction but anterior displacement of C1 on C2; treatment involves transoral biopsy and decompression, reduction by halo traction, then a posterior C1-2 fusion. Stage III has marked ligamentous and bone destruction with displacement of C1 forward on C2; the suggested treatment is transoral biopsy and decompression, reduction by halo traction, then fusion from the occiput to C2 or C3. One patient died before treatment started; all the others have gone on to solid union with resolution of any neurological deficit. There has been no evidence of reactivation of disease over an average follow-up of 36 months.

In the search for a simple method of assessing the therapeutic efficacy of sodium fluoride, a prospective study of vertebral radiography during such treatment was carried out. Treatment of osteoporosis with sodium fluoride, calcium and vitamin D was found to enhance the vertical markings of the vertebral trabecular pattern in 69% of patients. This response was graded 1 (failure), 2 (good) and 3 (excellent); Grade 2 or 3 was attained after a mean treatment period of 31.7 months. Subsequent analysis of the vertebral fracture rate revealed that new vertebral fractures had occurred only in patients with Grade 1 and not in those with Grade 2 or 3. We recommend that treatment should aim at increasing the vertebral trabecular pattern to Grade 2 or 3 and that the duration of therapy should be approximately 30 months.

Thirty-nine patients with neuralgic amyotrophy were reviewed. In addition to the clinical findings reported in the neurological literature, we commonly found pain throughout the upper limb, and diffuse involvement of the brachial plexus. Five patients had spinal accessory nerve lesions and five had glenohumeral instability. Sixty-four per cent of the patients had had an orthopaedic consultation during their acute illness. It is therefore important that orthopaedic surgeons are aware of this clinical syndrome and its management. The prognosis is excellent with non-invasive treatment.

A new technique for repair of neglected posterior dislocation of the elbow is described, consisting of open reduction with tendon graft stabilisation to create a medial collateral and an intra-articular "cruciate" ligament. This allows flexion-extension exercises to start six days after operation. Eleven cases are reported in which the average range of movement improved from 38 degrees before operation to 105 degrees after a minimum follow-up of two years, with a mean valgus-varus instability of only 13 degrees. One patient had a postoperative infection but all the others were satisfied with the functional result.

The results of excision of the distal ulna in 34 wrists of 25 patients with chronic rheumatoid arthritis of the distal radio-ulnar joint were reviewed. Rest pain had been cured or relieved in 77%, pain on pronation-supination in 86%, and limitation of pronation-supination in 90%, while 88% of the patients graded the result as excellent or fair. Despite this marked relief of symptoms, function of the upper limb was improved in only 25% of patients and remained unchanged in 60%. Ulnar subluxation of the carpus had occurred in 24% but seemed to be related to the destructive disease process rather than to the operation itself. The length of ulna resected was not related to the outcome of the operation.

In a prospective, controlled study 58 patients aged under 60 years with Colles' fractures were treated either by a forearm plaster or by the application of an external fixator. In 94% of those treated by a fixator it was possible to insert the distal pins of the frame into the fracture fragment, the fixation obtained being sufficient to forgo additional splintage. The external fixator proved more effective at holding the manipulated position, and the radiological loss of position during fracture union was minimal compared with that seen in patients treated in plaster.

We have reviewed 21 cases of dorsal dislocation of carpometacarpal joints. In 15 of them the diagnosis was missed when they were first seen in an accident and emergency department. General swelling may obscure the characteristic clinical deformity and routine radiographs may not show the displacement clearly. It is recommended that a true lateral radiograph of the hand be requested when this injury is suspected.

A characteristic dysfunction of the hand has been observed in various cervical spinal disorders when there is involvement of the spinal cord. There is loss of power of adduction and extension of the ulnar two or three fingers and an inability to grip and release rapidly with these fingers. These changes have been termed "myelopathy hand" and appear to be due to pyramidal tract involvement. The characteristic nature of the signs permit the distinction between myelopathy and changes due to nerve root or peripheral nerve disorder. The clinical significance of these signs has been assessed against other tests and their value in management is discussed.

Forty-four patients who had undergone 50 capsular arthroplasties for congenital dislocation of the hip were reviewed after a mean follow-up of 20 years. Their average age at operation was 5.9 years; 31 of the operations were undertaken because of late presentation, the remainder because of the failure of previous surgery. In all, 70% of the hips showed good function despite a reduced range of movement, but patients with bilateral arthroplasties fared poorly. Excellent containment within the acetabulum was found in 80%, but the femoral head was always abnormally high though not unduly lateral or medial. This configuration had remained unchanged during follow-up. The accuracy of reduction along the mediolateral axis was the only variable found to influence the outcome significantly. Functional deterioration, associated with pain, was noted to be more common after 20 years than before, and was associated with radiographic evidence of joint degeneration.

Total hip replacement has been very successful in patients with painful, stiff hips associated with protrusio acetabuli, but the heat of polymerisation of methylmethacrylate cement may cause necrosis of the thin medial wall with consequent danger of migration of the cup. Since 1968 at Wrightington, thin slices of the head of the femur have been used as bone grafts to reinforce the acetabulum. We have reviewed 61 hips in 51 patients at an average of 4 years 3 months after operation. Grading for severity is discussed and the degree of physiological remodelling of the medial wall of the acetabulum after grafting assessed. There was an average of about 4 mm of remodelling, but this varied considerably; most took place within the first year. In no case was there relapse of the protrusio.

Quantitative polarised light microscopy was applied to sections of unfixed, undecalcified bone taken at operation from patients with two types of proximal femoral fracture, subcapital and trochanteric. Specimens were also taken from the equivalent sites in otherwise normal subjects at autopsy, and from various other sites of traumatic fractures; these two latter groups acted as controls. Analysis of the 57 specimens disclosed changes in the nature of the bone at the site of subcapital fractures, namely the presence of relatively large crystals of hydroxyapatite and a change in the molecular orientation, but not total content, of the acidic proteoglycans of the bone matrix. Our results have confirmed and extended the findings of others on subcapital fractures, and have also shown very similar changes in the trochanteric fractures. It thus appears that the bony changes in the two types of proximal femoral fracture are not as different as has been suggested.

In a prospective five-year study, 294 episodes of acute transient synovitis of the hip were diagnosed in 275 children. The average annual incidence was 0.2% and the accumulated risk of suffering at least one episode was 3%. The risk of recurrence was 20 times greater than the risk of having a single episode. Perthes' disease was diagnosed from one to five months after the acute attack of synovitis in 10 cases (3.4%). Review of the initial radiographs revealed signs of avascular necrosis in three of the 10 cases, and an increased joint space in five. Only two cases had had completely normal radiographs. The value of routine radiographs taken after three months was minimal. Factors associated with the incidence of Perthes' disease included prolonged time in traction before the range of hip movement became normal, increase in joint space on the initial radiographs and the recurrence of hip symptoms after initial relief.

We have attempted to identify the most important long-term prognostic factors in Perthes' disease by studying 61 patients affected unilaterally. The average age at diagnosis was 7 years 5 months and at follow-up it was 32 years, an average interval of 25 years. The age at diagnosis, age at follow-up, Catterall group, acetabular coverage, femoral head subluxation and the other head-at-risk signs were statistically correlated with Stulberg, Cooperman and Wallensten (1981) radiographic classes and the Iowa hip score. Statistically significant correlations were found between Stulberg class and Iowa hip score; age at diagnosis and Stulberg class; age at follow-up and Iowa hip score; and between lateral subluxation of the femoral head and Iowa hip score. Three age-groups of patients were found to carry different long-term prognoses. Those below five years of age at diagnosis showed a statistically significant correlation between Catterall group and Stulberg Classes I and II. Patients between five and nine years of age at diagnosis showed a significant correlation between Catterall group and Stulberg Classes I, II, III and IV while in patients diagnosed after nine years of age there was no statistical correlation between Catterall group and Stulberg class, all having a poor prognosis and ending up in Stulberg Classes III, IV and V.

Of 693 elderly patients admitted with suspected hip fractures, 43 had normal radiographs and were investigated by isotope bone scan. The 30 patients (70%) with normal scans were mobilised and none developed a fracture. All 13 of the patients with specific bone scan abnormalities were subsequently proved to have fractures, five of which became displaced. Clearly conventional radiography does not exclude fracture of the femoral neck in elderly patients; bone scanning is advisable in doubtful cases.

Sonography was successfully used to diagnose an effusion in the hips of three adults with septic arthritis and four with aseptic synovitis. The effusions were confirmed by aspiration. All the patients had markedly increased intracapsular pressure which, in the extended position, exceeded the systolic blood pressure and could well compromise the blood supply to the head of femur. Aspiration reduced pain and intracapsular pressure, as did flexion of the hip to 45 degrees.

Two-hundred and fifteen children with 288 unstable hips have been treated by splintage during the first nine months of life. A simple treatment protocol was followed and the aim was to test the safety and reliability of this protocol as well as of the Von Rosen splint and the Pavlik harness. A vascular necrosis occurred in 3.8% of the splinted hips. Despite splintage, a proportion of children needed operation at a later date.

Impedance plethysmography has great potential in the non-invasive detection of dangerous iliofemoral thrombosis. It was used to examine 198 patients undergoing total hip replacement for evidence of proximal venous segment thrombosis. There were 13 abnormal results, and subsequent venography in 12 of these revealed a false-positive rate of 4.0%; there was one false-negative result giving a sensitivity of 85.7%. A venographic study of 46 other patients clinically suspected of having a proximal deep-vein thrombosis confirmed this sensitivity. The iliofemoral thrombosis rate was 3.9% after total hip replacement and this rate increased significantly in the group of patients over 70 kg in weight. Impedance plethysmography was found to be a useful non-invasive screening procedure for potentially fatal proximal venous thrombosis.

The calculation of femoral anteversion using a static ultrasound scanner has been compared with results obtained by computer tomographic (CT) scanning. Assuming the CT results to be accurate, the ultrasound method was frequently found to be unreliable.

Seven patients with Ewing's sarcoma of the pelvis were treated by chemotherapy followed by wide resection of the primary tumour. Although good function after operation is possible, survival in this series reflects the poor prognosis associated with the disease; two patients died, two are alive with local recurrence and metastases and three patients are alive with no evidence of disease.

We report the long-term clinical follow-up and survivorship analysis of 40 distal femoral replacements performed between 1964 and 1980 for traumatic, locally aggressive and malignant conditions. Custom-made prostheses with fully-constrained knee joints were used to replace a mean of 42% of the length of the femur. Survivorship analysis showed a cumulative success rate of 80% at eight years, with no subsequent deterioration at 18 years. Clinical assessment revealed 78% excellent or good results. Failure was due to infection in three cases, and in two to fracture of a now-outmoded femoral stem.

Complete dislocation of the knee is a relatively rare condition. When it occurs as a result of high-velocity injury, such as in a road traffic accident, associated vascular injury is generally suspected. In low-velocity injuries, however, distal pulses are often maintained throughout, and the possibility of vascular injury may erroneously be discounted. We report four cases of low-velocity dislocation of the knee, only one of which had an overt vascular disruption, but three of which had arterial damage. On the basis of our experiences, we recommend arteriography in all cases of complete dislocation of the knee.

The detection and recording of vibration emission from human joints, a technique which we have termed "vibration arthrography", is a sensitive, non-invasive method for the objective study of the locomotor system. Using vibration sensors attached to bony prominences around the knee, we studied the joints of both normal and symptomatic subjects. Normal subjects produced three signal types--physiological patellofemoral crepitus, patellar clicks, and the lateral band signal. In symptomatic subjects we identified and categorised many signal types and related them to pathology. Lesions of the menisci produced distinctive signals, and it was possible not only to lateralise the tear, but in many cases to determine the type of meniscal injury present. Vibration arthrography promises to be a useful tool in the non-invasive diagnosis of knee disorders.

A logical, objective and reproducible grading system for the pivot shift test is proposed. The rationale is based on performing the examination in varying positions of rotation of the tibia, allowing the type and degree of the different laxities to be defined and quantified. The system has been assessed against a new "unblocked" test for anterior subluxation and against radiographic measurements, operative findings and results. This grading system can be valuable in pre-operative assessment and planning and its use in postoperative evaluation would enable results from different centres and different procedures to be compared more accurately.

In nine patients with chronic compartment syndrome, the intramuscular pressure and muscle blood flow during constant dynamic exercise was studied by the microcapillary infusion method and by the 133-xenon clearance technique. Although muscle blood flow was normal at the start of exercise, pain and impaired muscle function eventually developed; muscle blood flow decreased while muscle relaxation pressure increased. The changes of muscle blood flow could not be correlated with any change of mean muscle pressure during exercise. Eight months after fasciotomy the exercise test was repeated. Patients experienced no symptoms and the muscle relaxation pressure and blood flow during exercise were normal. It is suggested that chronic compartment syndrome is due to increased muscle relaxation pressure during exercise which causes decreased muscle blood flow, leading to ischaemic pain and impaired muscle function.

We describe the technique of wedge resection for revision of an amputation stump, and report the results of this at below-knee level in 57 patients with peripheral vascular disease; healing occurred in 42 of these (74%).

Three women with osteoarthritis of the knee presented after sudden worsening of their symptoms. In each case this was found to be due to a stress fracture of the tibia. With treatment by rest and reduced activity, the fracture healed uneventfully in all three patients.

Four types of prosthetic replacement for the anterior cruciate ligament (carbon fibre, carbon fibre and Dacron composite, Dacron alone and bovine xenograft) were assessed at three, six and 12 months after implantation in the knees of New Zealand white rabbits. The synovium and both intra-articular and intra-osseous portions of the ligaments were examined macroscopically, by light microscopy and by scanning electron microscopy. All the knees showed mild synovitis, and there was no significant growth into the intra-articular part of any ligament. Carbon fibre and xenograft did not appear to be suitable materials in this animal model. The composite ligament showed short-term ingrowth of fibrous tissue only into the periphery of the sheath in its intra-osseous portion, whereas the Dacron ligament showed progressive fibrous tissue ingrowth with some bony incorporation of its outer fibres.

We describe three children with symptoms of damage to the attachment of an anomalous ossific centre of the lower fibular epiphysis. All three were aged 8 to 10 years at the time of the initial injury, had suffered recurrent ankle sprains and had well localised and consistent tenderness precisely at the site of the anomalous ossific centre. All their symptoms were relieved by excision of the ossicle with reconstitution of the fibular collateral ligament. Whilst a separate secondary centre of ossification at the lower fibula is present in 1% of healthy children between the ages of 6 and 12 years, the condition described is extremely uncommon. Excision of the fragment should be reserved for those patients with recalcitrant symptoms and with consistent tenderness precisely at the site of the accessory ossicle.

We reviewed 13 cases of osteochondritis dissecans of the patella followed-up for 18 months to 19 years. Two were treated conservatively with excellent results, and 11 by operation with six excellent, four good and one fair result. There was complete radiographic healing of the defect in 10 cases and partial healing in three. The size of the osteochondritic lesion appeared to be of prognostic significance. Osteochondritis dissecans of the patella is the result of repeated minor injuries to the articular surface. Operation is indicated for persistent pain, intra-articular loose bodies and subchondral sclerosis; excision of the fragment and curettage of the crater, with or without drilling, is recommended.

A prospective study of 295 infantry recruits has shown that the mediolateral width of the tibia measured radiographically at each of three different levels in the bone had a statistically significant correlation with the total incidence of stress fractures as well as with those in the tibia alone or the femur alone. A narrow tibial width was shown to be a risk factor, but cortical thickness was not found to be significant.

We describe a congenital deformity of the foot which is characterised by calcaneus at the ankle and valgus at the subtalar joint; spontaneous improvement does not occur and serial casting results in incomplete or impermanent correction of the deformities. Experience with five feet in four children indicates that release of the ligaments and tendons anterior and lateral to the ankle and lateral to the subtalar joint is the minimum surgery necessary; subtalar arthrodesis may be required in addition. The foot deformity described may occur as an isolated condition or in association with multiple congenital anomalies. The possibility of a neurological deficit should always be excluded.

Twenty-nine bone defects caused by chronic osteomyelitis have been treated by radical excision of necrotic bone followed by packing the cavities with cancellous homografts held in position by a fibrin sealant. At follow-up three years after operation all except one had healed, though one case had needed a repeat operation. Good incorporation and remodelling of the grafts was observed even when the osseous bed was severely sclerosed.