A total of 45 tibial shaft fractures, all conservatively treated and with union delayed for more than 16 but less than 32 weeks were entered in a double-blind multi-centre trial. The fractures were selected for their liability to delayed union by the presence of moderate or severe displacement, angulation or comminution or a compound lesion with moderate or severe injury to skin and soft tissues. Treatment was by plaster immobilisation in all, with active electromagnetic stimulation units in 20 patients and dummy control units in 25 patients for 12 weeks. Radiographs were assessed blindly and independently by a radiologist and an orthopaedic surgeon. Statistical analysis showed the treatment groups to be comparable except in their age distribution, but age was not found to affect the outcome and the effect of treatment was consistent for each age group. The radiologist's assessment of the active group showed radiological union in five fractures, progress to union in five but no progress to union in 10. In the control group there was union in one fracture and progress towards union in one but no progress in 23. Using Fisher's exact test, the results were very significantly in favour of the active group (p = 0.002). The orthopaedic surgeon's assessment showed union in nine fractures and absence of union in 11 fractures in the active group. There was union in three fractures and absence of union in 22 fractures in the control group. These results were also significantly in favour of the active group (p = 0.02). It was concluded that pulsed electromagnetic fields significantly influence healing in tibial fractures with delayed union.

New methods of limb lengthening are being adopted in the hope of overcoming the poor osteogenic responses characteristic of distraction. Delay between the osteotomy and starting distraction is said to be important but there is little experimental evidence. We have compared immediate with delayed distraction in the rabbit tibia and shown that delay is an important factor in promoting osteogenesis. It seems that its effects are partly mediated by an improvement in the extra-osseous blood supply.

We reviewed 57 adult patients at an average of 37 months after early internal fixation for displaced fractures of the distal humerus. Two-thirds had intercondylar (Muller type C) fractures, and one-third had articular comminution (type C3). A chevron olecranon osteotomy was used, with early active movement after fixation. Results were good or excellent in 76% with an average range of movement of 115 degrees. Early stable fixation by an experienced surgeon is recommended for these fractures.

We report a prospective study of 55 patients with acute primary patellar dislocation, all treated by operation and followed up for at least two years. Diagnosis was based on the history of a lateral displacement, with medial tenderness and a positive apprehension test; redislocations were excluded. Before operation, the difference in lateral shift on skyline views of the injured and control patellae was highly significant. At operation, rupture of the medial retinaculum of the patella was seen in all but one case. There were medial marginal fractures of the patella in 23 cases. Subjective results of the operation were excellent or good in 44 of the 55 at two years with a redislocation rate of only 9%. Most patients were able to return to the same level of sporting activity as before the injury.

We have shown that stress fractures can be induced in the tibial diaphysis of an animal model by the repeated application of non-traumatic impulsive loads. The right hind limbs of 31 rabbits were loaded for three to nine weeks and changes in the bone were monitored by radiography and bone scintigraphy. The presence of stress fractures was confirmed histologically in some cases. Most animals sustained a stress fracture within six weeks and there was a positive correspondence between scintigraphic change and radiological evidence. Microscopic damage was evident at the sites of positive bone scans. The progression, location, and time of onset of stress fractures in this animal model were similar to those in clinical reports, making the model a useful one for the study of the aetiology of stress fractures.

We report four cases of fracture of the cuboid treated by open reduction, bone grafting where necessary and internal fixation. We recommend this treatment where there is appreciable displacement of one or more of the articular surfaces. The preliminary results were better than those previously reported for conservative treatment or for later midtarsal fusion.

Computed tomography was performed on 40 patients with recent hip trauma. Radiographs of 25 showed a fracture of the femoral neck with slight displacement; 24 of these had intra-articular fluid and 20 had a lipohaemarthrosis on the CT scan. In 15 patients, radiographs at the time of admission were normal but suspicion of fracture remained. A fracture was later verified in five patients, four of whom had lipohaemarthrosis on admission. In the remaining 10 patients no fracture could be detected; only one patient had a hip joint effusion but no free fat. Thus all 24 patients with lipohaemarthrosis had an intracapsular fracture of the hip. We suggest CT for patients with hip trauma and negative radiographs. The presence of a lipohaemarthrosis of the hip strongly suggests an intra-articular fracture of either the femoral neck or the acetabulum.

We report a retrospective study of 54 acetabular fractures treated by open reduction and internal fixation, with an average follow-up of 9.6 years (3 to 17). Reduction leaving displacement of less than or equal to 2 mm was achieved in 36 hips (67%); good or excellent functional results were obtained in 33 patients (61%). Early complications requiring re-operation included postoperative loss of reduction in one case and an intra-articular screw in another. Arthrodesis or total hip arthroplasty had been performed in 10 patients (19%) who had late symptomatic degenerative changes. Failure to obtain accurate reduction was the most important factor leading to a poor result, but heterotopic calcification caused poor results in seven patients, five of whom had had an anatomical reduction.

We performed 41 core decompressions in 32 patients for stage I or stage II osteonecrosis of the femoral head. The intra-osseous pressure at the intertrochanteric level was raised in 28 (68%) and there was histological confirmation of necrosis in 36 hips (88%). After a follow-up of 10 to 84 months (mean 31) nine of the 12 stage I hips (75%) showed significant clinical or radiological deterioration; no evidence of necrosis had been found in the core specimens of the other three hips. Of the 29 hips in stage II, 25 (86%) showed significant radiological deterioration, and only five (17%) had improved clinically. We believe that once necrosis has occurred, core decompression will not significantly influence the subsequent course of the disease.

There has been a long-standing debate as to whether medullary or periosteal flow is the dominant vascular supply during the healing of diaphyseal fractures. We used radioactive microspheres to quantify blood flow to the canine tibia two weeks after an osteotomy. There was a significant contribution from the periosteum to the blood supply of healing cortical bone after nutrient artery ligation, with a reversal of flow from a centrifugal to a centripetal direction. Our study has confirmed the qualitative observations of Trueta (1974) regarding the significant recruitment of vessels from surrounding soft tissue during fracture healing. We have not studied the later stages of healing.

Intracompartmental pressures of 66 patients with 67 tibial fractures treated by intramedullary nailing were monitored. There was no difference in the pressures recorded between the different Tscherne fracture types, between open and closed fractures, between low energy and high energy injuries or between fractures dealt with early and those not treated until more than 24 hours after injury. The overall incidence of acute compartment syndrome was 1.5%. No patient developed any sequelae of compartment syndrome. We conclude that intramedullary nailing does not increase the incidence of acute compartment syndrome in tibial fractures and that delay does not reduce the risk of raised compartment pressures.

We used the MacIntosh over-the-top repair combined with a popliteal tendon plasty in 273 athletically active patients with chronic incapacitating functional instability due to anterior cruciate ligament rupture; 244 were reviewed at three to nine years after operation. We describe the technique and its results, with functional evaluation by the Tegner and Lysholm system. Excellent or good results were obtained in 71%; most of the 29% fair or poor results were due to extensive meniscal and degenerative changes. In a group of 11 patients with excellent results arthroscopic and histological findings were encouraging, showing good incorporation of the graft.

We assessed 16 patients before and after high tibial osteotomy by electrophysiological recordings, creatine phosphokinase levels, radiographs and intracompartmental pressure monitoring. We found mild electrophysiological abnormalities pre-operatively in 12 of the 16 patients, but postoperatively these had deteriorated in 11 of the 14 patients studied. Creatine phosphokinase levels, compartment pressure and radiological deformity were not predictive of the development of postoperative common peroneal nerve palsy. Patients who also had a proximal fibular osteotomy had greater electrical abnormalities postoperatively and two of them developed common peroneal palsies. Proximal fibular osteotomy appears to be a causative factor in the development of common peroneal nerve palsy; more work is needed on the blood supply of the nerve.

After severe poliomyelitis, which is still relatively common in some developing countries, lateral rotation deformity of the tibia may occur. We have reviewed 51 patients treated by O'Donoghue's rotation osteotomy of the tibia. An average lateral rotation deformity of 57 degrees was fully corrected in all the patients, and in 38 of them the graft obtained during the osteotomy was used for a simultaneous Grice-Green subtalar arthrodesis in one or both feet. All the osteotomies united in an average of 11 weeks, some with relatively minor and unintentional posterior angulation. There was no posterior angulation when the length of the step cut osteotomy was 4.5 cm or more. O'Donoghue's osteotomy is a simple and safe operation, being particularly advantageous if a Grice-Green procedure is also required.

In 44 consecutive patients, 60 porous-coated anatomic total knee (PCA) prostheses with a porous-coated central tibial stem were implanted without using cement. The clinical results and bony remodelling have been assessed after five years' follow-up. The average Hospital for Special Surgery knee score was 33.1 before operation and 95.7 at the latest follow-up, while the average range of movement improved from 63 degrees to 123 degrees. No subsidence or migration of the components was seen. A radiodense line appeared around the components at six months to one year after the operation and became more dense with time. There was no evidence of bone resorption related to stress-shielding in the tibial plateau.

Augmentation of the acetabular component of total hip replacements is a method of increasing stability and preventing recurrent dislocation. We report a series of mechanical experiments designed to evaluate the turning moments and angles required to dislocate standard, long posterior wall and two different augmented prostheses.

We reviewed the results of 545 consecutive total hip replacements using a cementless non-coated high-density polyethylene acetabular component combined with a cemented Muller stem at five to 10 years. In all, 421 patients (445 hips) were available for review, 118 by questionnaire and 303 by examination and radiography. Of these, 86% had a good or excellent result. We found a high rate of radiological loosening of the cup after the sixth year, and a high rate of clinical loosening after the eighth year. Loosening was commoner in women, in younger patients and where a smaller size of acetabulum had been used. Calcar resorption was significantly related to loosening of the acetabulum. Loosening appeared to be mainly due to polyethylene debris produced by micro-movement of the acetabulum against the bone, which had resulted in a giant cell foreign body reaction and subsequent bone erosion. We have abandoned the use of this prosthesis and suggest that direct contact between bone and polyethylene should be prevented by a coating of metal or some other material.

A leading problem with cementless hip replacement is thigh pain, probably due to some degree of loosening. This is most pronounced during activities such as stair climbing or getting up from a chair. Our study compares the immediate fixation of three stems in widespread clinical use, using a cadaver test simulation in which the femur was horizontal, and cyclic forces acted vertically downward on the prosthetic head with gradual increments of load. We implanted and tested 18 pairs of femurs, making analyses between stem types by right to left comparisons. We found no statistically significant differences in loosening between cementless AML and PCA prostheses, but cemented stems withstood greater loads than uncemented stems by a factor of five or more.

We present a new method of trochanter stabilisation designed for use in difficult revision hip arthroplasties. A fixator is secured to the metaphysis of the femur, and its two malleable prongs encompass the trochanter fragment and stabilise it using the tension band principle. The fixator is versatile, simple to apply and has better mechanical properties than any technique using wires. We reviewed 49 revisions after a mean follow-up of 40 months. Patients had been mobilised early, but there were no detachments or displacements from the initial postoperative position. Although 31% of patients were osteoporotic and 16% had poor trochanter fragments, there was bony union in 46 of the 49 hips, the remaining three developing stable fibrous union.

We studied the radiographs of 211 low-friction arthroplasties, followed for five to 15 years after operation. The first 92 simple hemispherical sockets were fixed with an old technique: eburnated bone in the acetabular roof was removed and only a few large anchor holes were bored for cement fixation. With the next 119 sockets, 111 of which were flanged, the eburnated and subchondral bone was preserved and multiple small anchor holes were used. The modified technique and the use of flanged sockets significantly improved the late radiological findings as regards socket demarcation and wear. On the femoral side, the intramedullary canal filling ratio, the distal packing of cement, calcar resorption and atrophy of the femoral cortex were correlated with prosthetic subsidence.

Bleeding from cancellous bone causes lamination within bone cement and at its prosthetic interfaces, and weakens the fixation of joint replacements. We examined the effects of anaesthesia and blood pressure on bleeding in human cancellous bone, and investigated the local response to freezing saline, 1:200,000 adrenaline and hydrogen peroxide. Spinal anaesthesia reduced cancellous bleeding by an average of 44%, local freezing saline by 24%. Saline at room temperature, adrenaline solution and hydrogen peroxide each reduced it by 14%. The effects of spinal anaesthesia and of freezing saline were additive: used together they reduced bleeding by 56%. The reduction of blood contamination of cement and its interfaces should contribute to better prosthetic fixation.

We studied the safety of combining the postoperative use of a non-steroidal anti-inflammatory drug with low-dose heparin. In a double-blind, placebo-controlled clinical trial we reviewed the complications in 235 patients after total hip replacement, all treated with low-dose heparin and either indomethacin or a placebo. The incidence and type of complications in the two groups were nearly equal; indomethacin-treated patients had no increase in complications related to bleeding. Postoperative bleeding into drains was marginally greater in the indomethacin group, although the difference was not statistically significant. We conclude that treatment with indomethacin and low-dose heparin after hip replacement does not significantly increase the bleeding or other complications. We also found that patients receiving indomethacin were mobilised an average of one day before those on placebo.

We have reviewed 107 patients of 80 years or over who underwent primary total hip replacement. They had many more complications than younger patients. Thus, acute dislocation occurred in 15%, and became chronic in 9%; there were femoral shaft fractures in 4.6% and these, with shaft perforation gave universally poor results. Nevertheless, 75% of patients had a satisfactory outcome, with worthwhile relief of pain. It would seem sensible to warn elderly patients and their relatives of the increased risks in this age group.

We describe a rare form of congenital snapping knee. In six knees in four children, the tibia subluxed anteriorly on the femur when the knee was extended and reduced spontaneously on flexion. The abnormal movements were seen and felt as sudden snaps or clunks at about 30 degrees of flexion. All six knees showed similar dysplastic features, although the patients had different clinical syndromes. The mechanism of the subluxation and its management are discussed.

We describe a simple, quick ultrasound screening test for CDH, and its use in a prospective study of babies with a 'high risk' factor, over one year from January 1987. From a birth population of 3,879, 812 hip scans were performed on 406 babies and 98 babies were abnormal. So far, there have been no late cases of CDH. Family history, breech malposition, and postural foot deformities were confirmed to be important risk factors, but babies with a simple click were equally at risk. Our early results indicate that a large proportion of the potential late cases are contained within our extended high-risk group.

We treated 91 congenital club feet in 59 children using a modified Denis Browne splint, and followed them for an average of 6 years and 3 months. The modified splint has an aluminium crossbar holding a pair of plastic shoe inserts moulded into corrected positions, and its use was started in children whose ages ranged from four weeks to nine months. Operation was later required in only 31 feet in 20 children. We have reviewed the other 60 feet in 39 children treated by splintage alone. All 60 feet had excellent or good function and from radiographic assessment, equinus, adduction, varus and cavus deformities had all been well corrected. Our results show that the modified splint can give good results.

Condensing osteitis of the clavicle was first described as a disease entity in 1974. There is painful localised swelling of the clavicle of undetermined origin, with increased radio-density, but an infective aetiology has not been excluded by previous authors. We report three children with the clinical and radiological findings of 'condensing osteitis'. Two of them had raised levels of antistaphylolysin titres and all responded to antibiotic therapy. We conclude that condensing osteitis is due to low-grade staphylococcal osteomyelitis; biopsy and treatment by antibiotics is recommended.

Delay in the diagnosis of posterior shoulder dislocation is common. We present two such cases treated satisfactorily by rotation osteotomy of the surgical neck of the humerus and discuss the indications for this procedure.

Among 41 adult haemophiliacs 15 suffered from shoulder symptoms. We examined 12 patients by radiography and ultrasound. Four had bilateral symptoms making a total of 16 symptomatic shoulders. Of these, 10 had abnormal ultrasound scans with eight having evidence of rotator cuff tears. Evidence of bicipital tendonitis was found in two. Pain with loss of range of movement and a positive impingement sign was the most reliable clinical indicator of a cuff tear. Joint incongruity and superior migration of the humeral head were the best radiographic indicators. Rotator cuff tears are a common component of haemophilic arthropathy of the shoulder.

Thirteen elbows affected by severe haemophilic arthropathy and treated by silastic interposition arthroplasty were followed up for at least five years. The severity of pain, the frequency and severity of spontaneous haemorrhage and the range of movement were assessed before operation and at review. All patients were much improved and needed less factor replacement. Three elbows were revised, one for infection and two because of fragmentation of the silastic sheet. They regained good function following revision.

We obtained specimens of growth-plate cartilage from four patients with osteogenesis imperfecta. Light microscopy showed structural changes in the tissue and morphological changes in chondrocytes and matrix, particularly in the hypertrophic zone. There were changes in the process of calcification in the primary mineralisation zone of the cartilage. We also found histochemical changes in the matrix glycosaminoglycans (GAGs) in the zones where physiological mineralisation was disturbed and where the trabeculae were interrupted and poorly mineralised. In addition to the known molecular defects in collagen, changes in GAGs and non-collagenous proteins are important factors in the pathogenesis of the disease.

Two different classifications of discograms have been used in a prospective study of 279 injected discs in 100 patients. The five-stage classification of Adams, Dolan and Hutton (1986) showed increased degeneration in the lower lumbar discs and more degenerative changes in men than in women. Exact reproduction of the patient's pain on injection was more common in fissured or ruptured discs than in less degenerate discs, with 81% sensitivity and 64% specificity of the discogram for pain. The additional information obtained by comparing computerised tomography (CT) with discograms was minimal. Discography was found to be useful in the evaluation of chronic low back pain in patients whose ordinary CT scans, myelograms and flexion-extension radiographs were normal. In spondylolysis and spondylolisthesis, discography can disclose whether fusion needs to be extended above the lytic level, and it may show if the pain in patients who have had posterolateral fusion is discogenic. Thus, discography gives information which is useful in deciding whether to operate on patients with chronic low back pain.

We report a case of benign giant cell tumour which over a 20-year period has given rise to pulmonary and bony metastases. The indolent nature of these metastases is remarkable, with considerable implications for the long-term management of such cases.

We reviewed 34 hindquarter amputations performed for malignant tumours around the hip from 1971 to 1988, classifying them as palliative or curative according to the resection margins or the presence of disseminated disease at the time of surgery. There were three peri-operative deaths, 12 palliative and 19 curative procedures. Ten patients died of disseminated disease within a year of surgery, eight of whom had had a palliative operation. Three patients died between one and five years after palliative surgery. One died of unrelated disease at nine years. Seventeen patients are disease free an average of 31 months from surgery, 16 after curative procedures. The median survival after palliative amputations was six months and the 5-year survival rate for curative cases was 83%.

We investigated 57 patients with sickle cell anaemia (HbSS) and bone and joint changes. Osteonecrosis simulating a wide range of conditions was a common radiological feature, and osteomyelitis occurred in 61% of cases. Salmonella species were the commonest causative organisms, occurring in 71% of patients with osteomyelitis, although salmonella septic arthritis occurred in only two. The distinction between vaso-occlusive bone crisis and acute osteomyelitis was often difficult since the classical clinical and radiological features and laboratory findings also occurred in bone infarction, a common feature of the disease.

We report a case of systemic Penicillium marneffei infection in a Chinese woman who presented with multiple osteolytic lesions and radiographic changes similar to those seen in other fungal osteomyelitides. This infection is often misdiagnosed as tuberculosis and has a high mortality rate. The correct diagnosis is important since early antifungal therapy is life-saving.

We reviewed 16 patients with salmonella osteitis or septic arthritis. All patients were immunologically normal and none had a history of typhoid fever. We discuss the importance of obtaining a bacteriological diagnosis and provide guidelines on the duration of antibiotic treatment.

We treated 249 patients for ingrowing toenails in a prospective randomised study which compared wedge excision with segmental phenol cauterisation. Follow-up of 97% was at a minimum of 14 months. The analgesic requirement was significantly lower after phenol cauterisation (p less than 0.001), and significantly fewer patients needed to miss school or work (p = 0.001). Recurrence of ingrowth was seen in 16% after wedge excision and 9.6% after phenol cauterisation (not significant), but re-operation was significantly less frequent after phenol (p less than 0.01). Phenol cauterisation gives better short-term and long-term results than wedge resection.

We report a double-blind study of the effectiveness of indomethacin suppositories in the relief of postoperative pain and the reduction in demand for opiate analgesia following orthopaedic procedures.

We have reviewed seven cases of synovitis caused by date palm thorns, six involving the knee and one the ankle. Five were satisfactorily treated by thorough irrigation of the joint with normal saline, but two required arthrotomy and synovectomy. All made a full recovery.

Our experience of five children with chronic thorn synovitis indicates that removal of free thorn fragments and all the macroscopically abnormal synovium is required in order to achieve a complete cure. Four children required total synovectomy for diffuse proliferative synovitis and one needed partial synovectomy of the area immediately around the embedded thorn. Joint washouts and partial synovectomy were unsuccessful in children with diffuse synovitis. Careful review is required following removal of a thorn as fragments may be retained within the joint.

We studied pressure in the carpal tunnel in patients with carpal tunnel syndrome and in normal control subjects, using a slit catheter and recording in the neutral position, 90 degrees dorsiflexion, and 90 degrees palmarflexion of the wrist. For each position the mean pressure in the patients was very significantly higher than in the controls, the highest pressure being in 90 degrees dorsiflexion, and the lowest in the neutral position. Using an upper limit of normal pressure of 5.5 mmHg in the neutral position gave a diagnostic sensitivity of 78.7%, a specificity of 78.1%, an accuracy of 78.5%, and a positive predictive value of 87.3%.