We reviewed the records of 431 patients who had open reduction and internal fixation of the scaphoid performed by one surgeon (TJH) over a 13-year period. The Herbert bone screw provided adequate internal fixation without the use of plaster immobilisation, promoting a rapid functional recovery.

On average, patients returned to work 4.7 weeks after surgery and wrist function was significantly improved, even when the fracture failed to unite. Healing rates for acute fractures were better than those reported for plaster immobilisation and were independent of fracture location. In the case of established nonunions, healing depended on the stage and location of the fracture, but the progress of arthritis was halted and carpal collapse significantly improved.

Internal fixation of the scaphoid using the Herbert bone screw, although technically demanding, has few complications and appears to offer significant advantages over other methods of treatment.

We reviewed 26 consecutive men of mean age 28 years who had had wedge bone grafting and Herbert screw fixation for symptomatic established nonunion of the waist of the scaphoid. The period between injury and operation averaged 30 months (10 to 96), and 11 of the 26 patients had had previous operations, seven with bone grafts.

At a mean follow-up of 14 months (6 to 42) 25 fractures (95%) had united at a median time of four months. Symptoms were improved in all patients. The outcome was not related to the time between injury and surgery or to pre-existing degenerative changes. Previous surgery carried a worse prognosis.

The technique is difficult but can achieve union even when previous surgery and bone grafting have failed. The usual result is improved function and some relief of pain.

We have assessed the value of using a simple apparatus, the Carpal Box, in patients with suspected scaphoid fracture, to produce elongated and magnified radiographs of the carpus. The interobserver agreement between 60 observers of standard scaphoid radiographs and longitudinal and transverse Carpal Box radiographs (X-CB) was compared in 11 patients. Three-phase bone scanning was used as a comparative standard. If at least 75% of the observers agreed and the result was confirmed by three-phase bone scanning, the outcome was termed reliable.

Scaphoid radiographs and the longitudinal X-CB films were reliable in four patients and the transverse X-CB films in six patients. The bone scan suggested a scaphoid fracture in five of the 11 patients.

Agreement in the interpretation of the standard scaphoid radiographs was acceptable in only 36% of patients: in interpretation of transverse Carpal Box radiographs this figure increased to 55%.

Decreasing proprioception of the knee is multifactorial and is a function of age and degenerative joint disease. Soft-tissue release during total knee replacement may have an influence. We have quantified soft-tissue imbalance at the time of knee replacement and attempted to eliminate it at full extension, using established methods.

We studied the influence of residual soft-tissue imbalance on postoperative proprioception, assessing this in 38 patients before total knee replacement and at three and six months postoperatively.

We found that proprioception improved in varus knees at three and six months after soft-tissue balancing procedures. Knees balanced in full extension and in flexion (< ±2°) showed a significant improvement in proprioception (p < 0.0005) whereas those which were not balanced in flexion but fully balanced in extension had no significant improvement. We conclude that soft-tissue balance in both flexion and extension is important to allow satisfactory postoperative proprioception of the knee.

Aseptic loosening is seen in a significant proportion of cemented total hip replacements (THR). In a small subgroup of patients who suffer early loosening polyethylene debris is unlikely to be responsible. We recently reported one case of allergic contact dermatitis to N,N-dimethylparatoluidine (DMT), an accelerator used in bone cement. We have therefore investigated this using skin-patch tests to a variety of substances including metals, polyethylene and the separated individual components of Simplex cement.

We studied 70 patients, 15 with aseptic loosening less than two years after THR, 25 with satisfactory long-term cemented fixation, five with infected loosening of cemented THRs and 25 awaiting hip arthroplasty. We found seven positive reactions to DMT, all of them in patients with the rapid onset of aseptic loosening.

Allergy to DMT is recognised in the dental profession in respect of the ‘denture sore mouth’ syndrome, and could also be an occupational hazard since some industrial glues contain DMT. Our results suggest the need for awareness of possible previous dental or occupational exposure to the constituents of bone cement. We recommend the use of skin-patch testing in high-risk cases.

We performed a prospective, randomised controlled trial in 177 patients who were having either total hip or knee replacement, to evaluate the use of both above- and below-knee graded compression stockings in the prevention of deep-vein thrombosis (DVT).

With above-knee stockings, we found no significant reduction of the overall, proximal or major calf (> 5 cm) DVT rates. With below-knee stockings, the overall thrombosis rate was similar to that of the control group but the stockings appeared to have altered the pattern of thrombosis. Patients who had total hip replacement and wore below-knee stockings had a significantly higher rate of proximal or major calf DVT (p = 0.03). This pattern was reversed in patients with total knee replacement who developed a significantly lower rate of proximal or major calf DVT with below-knee stockings (p < 0.05).

Our results showed that, with the exception of below-knee stockings in knee replacement patients, graded compression stockings were ineffective in preventing DVT after hip or knee replacement surgery.

There are many studies of long-term recovery from major joint arthroplasty, but little is known about the first days and weeks after operation. We measured function, emotional state and life evaluation before arthroplasty and at seven and 50 days after in a consecutive series of 40 hip and 23 knee replacements.

Pain was relieved significantly at seven days after hip arthroplasty and even more at 50 days. In knee patients, pain relief was modest and was not apparent until 50 days. Functional ability was much improved by 50 days in hip patients, but hardly changed in knee patients. Positive mood and life satisfaction did not improve in either group.

Our findings will help with more accurate information for patients before operation and also in judging the rate of recovery.

We describe a modified lateral approach to the hip which exploits the functional continuity of gluteus medius and vastus lateralis and their dense crescentic attachment to the greater trochanter. The gluteus medius is not incised or split, but is detached and mobilised with gluteus minimus as one unit. This facilitates reattachment of the glutei and helps to preserve abductor function.

After a severe ankle sprain the incidence of residual complaints, particularly on the medial side of the joint, is high. We studied a consecutive series of 30 patients who had operative repair of acute ruptures of lateral ligaments. During operation, arthroscopy revealed a fresh injury to the articular cartilage in 20 ankles, in 19 at the tip and/or anterior distal part of the medial malleolus as well as on the opposite medial facet of the talus. In six patients, a loose piece of articular cartilage was found.

We conclude that in patients with a rupture of one or more of the lateral ankle ligaments after an inversion injury, an impingement occurs between the medial malleolus and the medial facet of the talus. Patients with a lesion of the lateral ankle ligament caused by a high-velocity injury (a faulty landing during jumping or running) had a higher incidence of macroscopic cartilage damage (p < 0.01), medially-located pressure pain (p = 0.06) and medially-located complaints at one-year follow-up (p = 0.02) than those with a low-velocity injury (a stumble).

We compared two conservative methods of treating Weber B1 (Lauge-Hansen supination-eversion 2) isolated fractures of the lateral malleolus in 65 patients. Treatment by immediate weight-bearing and mobilisation resulted in earlier rehabilitation than immobilisation for four weeks in a plaster cast. There was no significant difference in the amount of pain experienced or in the requirement for analgesics and early mobilisation was not associated with any complications. We therefore advocate early mobilisation for these stable ankle fractures.

We treated 17 knees in 15 patients with severe ligament derangement and dislocation by open repair and reconstruction. We assessed the competence of all structures thought to be important for stability by clinical examination, MRI interpretation, and surgery.

Our findings showed that in these polytrauma patients clinical examination was not an accurate predictor of the extent or site of soft-tissue injury (53% to 82% correct) due mainly to the limitations of associated injuries. MRI was more accurate (85% to 100% correct) except for a negative result for the lateral collateral ligament and posterolateral capsule.

The detail and reliability of MRI are invaluable in the preoperative planning of the surgical repair and reconstruction of dislocated knees.

We performed a prospective, randomised study on 50 patients with Tscherne C1 tibial diaphyseal fractures comparing treatment with reamed and unreamed intramedullary nails. Our results show that reamed nailing is associated with a significantly lower time to union and a reduced requirement for a further operation. Unreamed nailing should not be used in the treatment of the common Tscherne C1 tibial fracture.

We present three young men who sustained closed diaphyseal fracture of the tibia and later developed severe osteocutaneous necrosis induced by heat during intramedullary reaming. They all had a narrow medullary cavity and in all a tourniquet had been used. Each developed a pretibial cutaneous blister soon after operation. In the following month severe osteomyelitis ensued, requiring segmental resection and osteocutaneous reconstruction.

Fractures of the distal end of the radius should be treated on the same principles as other fractures involving joints. Displaced articular fractures require open reduction to allow anatomical reconstruction of both the radiocarpal and the radio-ulnar joints. For extra-articular fractures with severe comminution and shortening this enables the radial length to be re-established achieving radio-ulnar congruency.

Stable internal fixation can be achieved with two 2.0 AO titanium plates placed on each of the ‘lateral’ and the ‘intermediate’ columns of the wrist at an angle of 50° to 70°. This gives good stability despite the tiny dimensions of the plates, and allows early function. We report a series of 20 fractures treated by this method of internal fixation with satisfactory results in all.

We developed a 12-item questionnaire for completion by patients having shoulder operations other than stabilisation. A prospective study of 111 patients was undertaken before operation and at follow-up six months later. Each patient completed the new questionnaire and the SF36 form. Some filled in the Stanford Health Assessment Questionnaire (HAQ). An orthopaedic surgeon assessed the Constant shoulder score.

The single score derived from the questionnaire had a high internal consistency. Reproducibility, examined by test-retest reliability, was found to be satisfactory. The validity of the questionnaire was established by obtaining significant correlations in the expected direction with the Constant score and the relevant scales of the SF36 and the HAQ. Sensitivity to change was assessed by analysing the differences between the preoperative scores and those at follow-up. Changes in scores were compared with the patients’ responses to postoperative questions about their condition. The standardised effect size for the new questionnaire compared favourably with that for the SF36 and the HAQ. The new questionnaire was the most efficient in distinguishing patients who said that their shoulder was much better from all other patients.

The shoulder questionnaire provides a measure of outcome for shoulder operations which is short, practical, reliable, valid and sensitive to clinically important changes.

We reviewed 166 adult patients on long-term haemodialysis, dividing them into three groups according to the presence and type of shoulder pain. The 24 patients in group A, with spontaneous pain related to a supine posture, had been under haemodialysis for significantly longer than the others, and had a much higher incidence of carpal tunnel syndrome.

Open or arthroscopic resection of the coracoacromial ligament in 21 shoulders relieved pain during haemodialysis and night pain, and histological examination showed amyloid deposits and inflammatory-cell infiltration in the subacromial bursa in almost all cases, and in the tenosynovium of the bicipital groove in some.

We conclude that one type of shoulder pain experienced by patients on long-term haemodialysis is caused by the subacromial impingement of amyloid deposits. This should be distinguished from other types of shoulder pain, because it can be relieved by resection of the coracoacromial ligament.

The afferent pathways of discogenic low-back pain have not been fully investigated. We hypothesised that this pain was transmitted mainly by sympathetic afferent fibres in the L2 nerve root, and in 33 patients we used selective local anaesthesia of this nerve.

Low-back pain disappeared or significantly decreased in all patients after the injection. Needle insertion provoked pain which radiated to the low back in 23 patients and the area of skin hypoalgesia produced included the area of pre-existing pain in all but one. None of the nine patients with related sciatica had relief of that component of their symptoms.

Our findings show that the main afferent pathways of pain from the lower intervertebral discs are through the L2 spinal nerve root, presumably via sympathetic afferents from the sinuvertebral nerves. Discogenic low-back pain should be regarded as a visceral pain in respect of its neural pathways. Infiltration of the L2 nerve is a useful diagnostic test and also has some therapeutic value.

We have reviewed the cervical spine radiographs of 180 patients with athetoid cerebral palsy and compared them with those of 417 control subjects.

Disc degeneration occurred earlier and progressed more rapidly in the patients, with advanced disc degeneration in 51%, eight times the frequency in normal subjects. At the C3/4 and C4/5 levels, there was listhetic instability in 17% and 27% of the patients, respectively, again six and eight times more frequently than in the control subjects. Angular instability was seen, particularly at the C3/4, C4/5 and C5/6 levels.

We found a significantly higher incidence of narrowing of the cervical canal in the patients, notably at the C4 and C5 levels, where the average was 14.4 mm in the patients and 16.4 mm in normal subjects.

The combination of disc degeneration and listhetic instability with a narrow canal predisposes these patients to relatively rapid progression to a devastating neurological deficit.

We report a series of 15 children, six male and nine female, of average age 20 months, seen at a paediatric orthopaedic clinic with torticollis. Orthopaedic examination revealed a normal range of neck movement in all cases but in seven there was palpable tightness in the absence of true shortening or contracture of the sternomastoid muscle.

The patients were prospectively referred for ocular examination. In five of the 15 an ocular cause for the torticollis was detected with underaction of the superior oblique muscle in three, paresis of the lateral rectus muscle in one and nystagmus in one. Another two patients were found to have an abnormal ocular examination which was thought to be unrelated to their torticollis. Three of the patients with ocular torticollis required extra-ocular muscle surgery to abolish the head tilt and one of these had a tight sternomastoid muscle. Two of the non-ocular group had surgical release of the sternomastoid muscle; in the rest, the condition either resolved with physiotherapy or required no active treatment.

We recommend that all patients with torticollis and no clear orthopaedic cause are referred for ocular assessment since it is not possible clinically to distinguish ocular from non-ocular causes.

We analysed the short-term outcome after varus osteotomy for Perthes’ disease in 48 older children from south-west India, comparing them with 30 historical controls.

The children were between 7 and 12 years of age at the onset of the disease. All had stage-I or stage-II disease, with half or more of the epiphysis involved. The operated children had an open-wedge subtrochanteric varus osteotomy with derotation or extension and a trochanteric epiphyseodesis. Weight-bearing was avoided until late stage III. The non-operated children had been treated symptomatically by conservative methods.

At the time of healing, 62.5% of the operated group had spherical femoral heads compared with 20% of those treated non-operatively (p < 0.001). Of the operated children with Catterall group-IV involvement, 48% had good results as against 24% of the non-operated group (p < 0.05). The percentage increase in the radius of the affected femoral head compared with the normal side was significantly lower in children who had operations (14.68 v 25.65; p < 0.001).

We have shown that the short-term results of early surgical containment in children over seven years of age are satisfactory.

We analysed the incidence of avascular necrosis in 101 hips of 90 infants with congenital dislocation treated with the Pavlik harness and followed up for more than one year. Using ultrasonography in the flexed-abducted position the hips were classified as type A when the femoral head was displaced posteriorly, but within the socket and making contact with the posterior inner wall of the acetabulum; type B when it was in contact with the posterior margin of the acetabulum, with its centre at this level or anterior to it; and type C when it was displaced out of the socket, with its centre posterior to the posterior rim of the acetabulum.

Eighty-seven hips were reduced by the harness (86%), and seven of these developed avascular necrosis (8%). All 69 hips with type-A dislocation were reduced, and only one (1.4%) showed slight avascular necrosis. Eighteen (78.3%) of 23 hips with type-B dislocation were reduced, and six developed avascular necrosis (33.3%). In one hip, the femoral head was severely damaged. None of the nine hips with type-C dislocation was reduced in the harness.

We conclude that the Pavlik harness is indicated for type-A, but not for type-B or type-C dislocations.

We have followed the natural progress of newborn infants in whom ultrasound examination showed abnormalities in hips which appeared to be clinically normal. Over six years we saw 306 such children out of 9952 examined (31 per 1000 live births). The examination was repeated at two to three months and those who still showed an abnormality were followed up further.

At four to five months a standard radiograph was obtained, and treatment began if this and another ultrasound scan were both abnormal. At this stage, 291 infants had normal hips. In the 15 infants with abnormal hips there was no pronounced deterioration, none developed a frank dislocation, and all became normal after treatment in an abduction splint.

Newborn infants with abnormal and suspicious ultrasound findings who are normal on clinical examination do not need treatment from birth; most of these hips will settle spontaneously. Treatment can be postponed until the age of four to five months unless clinical instability develops or ultrasound shows dislocation. The criteria for treatment should be based on measurements by both ultrasound and radiography: both should show an abnormality before intervention is considered necessary.

Using a rat model, we created a bone-to-titanium interface and applied phagocytosable high-density polyethylene pArticles between the bone and implant, either initially or when the interface had matured. No fibrous membrane developed and no bone resorption was found.

If sliding movements were initiated at the interface after two weeks, there was formation of a fibrous membrane. The additional application of pArticles did not change the thickness of the membrane, and there were only minor qualitative changes. Creation of a membrane by movement followed by cessation of movement and the application of pArticles caused the membrane to persist, whereas in a pArticle-free control group bone-to-metal contact was re-established.

Our findings suggest that mechanical stimuli are of primary importance for prosthetic loosening, and that pArticles may modulate the later stages of the loosening process.

Resistance to infection may be influenced by foreign bodies such as devices for fracture fixation. It is known that stainless steel and commercially-pure titanium have different biocompatibilities. We have investigated susceptibility to infection after a local bacterial challenge using standard 2.0 dynamic compression plates of either stainless steel or titanium in rabbit tibiae. After the wounds had been closed, various concentrations of a strain of Staphylococcus aureus were inoculated percutaneously.

Under otherwise identical experimental conditions the rate of infection for steel plates (75%) was significantly higher than that for titanium plates (35%) (p < 0.05).

Improvement in the life expectancy of patients with primary bone tumours has led to increased emphasis on limb salvage and preservation of function.

Between 1979 and 1994 we used custom-made endoprostheses in 18 patients to reconstruct diaphyseal defects after excision of primary bone tumours. The mean age at operation was 26 years (9 to 64) and the median follow-up 65 months (6 to 188).

Fifteen patients have survived and are free from local or metastatic disease. Local recurrence developed in one patient. Using the modified Enneking functional scoring system, 77% of the patients achieved 80% or more of their premorbid functional capability. Mechanical loosening, limb shortening and secondary osteoarthritis were the main complications. There were no infections.

We conclude that diaphyseal endoprostheses offer a good clinical and functional outcome in the lower limb.

We reviewed retrospectively 236 consecutive patients seen in our soft-tissue sarcoma clinic. Of these, 95 had had a primary soft-tissue sarcoma excised elsewhere, but with histologically inadequate resection margins. All these patients had a secondary and wider re-excision.

The tissues removed at the secondary re-excision were examined histologically for the presence of residual tumour. Definite tumour tissue was found in 29 of 55 lower-limb specimens, 16 of 25 upper-limb, 7 of 10 trunk and 4 of 5 head and neck specimens. In 31 cases some residual tumour was visible macroscopically, and in 56 of the 95 patients (59%) the primary tumour had been incompletely excised.

Our results indicate that surgical assessment of the adequacy of excision is very inaccurate and that most local recurrences are the consequence of inadequate primary surgery. The large number of patients who had inadequate initial treatment emphasises the need for a co-ordinated multidisciplinary approach to the management of patients with soft-tissue sarcoma.