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.
An unusually wide pneumatic tourniquet has recently become available; we provide a simple formula for its use with a low but effective inflation pressure. A prospective, randomised and controlled trial in 600 lower limb and 150 upper limb operations is reported. The wide tourniquet (12.5 cm) was as effective at low pressure as was a conventional tourniquet (9 cm) inflated to significantly higher pressures. Fewer patients suffered from painful paraesthesiae after operation using the broad, low-pressure tourniquet.
We have made a retrospective comparison between the results of 49 high tibial osteotomies and 42 unicompartmental replacement arthroplasties performed for the treatment of osteoarthritis of the knee, assessed 5 to 10 years after operation. The type of operation depended on the policy of the consultant responsible for treatment but analysis of the pre-operative findings showed that the two groups were sufficiently similar for direct comparison between them. In the replacement group, 32 (76%) were good, 4 were fair, 3 were poor and 3 had been revised. In the osteotomy group 21 (43%) were good, 11 were fair, 7 were poor and 10 had been revised. It was concluded that, in this series, the results of unicompartmental replacement were significantly better and that this group had shown no sign of late deterioration.
A model of tourniquet ischaemia was developed in the hind limb of the rat, and the metabolic changes that occurred in the calf muscles were monitored by the non-invasive technique of phosphorus-31 nuclear magnetic resonance spectroscopy. During ischaemia the intramyocellular pH became acidic as the level of phosphocreatine declined and that of inorganic phosphate rose. Phosphocreatine was no longer detectable after approximately 2 hours and ATP was depleted after approximately 3.5 hours. Metabolic recovery was rapid (1 hour) if ATP was present when the tourniquet was released but was prolonged (3 or more hours) if ATP was depleted. Hourly release of the tourniquet for 10 minutes ensured the maintenance of ATP and rapid metabolic recovery. Release for intervals of only 5 minutes did not have the same protective effect and in fact worsened tissue pH during the period of tourniquet ischaemia. Heparin and corticosteroids were without effect during and after periods of tourniquet ischaemia.
Five elderly patients with chronic pyrophosphate arthropathy developed stress fractures of the tibia. All patients had deformed, painful knees with the result that their increasing symptoms were not readily attributed to a stress fracture. Such a possibility should be considered in patients with chronic pyrophosphate arthropathy since early recognition makes management of the stress fracture easier.
Six different conditions of non-infective bone and joint pathology have been seen amongst 67 patients with diabetic neuropathy. The characteristics of each are described. Not all the conditions require treatment but they should be differentiated from osteomyelitis. Charcot osteoarthropathy is the most common condition seen but spontaneous fractures and dislocations generally present greater therapeutic problems. The aim of treatment should be to obtain a stable foot in which there is no undue pressure on the skin from a bony prominence.
The clinical details of six patients who developed spontaneous dislocations in the foot or ankle are presented. All were shown to have diabetic neuropathy. This previously unreported condition can occur with a short history of diabetes. Some cases can be managed without operation, though arthrodesis probably offers the best chance of obtaining a stable foot of satisfactory shape.
Intertrochanteric osteotomy gives compensatory correction for the severely slipped upper femoral epiphysis without endangering its blood supply. The results of thirty-five such osteotomies carried out over an eighteen-year period are reviewed. The indication for operation was a chronic slip of a third or more of the growth plate in the lateral radiograph. The mean age at operation was fourteen years and the mean follow-up period seven and a half years. The results showed that even a moderate correction of deformity as shown by the radiograph could produce a hip with a functionally satisfactory range of movement. Chondrolysis was the most serious complication and occurred in four hips. The radiological results are discussed in relation to details of operative technique and also to long-term prognosis.
A clinical study has been made of forty-three patients with symptoms arising from degenerative spondylolisthesis of the lumbar spine. Attention is drawn to the lower average level of the iliac crests in these patients, and to the high incidence of osteoarthritis of the hips. Many patients in this series had been referred specifically for operation and fourteen were so treated. The techniques of decompression and of spinal fusion are discussed. It is concluded that patients with back pain predominant are well treated by corsetry, only a minority needing fusion, and that patients with nerve root involvement or with symptoms of spinal stenosis need decompression. The place of spinal fusion is the main problem, but it seems reasonable, firstly, in younger patients with clear evidence of instability and degenerative change at a single level, and secondly, when radical decompression is judged to increase the risk of instability.
1. Some of the more common and obvious clinical syndromes arising from mechanical and degenerative derangements of the lumbar spine are defined. 2. Some principles in the selection of cases for surgical treatment are discussed and it is stressed how small a part operative intervention plays in the overall problem of low back derangement. 3. Details of surgical technique in the eight types of syndrome are described from past experience in the author's clinic, but not without recognition of the fluidity of this comparatively new field and its continuing evolution.
1. A relatively simple method of occipito-cervical fusion using autogenous bone chips without internal fixation is described. 2. In patients with atlanto-axial subluxation posterior fusion from the occiput to the axis rather than from the atlas to the axis is more reliable and is preferred. Inclusion of the occiput adds no more than a few degrees to the restriction of movement that follows C. 1-2 fusion. 3. The indications for occipito-cervical fusion are discussed, particularly in relation to C. 1-2 instability in rheumatoid arthritis.
1. The literature on pigmented villonodular synovitis has been reviewed and a series of eighty additional cases is reported. 2. The condition usually presents either as a nodule in a finger or knee, or as a diffuse lesion in a knee. The lesions, although benign, sometimes erode or invade the tissue of adjacent bones. 3. Distinction from malignant synovioma can be made on the basis of the macroscopic appearance of the lesion at operation (relationship to joints or tendon sheaths: villonodular appearance: pigmentation), and by histological examination. 4. Treatment of the nodular form by excision is satisfactory but extensive synovectomy for diffuse lesions of the knee gives poor results. 5. The etiology of pigmented villonodular synovitis is unknown, but it appears to be a self-limiting process, possibly inflammatory in nature.
