We reviewed 188 patients at one to 20 years (mean 9.5) after surgery for anterior shoulder instability. Twenty-one had shown bilateral instability at the time of surgery, and 26 of the remaining 167 subsequently developed instability of the contralateral shoulder, giving an overall incidence of 24% bilateral involvement. Fourteen of these patients ultimately required bilateral surgery. The onset of contralateral instability was at one month to 15 years (mean 5.7 years) after anterior repair of the operated shoulder, the cumulative incidence increasing with time (p less than 0.01). The incidence was significantly higher in those under 15 years at the time of initial dislocation or under 18 at the time of surgery. One-half of the patients with contralateral instability had signs of posterior instability at follow-up. Other predisposing factors included having sustained the initial injury to the operated shoulder as a result of minimal trauma, and persistence of a sensation of instability in the operated shoulder. Factors which were not statistically significant included sex, dominant side, athletic activity, work history, and whether the initial surgery was for recurrent subluxations or dislocations. The high prevalence of bilateral shoulder instability suggests an intrinsic abnormality such as capsular and ligamentous laxity or muscle imbalance and warrants further investigations.
Haemophilia is a rare cause of avascular necrosis of the femoral head. We report three cases from one centre, an incidence of 2.8%. All three cases presented "silently", and this makes the early diagnosis difficult. Awareness of the condition should lead to examination of the hips of haemophiliac patients at every outpatient visit and admission in the hope that hip disease can be diagnosed at an early stage. This may allow earlier treatment, less femoral head deformity, and an improvement in the long-term prognosis.
One hundred and seven patients with intertrochanteric fractures of the femur treated with a Richards screw-plate were compared retrospectively with 103 patients treated with a Jewett nail-plate. The mortality and morbidity were similar in the two groups. In patients with comparable fractures, those treated with a Richards device mobilised more quickly and left hospital sooner, and more of them returned to their homes. Failures of stabilisation, both clinically and radiographically, were fewer in this group. The reliability of fixation with a correctly positioned Richards screw-plate could justify the omission of outpatient follow-up in all but a small group of patients with severe unstable fractures or grossly defective bone stock. The higher cost of a Richards implant and the slightly longer operative procedure were outweighed by savings in occupancy of acute and long-stay hospital beds.
Dislocations of the cervicothoracic junction are frequently missed. Experience of this rare injury over 27 years at the Spinal Injuries Unit in Sheffield confirms that nearly two-thirds were not properly diagnosed on admission. Only two of the 14 dislocations studied were reduced by conservative methods and these were both associated with fractures of the posterior bony elements. Open reduction is necessary to replace pure dislocations at the C7-T1 level. It seems likely that the spinal cord lesion is not influenced by reduction of the displacement. The three patients who had an incomplete lesion of the spinal cord made excellent neurological recoveries although none of the dislocations was reduced. It is concluded that on theoretical grounds it is justified to embark on operative reduction of displacements at this spinal level only if the cord lesion is incomplete, nerve root recovery therefore possible, and if the operation can be brought about soon after the injury.
Thirty-four patients wtih fibrodysplasia (syn., myositis) ossificans progressiva are described. Marked delay in diagnosis was usual, but all had characteristic skeletal malformations and ectopic ossification. The clinical features included: four types of malformation of the big toe, reduction defects of all digits, deafness, baldness of the scalp, and mental retardation. Progression of disability was erratic in all, but severe restriction of movement of the shoulder and spine was usual by the age of 10 years; the hips were usually involved by the age of 20 years; and most patients were confined to a chair by the age of 30 years. Exacerbating factors included trauma to the muscles, biopsy of the lumps, operations to excise ectopic bone, intramuscular injections, careless venepuncture and dental therapy. Progression of disability did not appear to be influenced by any form of medical treatment and therefore management of the patients must concentrate on the avoidance of exacerbating factors.
Anterior subluxation of the cervical spine from flexion-rotational violence is often overlooked. Either radiography is omitted or the slight displacement visible on the films is not recognised. A method for recognising these injuries is suggested. Five cases are described showing that in these subluxations the soft-tissue damage is severe, that late increasing displacement can occur, with varying neurological sequelae, and that instability can persist indefinitely. Four of the patients required stabilisation by operation, in contrast with complete dislocations in which 80 to 90 per cent fuse spontaneously.
The medial displacement osteotomy of Chiari has an established place in the management of older children and adults with severe hip dysplasia. The results claimed for the operation are, however, variable. There have also been reports of sciatic nerve lesions. In this study ten cadavers were operated upon. Chiari osteotomy was performed upon five, and five acted as controls. The hemipelvis was removed from each cadaver; each specimen was deep-frozen and sectioned transversely. The distance of the sciatic nerve from the nearest bony point was measured in each section and the results were recorded graphically. A further radiographic and photographic study was performed to determine whether apparent displacement at the osteotomy might be misleading. The conclusion was drawn that the sciatic nerve is angulated at the osteotomy and further endangered by the risk of bone splintering at the sciatic notch. The radiographic study suggested that some poor clinical results may be explained by a radiological artefact, because there is a tendency for the osteotomy to hinge posteriorly at the sciatic notch opening anteriorly like a book. Radiographs may suggest excellent medial displacement whereas in fact the femoral head is very poorly covered.
A discussion of the essential deformity in calcaneo-valgus feet develops a theme originally put forward in 1961 on the relapsed club foot (Evans 1961). Whereas in the normal foot the medial and lateral columns are about equal in length, in talipes equino-varus the lateral column is longer and in calcaneo-valgus shorter than the medial column. The suggestion is that in the treatment of both deformities the length of the columns be made equal. A method is described of treating calcaneo-valgus deformity by inserting cortical bone grafts taken from the tibia to elongate the anterior end of the calcaneus.
1. An operation which can correct congenital club foot deformity in older children is described. 2. The operation is based on the assumption that the essential element in a complex tarsal deformity is a displacement of the navicular bone on the talus and that all other elements of the deformity are secondary and adaptive. 3. The results of the operation are noted and the implications of some of its effects are discussed.
