1. There seem to be two distinct methods of destruction of the foot, once pain sensibility has been lost: the first is a slow erosion and shortening associated with perforating ulcers under the distal weight-bearing end of the foot. The second is a proximal disintegration of the tarsus in which mechanical forces often determine onset and progress of the condition.

2. Once the tarsus begins to disintegrate it is difficult to halt the rapid destruction of the foot.

3. It is possible to detect early stages of this condition in time to take preventive measures. Routine palpation of anaesthetic feet will reveal patches of warmth localised to bones and joints which are in a condition of strain. Radiographs of such feet and a study of posture and gait may define early changes which point to one of several possible patterns of disintegration which may follow.

4. These patterns are described and discussed and suggestions made for preventive and corrective measures.

This study attempts to establish the factors on which the prognosis of an intracapsular fracture of the femoral neck depends, and to draw attention to certain causes of non-union and ischaemic necrosis. These factors are of two kinds: those inherent in the fracture, and those produced by the surgeon.

The prognosis depends largely on the nature of the fracture. Original displacement and comminution are the factors which have most influence. Fractures of Type IV with severe comminution have mainly contributed to the bad reputation of intracapsular fractures. Accurate reduction and firm fixation are necessary if the best results for the type of fracture are to be expected. Accurate reduction does not mean merely accurate apposition of the fragments. Fixation of the fracture in certain rotational malpositions such as valgus of over 20 degrees and rotation round the long axis of the neck may occlude the only remaining source of blood supply, the vessels of the ligamentum teres. If these vessels remain open they may produce revascularisation in a femoral head deprived of its blood supply. The degree of valgus can easily be measured but it is impossible to detect rotation round the long axis of the neck.

In this analysis only two methods of fixation were studied. It is clear that rigid fixation is of great significance, and a nail-plate, though it may not be the ideal method of fixation, is greatly superior to a Smith-Petersen nail introduced in the usual way. From the results of this survey there is no justification for continuing the use of this method except perhaps in Type II fractures.

The greater the risk of non-union the more important is the fixation, and this is true of all fractures.

This study also has a bearing on the indications for primary prosthetic replacement. If the nature of the fracture and the result of the reduction make it likely that replacement by a prosthesis is going to be the ultimate solution, and if the patient is over seventy years old, it is wiser to do it as a primary measure.

Finally it was shown that condensation and collapse of the femoral head are not the only radiological signs of ischaemic necrosis. An earlier sign is flattening of the weight-bearing area, which appears on an average six and a half months after injury, as compared to condensation, which may not be apparent until eighteen months after injury.

1. The movements of the talus are described with particular reference to the anatomy of congenital talipes equinovarus.

2. It is suggested that the fundamental deformity in severe club foot is the fixed plantar-flexion of the talus.

3. Early operation is advised whenever serial stretching fails to bring the heel quickly into its normal position.

We suggest that, after an initial course of treatment in the accepted manner by gentle manipulations without anaesthetic, followed by splinting for a period of three or four months, the talo-calcaneal index should be measured on radiographs taken in the standard positions described.

Should the correction be inadequate–that is, should the talo-calcaneal index be under 40 degrees even though clinically the foot appears corrected–further treatment should immediately be undertaken.

1. Two cases of pseudogout are described with an onset acute enough to be mistaken for septic arthritis.

2. The radiological and laboratory investigations for diagnosis are described.

1. Five elderly patients who suffered acute synovitis of one or both knee joints are reported.

2. All showed radiological evidence in several joints of cartilage calcification.

3. It is suggested that the synovitis in each case was due to calcium irritation of the synovial membrane.

4. In three of the patients it is shown that the synovial fluid calcium content was raised during the acute attack.

5. In all patients acute symptoms were relieved by aspiration of the effusion.

Both osteochondritis dissecans and coxa plana are diseases with identical pathological changes, namely avascular necrosis. Although the etiology is not known in either case, it seems likely that when the etiological factors are fully determined they will prove to be applicable to either condition. The relative importance of each etiological factor in the multiple pathogenesis of these two conditions is almost certainly different in each disease process, and probably in each individual case. Present day concepts suggest that there is an underlying constitutional disturbance, which is associated with other factors (of which trauma is almost universally accepted as being one; perhaps the only one), to predispose the individual to these conditions.

It is hoped that further studies along these lines will not only help to provide a better understanding of the two conditions mentioned above, but will also be of value in the appreciation of the pathogenesis and etiology of a large number of disturbances including such varied conditions as dysplasia epiphysialis multiplex congenita, cretinoid dysgenesis of the capital femoral epiphysis, adolescent coxa vara, transient synovitis of the hip, and the recently discussed (Merle d'Aubigné 1964) idiopathic avascular necrosis of the femoral head in adults.

That there is an etiological relationship between osteochondritis dissecans and coxa plana seems clear, but much more work is required before we will have at hand the patho-physiological evidence that will permit an accurate correlation of these two conditions.

1. This is a small series and patients have been treated in a variety of ways. Some impressions emerge, however, concerning the importance of initial trauma, the importance of the factor of heredity and the results of treatment.

2. More than 40 per cent of the patients in the series had an injury to the knee before symptoms began, which tends to support the traumatic theory. Twenty of the twenty-three patients who gave a past history of trauma had a lesion on the medial condyle, next to the intercondylar notch, and one patient of the three who had lesions on the lateral femoral condyle suffered from recurrent dislocation of the patella.

3. Although numerous examples have been reported in the literature of osteochondritis dissecans occurring in several members of a family, the family history of only one patient in this series suggested a familial tendency, and this was doubtful. It seems that patients showing a familial tendency are not commonly seen compared with the number of patients presenting with osteochondritis dissecans.

4. It is often stated that osteoarthritic changes will follow if part of the articular surface is lost, as in osteochondritis dissecans, and this belief has led to the school of thought which advocates restoration of the articular surface by reposition of the fragment. While there is no doubt that this method should be used if a large proportion of the weight-bearing surface of a femoral condyle is affected, the argument has less force if a small area is affected. It is interesting to find that of the five patients treated by replacement of a separated fragment four developed osteoarthritis, whereas in the first series only six patients out of the twenty-two developed such changes. Although these former had what appeared to be an accurate reposition of the fragment it is possible that a "step up" on the joint surface was produced, which gave rise to a more rapid deterioration of the articular cartilage. Accurate conclusions cannot be drawn from five patients, but it may be that attempts to reconstruct the articular surface of a femoral condyle can, over a long period of time, give worse results than simple removal of the lesion.

5. The group of patients treated conservatively gave encouraging results, and improved radiographic appearances were seen in most cases. There was also a notable absence of osteoarthritic changes and these results support the view that conservative treatment is indicated in adolescents and children.

1. Benign chondroblastoma is a rare primary neoplasm of bone with excellent prognosis. It is believed that instances of it are still being missed.

2. Six cases are described with special emphasis on diagnostic pitfalls.

3. A critical survey of the literature and a discussion on nomenclature and histogenesis are included.

1. It appears that fracture of the humeral shaft occurs more often in persons over fifty. This incidence corresponds with that found in a study carried out by the Pennsylvania Orthopaedic Society in 1959.

2. The middle third of the bone is the most vulnerable portion of the shaft, where transverse fracture and radial nerve palsy most commonly occur.

3. Most fractures of the shaft of the humerus are best treated by simple splintage. The degree of radiological deformity that can be accepted is far greater than in other long bones. In this group anterior bowing of 20 degrees or varus of 30 degrees was present before it became clinically obvious and even then the function of the limb was good.

4. Internal fixation is only occasionally indicated but operation on the middle third of the bone increased the chances of delayed union.

5. In the treatment of delayed union intramedullary fixation and the application of slivers of iliac bone is effective in stimulating the fracture to join.

1. Seven cases of infection following medullary nailing of the femur have been studied.

2. Points in the diagnosis of nail track infection are emphasised, especially periosteal reaction.

3. It is felt that a sinograph is an essential part of the investigation and can be useful to assess progress.

4. The principles of treatment of established nail track infection are: adequate drainage of the fracture site; dependent drainage of the whole track by draining the pocket at the lower end; the use of instillation tubes to irrigate the nail track with antibiotics. Once the fracture is stable and the nail track adequately treated by local and general antibiotics the nail should be removed. It is not considered necessary to wait for bony union before removal of the nail.

1. Convulsions causing fractures complicated the post-operative course of two patients after parathyroidectomy.

2. One patient with primary hyperparathyroidism and osteitis fibrosa developed tetany which was controlled with difficulty with the usual measures to correct hypocalcaemia. The convulsion occurred during hypomagnesaemia. This seemed the main immediate cause of symptoms and was easily corrected when recognised.

3. The second patient had been subjected to total parathyroidectomy for treatment of renal glomerular osteodystrophy. The complications were entirely due to hypocalcaemia and the usual treatment was inadequate until oral aluminium hydroxide was given.

4. Further experience shows that aluminium hydroxide can be a valuable addition to other measures for dealing with hypocalcaemia due to the "hungry bones" phenomena.

1. Three cases of abduction contracture of the shoulder caused by fibrosis of the intermediate part of the deltoid muscle are described.

2. Treatment by removal of the affected part of the muscle was successful in each case.

3. Histological findings are described and the nature of the condition is discussed.

1. A case of glomus tumour of the subcutaneous tissues of the knee which presented with extreme pain is described. Successful removal of the tumour led to complete relief of pain and return to normal function.

2. The histological features are given.

3. The literature is briefly reviewed.

1. A case of adamantinoma of the tibia was followed radiographically for seventeen years before a biopsy was performed. During this time there was an increase in size of the tumour and a gradual transformation of radio-opaque into polycystic areas.

2. Biopsy revealed a peculiar osteoid-like differentiation of the epithelial tissue.

1. A patient of sixty-eight suffering from enchondromatosis (Ollier's disease) is described.

2. A malignant tumour developed in the region of the lesser trochanter of the femur. Histological investigation established that it was an osteosarcoma.

3. Other features of interest are the radiographic appearance of Ollier's disease at an advanced age, and the presence of subcutaneous subcostal and retroperitoneal haemangiomata.

1. A patient with complete ischaemia of the muscles of the calf and anterior compartment of the leg is described.

2. In diagnosis, tenseness of the calf, equinus and pain on attempted dorsiflexion of the ankle are most important.

3. Peripheral pulses may be present and do not contra-indicate decompression by operation to prevent ischaemia.

1. Direct injury to skeletal muscle results in fragmentation and necrosis of muscle fibres, though this is patchy in distribution.

2. The sarcolemmal basement membranes form the interface along which fibre regeneration takes place.

3. Phagocytosis of disorganised sarcoplasm is an essential prelude to the reconstitution of severely damaged fibres.

4. Regeneration of injured muscle begins with proliferation of basophilic cells probably originating from muscle satellite cells. After a few days typical myoblast nuclear chains are present. By a week following injury the chains of myoblasts have formed myotubes, which possess myofibrils and sarcomeres.

5. By twelve days in the monkey and by eighteen days in man the muscle fibre regenerative process shows many new fibres which have not reached a mature diameter.

6. Much collagen may be formed in the tissue space at the site of injury. It appears that as the muscle fibres increase in diameter the collagen decreases in extent.

7. In the monkey by three weeks the muscle at the fracture site appears normal. This is also true in the specimens examined at four, six and twelve weeks.

8. In the monkeys the injured limb was immediately used to run and jump. A parallel intense and early activity of muscle and joints was a cardinal point in the management of this series of fracture patients. The clinical results were satisfactory.

9. It is concluded that in both the monkey and in man, given active limb movements, permanent and functionally useful muscle regeneration occurs following soft-tissue injury associated with a bone fracture.

1. Diametric growth and organisation of the epiphysial cartilage plate have been studied by microradiography of human bone and autoradiography of the epiphysial plate in growing rabbits, using sulphur³⁵. These investigations were supplemented by a radiographic study of four patients with dyschondroplasia in whom the progress of the characteristic epiphysial defects were traced during several years' growth.

2. A perichondrial sheath of bone, at the junction of the epiphysial plate with the metaphysis, was demonstrated by microradiography of the distal end of the human femur. Its relationship to epiphysial growth is discussed.

3. Autoradiography, to determine the direction of the cellular proliferation between the epiphysial plate and the overlying perichondrium, demonstrated the appearance of new cartilage cells at the periphery of the plate over a period of six days.

4. The evidence presented strongly favours the postulate that the transverse diameter of the epiphysial cartilage plate increases by appositional growth from the overlying perichondrium and that the same source is responsible for lateral extension of the articular cartilage during growth.