Soft tissue surgery in Charcot-Marie-Tooth disease.

Ten patients with Charcot-Marie-Tooth disease have been reviewed at an average of 14 years after soft tissue procedures to correct foot deformities. No patient has so far required triple arthrodesis and the overall results as regards function, appearance and symptoms are satisfactory in all patients. It is concluded that soft tissue procedures can certainly postpone the need for triple arthrodesis and in many cases may obviate it altogether.

The surgical treatment of equinovarus deformity in adults with spasticity.

Adults with deformities of the lower limb due to spasticity may be considerably improved by operation, but thorough pre-operative assessment as an inpatient is essential in order to pinpoint the disability. The commonest deformity is equinovarus which often responds to simple operative procedures. The results of seventy-seven operative procedures in fifty patients are recorded. Correction once achieved is stable and the deformity does not recur.

The Roper-Day total shoulder replacement.

A simple unconstrained shoulder prosthesis has been used in 22 patients (25 shoulders) with incapacitating pain and severely damaged joints who, because of age or generalised rheumatoid disease, have limited functional requirements. All reported good and lasting pain relief. Improvement in range of movement was modest, but there was marked improvement in function. In this group of patients, rotator cuff damage is common, but does not preclude a satisfactory result.

A new unconstrained elbow. A prospective review of 60 replacements.

Sixty unconstrained elbow replacements of a new design have been followed prospectively for three to nine years. Review showed that 50% had excellent relief of pain and return of function, 27% had had major complications requiring removal or revision of the prosthesis and 23% had minor complications which marred the result. Further research in this field seems worthwhile.

Functional assessment after pollicisation.

Nine children with congenital aplasia or hypoplasia of the thumb were treated by pollicisation of the index finger. Functional assessment was performed on average five years after surgery. It demonstrated normal sensation and a power grip, pinch grip and adductor grip of the thumb of 63%, 56% and 63% respectively of the unoperated hand. Efficient use of the hand increased after surgery and continued to improve for some years. The results indicate that pollicisation benefits hand function and should be performed early.

Olecranon spur.

Full extension of the elbow is normally made possible by accommodation of the olecranon within an appropriately shaped fossa in the distal humerus. We report three cases where disability has resulted from an abnormally shaped olecranon.

The orthopedic management of the stroke patient.

The basic problem following a cerebrovascular accident is that the normal inhibitory regulating mechanism, the cerebral motor cortex, is damaged to a variable extent. This releases primitive peripheral reflex activities resulting in aberrant function of limbs and restricted motion in joints. The sensory cortex can equally be damaged and careful assessment of sensory appreciation in the stroke patient has to be made. The initial treatment of patients after a stroke consists of a variety of physiotherapy techniques, the rationale of which is to reduce the power of dominant aberrant reflex activities and build the strength in the antagonistic group of muscles. The potential for the efficacy of physiotherapy is somewhat restricted, but there is a place for appropriate bracing. A certain number of patients exist, however, for whom physiotherapy cannot achieve the desired results and for whom bracing is either ineffective or unacceptable. The only alternative for these patients is functional electrical stimulation or reducing the activity in the deforming muscles. This can either be done by direct inactivation of the motor nerve or by actually lengthening the muscle tendon unit to reduce the power of the muscle group. An alternative is to transfer tendons.

The arthrogram in diagnosis of meniscal lesions in the fourth decade of life.

Forty-nine patients older than 35 years of age (mean, 45 years) undergoing arthrotomy for clinically diagnosed meniscal tears had preoperative double-contrast arthrograms. Fifty of 53 meniscii were visualized as torn and treated by surgical excision. At the time of operation the incidence of transverse tears was high (34%). In only 72% of cases was there complete correlation between the preoperative arthrographic diagnosis and the definitive surgical diagnosis. This diagnostic disparity was most marked on the lateral side (53% correlation) and unrelated to the high incidence of transverse tears (66% correlation). In this age group, arthrography is not a reliable indicator to the diagnosis of torn meniscii.

Experience with the use of a Vitrathene brace in the treatment of femoral shaft fractures.

Sixty consecutive unselected fractures of the femoral shaft have been treated in a Vitrathene brace lined with Plastazote. All fractures were united at an average of 16 weeks with little shortening. The patients were in hospital for an average of 8 weeks and obtained and average of 115 degrees of knee flexion at 6 months after the original injury. To avoid angulation in fractures of the middle and upper thirds of the shaft a pelvic band with the hinge in abduction is necessary. Four other patients referred for treatment, who had delayed union of their fractures, were braced for between 5 and 12 months and all united. The method appears successful and merits further trial. Weight-bearing characteristics of the brace were studied and it was found that 20 per cent of the axial force passed through the brace and 80 per cent through the soft tissues and fracture site.

Chronic dislocation of the sternoclavicular joint: an operative repair.

Chronic spontaneous dislocation of the sternoclavicular joint occurs more frequently in athletes than nonathletes, causing weakness and sometimes pain during prolonged stress upon the arm. Five such joints were successfully treated in 4 patients by means of a dynamic method of repair--tenodesis of the sternal head of the sternomastoid muscle. The sternal origin of the sternomastoid muscle in continuity with its muscle belly and strip of sternal periosteum is looped under the first rib, back through a drill hole in the clavicle and sutured to itself to replace the damaged costoclavicular ligament. Dislocations of the joint should not be repaired for purely cosmetic reasons as the risk of keloid scar formation in this region is notoriously high. All the patients who were young and athletically inclined, recovered fully within 4 months of the operation and returned to their sporting activities. Follow-up has ranged from 12 to 38 months. There have been no late complications or failures of the technique.

Adamantinoma associated with fibrous dysplasia.

Three cases of adamantinoma of the tibia, seen in one hospital over a period of 7 years, are described. They illustrate the difficulty in differentiating this lesion from fibrous dysplasia on radiographic and histological grounds. Thermography may help in the differential diagnosis.

Attempt to classify patients with arthritis of the hip suitable for prosthetic replacement, and their femoral heads.

Using clinical, radiological, and morbid anatomical data about patients with arthritis of the hip and their femoral heads resected during total hip replacement, an attempt has been made first, to classify patients and femoral heads by a cluster analysis technique, and secondly and more realistically, to use existing clinical and radiological classification as a basis for seeking discriminating features in the data from the femoral head. Both types of analysis failed to give results, and led to a conclusion that arthritis of the hip is a spectrum of disease. This may not pose problems to the clinician, but it does to the investigator studying the pathogenesis of osteoarthrosis. This problem is briefly discussed.