A little-known aspect of Arthur Conan Doyle (1859-1930): the call of India and a debt to Walter Scott (1771-1832).

This paper recalls the early life of Dr Arthur Conan Doyle when his writing centred briefly on India. The significance of a young female skeleton given to the museum of the Royal College of Surgeons of Edinburgh in 1879 is reviewed. Morphometric and genetic evidence is provided to show that the skeleton originated in the Andaman Islands. It is suggested that Doyle saw it during his undergraduate or early postgraduate years, leading him to introduce an Andaman Islander into his novel The Sign of the Four, published in 1890. Like his inspiring predecessor Walter Scott, Doyle wrote of India but did not visit the country: both authors learned indirectly of the Indian Raj and the Indian Medical Service. Doyle knew of the convict colony established after the Sepoy Mutiny of 1857 at Port Blair, capital of the Andamans, but the reason he chose an Islander to commit murder in London has, until now, remained contentious.

New insights into function of the growth plate: clinical observations, chondrocyte enlargement and a possible role for membrane transporters.

The mammalian growth plate is a complex structure which is essential for the elongation of long bones. However, an understanding of how the growth plate functions at the cellular level is lacking. This review, summarises the factors involved in growth-plate regulation, its failure and the consequence of injury. We also describe some of the cellular mechanisms which underpin the increase in volume of the growth-plate chondrocyte which is the major determinant of the rate and extent of bone lengthening. We show how living in situ chondrocytes can be imaged using 2-photon laser scanning microscopy to provide a quantitative analysis of their volume. This approach should give better understanding of the cellular control of bone growth in both healthy and failed growth plates.

Management of congenital talipes equino varus in Scotland: a nationwide audit.

The Scottish Talipes Register is a record of all newly diagnosed cases of idiopathic congenital talipes equinovarus (CTEV) in Scotland over a four.year period. Two hundred and sixteen children were entered into the register, which recorded initial management and all subsequent interventions, both non-operative and operative. The data, therefore, represent a record of the different management regimens used within Scotland highlighting the variations in duration of conservative management and variations in surgical intervention following different methods of conservative management.

Pelvic remodelling after the Chiari osteotomy. A long-term review.

Survivorship analysis of 215 medial displacement pelvic osteotomies undertaken for symptomatic, incongruent dysplasia of the hip since 1966 showed that four of every five hips had not required conversion to a total hip arthroplasty. The radiological characteristics of 86 osteotomies were evaluated at a mean of 18 years (5 to 30) after surgery which was performed at the age of 15.9 +/- 9.5 years. Revision was significantly (p < 0.05) more likely in those patients operated on after the age of 25 years. The centre-edge (CE) angle increased from 2.5 +/- 13.9 degrees before to 41.8 +/- 15.0 degrees immediately after operation. The increase in CE angle was maintained at later review (38.5 +/- 16.5 degrees). Even with severe dysplasia with a CE angle less than zero a substantial improvement in the cover of the femoral head was achieved, usually by medial shift of the lower pelvic fragment. However, the head was not invariably medialised by the osteotomy and lateral movement of the ilium was noted when the position of the joint was relatively medial before operation or when the hip was arthritic. In the longer term pelvic remodelling did not reverse the medialisation produced by the osteotomy, and the cover of the femoral head was maintained.

10-16 year results of Leeds-Keio anterior cruciate ligament reconstruction.

Following initial enthusiasm in the late 1980s, the use of artificial ligament substitutes for anterior cruciate ligament (ACL) reconstruction has declined. However, the disadvantages of donor site morbidity for autologous graft and concerns about cross-infection from allogenic material have resulted in a maintained interest in prosthetic ligament substitutes. This study presents the outcome of ACL substitution using the Leeds-Keio (LK) polyester ligament at a mean of 13.3 years (range 10-16 years). Outcome was assessed using the International Knee Documentation Committee score, the Lysholm knee score, Tegner activity scale and American Knee Society Score and laxity by clinical examination and the Stryker Knee Laxity Tester. Standardized radiographs were taken to assess for evidence of degenerative change. The objective scoring tests showed that all patients experienced some degree of symptoms from their knee but functional impairment varied widely. Of the group, 28% were known to have ruptured their LK ligament and 56% had increased laxity compared with their opposite knee but no correlation could be shown between rupture, increased laxity and poor function. Of particular concern, all post-operative knees had radiographic signs of degenerative change compared with a rate of 39% in the contralateral knees.

Identification of the saphenous nerve at arthroscopy.

Injury to the saphenous nerve can be a troublesome complication of arthroscopic procedures to the posterior half of the medial meniscus. In this article, we outline a technique for accurately identifying saphenous nerve position using transillumination of the saphenous vein.

Osteochondritis dissecans of the femoral head in Perthes disease: a cause for concern?

Osteochondritis dissecans (OCD) and loose body formation are rare following Perthes' disease. We have reviewed the literature about clinical presentation, treatment and outcome and added a further three cases of the condition. Cases mentioned in the literature were poorly documented. We feel that a thorough documentation should be carried out as soon as the diagnosis is made. Conservative treatment should be given when the disability is moderate. The loose body should only be removed surgically when it is mobile, when it bulges into the joint space or when there are signs of early arthritis.

Growth arrest lines and recurrent patellar dislocation: a new sign.

The phenomenon of growth arrest lines has been widely described in the medical literature. They are usually found at the metaphysis of growing long bones and are the result of short periods of partial growth arrest. Recurrent dislocation of the patella is a well-recognised problem, particularly in adolescents. Several radiological features have been reported in association with patellar dislocation or instability. We have reported a hitherto undescribed radiological sign of patellar growth arrest lines on the skyline radiographs of two patients with this condition. The shape of the patella when symptoms were at their worst corresponded remarkably closely to the outline of the subsequent growth arrest line. We postulated that repeated dislocations adversely affect the process of normal maturation of the patella. With the resolution of symptoms, patella ossification resumes, leaving the telltale sign of previous injury in the form of a growth arrest line and an improvement in bone density once the patella has been stabilised and tracks normally.

Osteomyelitis of the pelvis and proximal femur: diagnostic difficulties.

Osteomyelitis of the pelvis or proximal femur may still be diagnosed late because the infection is deeply placed and investigations may concentrate solely upon the possibility of septic arthritis. Periacetabular infection was diagnosed in 16 children between 1994 and 1998. A high index of suspicion and the use of appropriate imaging will ensure that the condition is not allowed to progress, although in this series one child underwent an unnecessary appendectomy, and a subsequent sepsis of the hip joint was drained in another case. Radiographs of the pelvis were rarely abnormal within 7 days of the onset of symptoms and an ultrasound scan focused on the hip joint may miss the periarticular changes.

Somatosensory evoked potentials as a means of assessing neurological abnormality in congenital talipes equinovarus.

Somatosensory evoked potentials (SSEPs) are a very sensitive measure of the functional integrity of the neuroaxis, including peripheral and central structures. When used in diagnostic mode they can provide additional information regarding the probable areas of dysfunction. SSEPs were recorded from 44 children (64 feet with congenital talipes equinovarus, CTEV), between the ages of 2 to 15 years, who had structural CTEV deformity previously treated by surgery, with no clinical evidence of neurological deficit. SSEPs were elicited after sequential and bilateral stimulation (0.1 ms/5 Hz/10 to 20 mA) of the posterior tibial nerve and the common peroneal nerve and were recorded cortically (P40). In half the children, additional recordings were conducted at the knee (N5), the first lumbar spinous process (N14), and the seventh cervical spinous process (N20). Eighteen children had abnormal responses, four children had non-reproducible responses, and 22 children had normal responses. Analysis of the data at different levels of the nervous system showed that eight children had abnormality at the spinal level. The surgical outcome was influenced by the neurological abnormality, with an excellent or good outcome in 34 of 36 feet with normal neurology and 19 of 28 feet where a deficit was present (p<0.05). These findings support the neurological theory as an etiological factor in CTEV deformity.

Evaluation of the deformity in club foot by somatosensory evoked potentials.

Somatosensory evoked potentials (SSEPs) measure the conduction pathways from the periphery to the brain and can demonstrate the site of neurological impairment in a variety of locomotor conditions. SSEPs were studied in 44 children (64 feet) with surgically corrected club feet. Four children had unreproducible responses, 18 showed abnormal recordings and 22 showed normal responses. In a further 31 feet (21 children) subjected to motor electrophysiological tests, 16 (52%) were abnormal. Overall, 44 of 95 feet (46%) showed abnormal SSEPs or motor electrophysiological tests. Neurological abnormality was related both to the severity of the deformity and the surgical outcome. It was seen in 38% of feet with grade-2 and in 53% of feet with grade-3 deformity. A fair surgical result was obtained in 36% of feet with a conduction deficit and in only 6% with no abnormality. These results suggest an association between neurological abnormality as demonstrated by SSEPs or motor electrophysiological studies and the severity of deformity in club foot and its response to surgical treatment.

The Scottish incidence of traumatic dislocation of the hip in childhood.

Traumatic dislocation of the hip was reviewed over a 20-year period in Scotland. The incidence of the condition was 0.8 cases per million children annually. Posterior dislocation predominates and the presence of an associated femoral fracture must always be considered. Avascular necrosis developed in two of the 15 cases (13.3%) and is more likely if the injury is severe or if there is an appreciable delay in reduction.

Functional results of surgical treatment in congenital talipes equinovarus (clubfoot): a comparison of outcome measurements.

A total of 151 children with 234 grade 2 or grade 3 congenital talipes equinovarus were treated by lateral-posteromedial peritalar release utilizing the Cincinnati incision. The feet were reviewed independently after a mean follow-up period of 10 years (5-19 years), using a modified rating scale, and the results compared to the severity of the initial deformity. An excellent or good result was achieved in 196 feet (84%) and a modest correlation (r = 0.48) noted between the preoperative grading of the foot and the functional result at later review. Both gender and bilaterality were also influential since a boy with bilateral deformity has a 1 in 4 chance of only a fair result, compared to a girl with a unilateral clubfoot where the chance is 1 in 10. The total range of ankle movement and the talocalcaneal index correlated strongly with the eventual surgical outcome [r = 0.69 and 0.65 (P = 0.001 and 0.01) respectively].

Arrest of the growth plate after arterial cannulation in infancy.

Seven children who had partial arrest of the growth plate after neonatal arterial cannulation, developed obvious skeletal changes in adolescence. Cannulation of the femoral artery produced ischaemia which led to four cases of ipsilateral shortening of the lower limb and one of partial arrest of the proximal femoral physis with subsequent coxa valga. The two arrests in the upper limb affected the humerus, ulna and radius, and the radius alone, after cannulation of the brachial and radial arteries, respectively. These late effects of cannulation are not widely appreciated, and may occur as a result of thrombosis rather than extravasation.