Relationship of pain to the radiological anatomy of the hip joint in adults treated for congenital dislocation of the hip as infants: a long-term follow-up of patients treated by three methods.

Sixty female patients with congenital dislocation of the hip treated by three methods were followed up to a mean age of 27.3 years. Standard radiographic measurements of hip joint morphology, including stereoscopic measurements of acetabular and femoral neck anteversion, were made. The Severin score of the hip joint, but not acetabular or femoral neck anteversion, was related to symptoms. Hips treated by femoral derotation osteotomy had superior results to hips treated by traction reduction alone. Both of these methods gave much better results than treatment by closed manipulative reduction. The "normal" opposite hip was morphologically abnormal, although usually asymptomatic.

The results of early posterior release in resistant club feet. A long-term review.

Seventy resistant club feet in 46 patients were treated within the first six months of life by posterior release as an incident in continuing conservative care and were later assessed at an average age of 15 years. Assessment was made upon strict clinical criteria, including appearance, function and degree of pain during activity; the results were excellent in 22 feet, good in 19, and poor in 29. We also studied the correlation between the radiographs and the final outcome. From these data we propose certain indications for the timing and technique of this type of management, and also discuss the relative merits of this approach compared with more conventional radical release operations.

Avulsion of the distal pole of the patella in cerebral palsy. A cause of deteriorating gait.

Avulsion of the distal pole of the patella in spastic children with a flexed knee gait may upset the equilibrium of the knee and cause deterioration in walking. We emphasise the clinical features, discuss the mechanism and outline the principles of treatment.

Trochanteric advancement for premature arrest of the femoral capital growth plate.

Premature closure of the growth plate of the femoral capital epiphysis associated with limitation of abduction and gluteal insufficiency is described. The indications for trochanteric advancement and the results obtained in the late treatment of Perthes' disease and of congenital dislocation are discussed. Nine hips treated after Perthes' disease had satisfactory results, in that all were improved; but in eight hips with deformity arising from congenital dislocation the outcome was less favourable.

Talectomy for arthrogryposis multiplex congenita.

Eighteen patients (34 feet) with arthrogryposis multiplex congenita treated by talectomy for rigid equinovarus deformity were reviewed. The average follow-up was 11 years. Twenty-four feet (71%) were considered satisfactory; the remainder were improved. Seven feet required further operations to correct recurrence of the deformity, but finally all could be fitted with boots or shoes and all patients could walk. The history of talectomy is reviewed and the operative details described.

A review of the Dillwyn Evans type collateral operation in severe club feet.

A modified form of the collateral operation originally described by Dillwyn Evans has been used in severe relapsed club feet to correct the sagittally breached or bean-shaped foot. Forty-five feet in 37 patients were followed up for an average of nine years and nine months. Previous operations had been performed on 42 feet. Thirty out of 45 feet were considered satisfactory at review when evaluated by a simple, functional system of scoring. The majority of the feet were stiff but relatively free of pain and able to fit into normal shoes. The collateral operation was considered successful in 42 feet if the patient's ability to take part in any desired sporting and recreational activities was taken as the criterion for success.

The use of stereophotogrammetry to measure acetabular and femoral anteversion.

Stereoradiography with a base shift of the source of illumination was used to produce pairs of radiographs to be measured by stereophotogrammetric techniques. The direction of shift was parallel with the longitudinal axis of the body, so that each radiograph in the stereopair could be used for other clinical purposes. A base shift of 10 centimetres with a distance of 100 centimetres between the focus and the film gave acceptable value of stereoscopic parallax. The radiographs were measured using a Hilger and Watts medical stereometer. This method was checked with test specimens, namely an osteotomised pelvis in which one acetabulum could be rotated and an osteotomised femur in which the whole upper portion could be rotated against the shaft. Measurements made on the acetabulum and its radiographs showed a correlation coefficient of 0.9838 over the range 0 to 30 degrees of anteversion, with a mean error +2.54 degrees and a standard deviation of +/- 1.52 degrees (n = 21). For the femoral neck, over the range from 10 degrees of retroversion to 80 degrees of anteversion, the correlation coefficient was 0.9979, the mean error +2.46 and the standard deviation +/- 1.48 degrees (n = 30).

A controlled study of the results of femoral osteotomy in severe Perthes' disease.

We compared 63 hips (Catterall Groups 3 and 4) contained by femoral osteotomy with 85 untreated hips and found that 50.7 per cent of treated patients developed congruous spherical femoral heads in contrast to 14.1 per cent of those untreated. We have also considered certain other features relevant to the outcome. We suggest that the indications should not be modified on the grounds of early age of onset. Relief from weight-bearing does not appear to improve the results of containment. We have assessed the shortening which follows femoral osteotomy and conclude that this is only significant when there is growth disturbance at the capital epiphysis. These changes are at least as frequent in untreated patients.

Progression in idiopathic scoliosis: A preliminary report of a possible mechanism.

Recent surveys have shown that idiopathic structural scoliosis of mild degree is generally not progressive. We will propose a mechanism which may be responsible for deterioration in the few. It has been observed that the spinal cord, although displaced towards the concavity, does not rotate in company with the vertebrae, thus exposing the emerging nerve roots to the effects of traction and possibly of entrapment. We suggest that progression occurs when the neuraxis is unable to adjust to the change in the anatomy of vertebral column. Our proposition is based upon our findings in a complete spinal column obtained from a baby with structural scoliosis. Support is provided by intercostal angiography, and by observations upon normal anatomy, the pathological anatomy of mature scoliotic spines and the anatomy of contrived scoliosis in normal spines. Although our histological and electrophysiological investigations are incomplete we can demonstrate a significant increase in degenerate cells in the dorsal root ganglia at the apex on the convex side. Lack of suitable necropsy material prevents us from confirming our observations so that our report is inevitably preliminary. We enter a plea that careful examination of the neuraxis be undertaken whenever a specimen of a scoliotic spine becomes available.

Anterior dislocation of the radial head in children: aetiology, natural history and management.

The results of operation for traumatic anterior dislocation of the head of the radius in eight children have been reviewed. We are satisfied on the basis of the results obtained and the outcome in one untreated patient that operative reduction is fully justified, provided that the annular ligament is reconstructed and internal fixation employed. We have not seen unilateral congenital dislocation and doubt its existence. Secondary subluxation of the distal radio-ulnar joint has been noted in an untreated patient.

The natural history and management of congenital short tibia with dysplasia or absence of the fibula.

Forty-three patients with unilateral congenital short tibia with partial or complete absence of the fibula are reviewed. The factors influencing the degree of leg shortening at maturity are considered. Serial radiographic measurements of leg length in fourteen patients covering an average observation period of 9-3 years support the hypothesis that the relative difference in growth between the two limbs remains remarkably constant. By estimating the percentage difference between the normal and abnormal leg lengths on the first measurable radiograph it is therefore possible to predict the likely shortening at maturity. This method of prediction allows the surgeon to make the decision to proceed to Syme's amputation or to the use of an extension prosthesis at about one year of age when the child starts to walk.

The results of early operation in talipes quino-varus. A preliminary report.

The results of operation performed within the first six months of life upon seventy-seven resistant club feet are presented. The indications for and the rationale of early operation are discussed. Particular attention has been paid to the relationship between the age at operation and the outcome more than four years later; the results were greatly superior when operation was undertaken early. Two surgical techniques are compared, the postero-medial release proving better than a simple posterior release. The relationship between clinical and radiological assessment is discussed, and also the influence of the results reported upon future practice.

Arthrogryposis multiplex congenita. Search for prenatal factors in 66 sporadic cases.

In a family and epidemiological survey of 66 cases of arthrogryposis multiplex congenita all cases were found to be sporadic and no family association with clubfoot, congenital dislocation of the hip, or hereditary neuromuscular disease was found. The mothers were significantly older than average. Oligohydramnios was noted in only one-third of cases but many other complications of pregnancy, including probable attempts at abortion, had occurred. It is likely that most cases of arthrogryposis are nongenetic and result from a defective intrauterine environment, whether hormonal, vascular, mechanical, or possibly infective.

Transposition of the tendon of pronator teres in cerebral palsy.

We have considered the indications for and results of transplanting pronator teres to extensor carpi radialis brevis in cerebral palsy. The operation has some virtue but a very limited application. We achieved satisfactory functional results in six of nine patients and some improvement in one. Two operations failed because of poor selection. In all patients the appearance of the limb was improved.