Showing papers in "Journal of Bone and Joint Surgery-british Volume in 1948"

Knee joint changes after meniscectomy

Abstract: Changes in the knee joint after meniscectomy include ridge formation, narrowing of the joint space, and flattening of the femoral condyle. Investigations suggest that these changes are due to loss of the weight-bearing function of the meniscus. Meniscectomy is not wholly innocuous; it interferes, at least temporarily, with the mechanics of the joint. It seems likely that narrowing of the joint space will predispose to early degenerative changes, but a connection between these appearances and later osteoarthritis is not yet established and is too indefinite to justify clinical deductions.

The congenital discoid meniscus

Abstract: 1 . A personal series of twenty-nine discoid menisci is reviewed. 2. Three anatomical types are recognised and described. 3. The characteristic lesions incurred by each type is recorded. 4. The anatomical and pathological features of the specimens are compared with those of cases previously recorded. 5. A discoid medial meniscus is described, and compared with the only other specimen known to be recorded in the literature.

Etiology of peroneal spastic flat foot

Abstract: 1. Peroneal spastic flat foot is a term loosely and often inaccurately used to describe rigid valgus feet developing from widely different causes. 2. The most common causes are two anomalies of the bones of the tarsus—the calcaneonavicular bar, and the talocalcaneal bridge. The first was described in 1921 by Sloman and in 1927 by Badgley; the other is described for the first time in this paper as an etiological factor in rigid flat foot though it has been recognised by anatomists for fifty years as a skeletal variation. The term peroneal spastic flat foot, as applied to these cases, is inaccurate since there is no spasm of the peroneal muscles. The deformity is a fixed structural deformity due to anomalous bone structure, and the apparent spasm of peroneal muscles is in reality an adaptive shortening. A better term would be rigid flat foot due to talocalcaneal bridge or calcaneonavicular bar. 3. The smaller group of patients who suffer from inflammatory lesions of the tarsal joints, chiefly due to rheumatoid arthritis, do in fact develop valgus deformity from peroneal spasm. The resemblance between the two groups is superficial and it is limited to the apparent similarity of the deformity. Though it might be justifiable to designate this type as peroneal spastic flat foot, it would be better to use the more accurate title—arthritic flat foot with peroneal spasm. 4. Lipping of the upper margin of the talonavicular joint strongly suggests the existence of one or other of the congenital anomalies. Both anomalies are visualised only by special radiological projections.

Evolution of mould arthroplasty of the hip joint

Abstract: This is the first time that the principle of the mould—the principle of guiding the repair of nature for the purpose of recreating a destroyed or damaged structure, has been applied to surgery. The evolution of the method to its present encouraging stage is the result of the co-operative, professional family spirit of the Massachusetts General Hospital. We all share in it. We share it with the general surgeon because of his contributions to surgical technique. We share it with the "medical man" because of his pre-operative and post-operative care of the patient; because of his guidance as to when, and when not, to operate; and because of the many friendly arguments which are productive of so much good. We share it with the anaesthetist because of his clinical judgment of the patient, his selection of anaesthetic agent, and his continuous, conscientious administration of the anaesthetic throughout the operation. I am going to change from "we" to "I." I owe so much to my assistants, from the first to the last: Bill Rogers, Eddie Cave, George Van Gorder, Paul Norton, Milton Thompson, Otto Aufranc, and Carroll Larson. I want to thank them all for helping to carry the load, for remembering the things that I forgot, and for making helpful suggestions which often led to improvement in surgical technique or to the construction of a useful instrument. I want to pay tribute to the staff of the Orthopaedic Service of the Massachusetts General Hospital and to thank its members for kindly scepticism, constructive criticism, and neverfailing loyal support. The subject of this lecture, "Evolution of Mould Arthroplasty of the Hip Joint," is appropriate for a Moynihan lecture. It is not the work of one man alone. It is the work of one man, supported by a co-operative, helpful, and friendly hospital staff. This is what Lord Moynihan strove so hard to bring about at a time when surgeons viewed one another as rivals. To quote Dr William Mayo: "It is to Lord Moynihan's everlasting credit that, largely as a result of his unceasing efforts, surgeons came to consider themselves as fellow-workers in a cause."

Paraplegia in hyperextension cervical injuries with normal radiographic appearances

Abstract: 1) A case is reported of paraplegia with normal radiographic appearances in which cervical cord damage was shown at autopsy to have been due to hyperextension injury. 2) The mechanism of such injuries is discussed, together with the differential diagnosis from acute prolapse of an intervertebral disc. 3) The grave dangers of using the fully extended position of the cervical spine in the management of these cases is noted.

Habitual dislocation of the shoulder

Abstract: 1. The history of the genesis of the Putti-Platt operation for habitual dislocation of the shoulder is outlined so far as it is known. 2. The operation is described and briefly commented upon. 3. Since there is both gleno-labrial detachment and defect in the humeral head successful treatment depends upon: i) a block to the exit of the humeral head in front and ii) limitation of external rotation movement.

Positive pressure in arthrodesis of the knee joint

Abstract: 1. The technique of compression-arthrodesis of the knee joint is described. 2. Fifteen consecutive cases are reported in which clinical union was detected at the first inspection from twelve days to six weeks after operation. By this method the total period of disability is reduced to three months. 3. Three mechanical factors which might be responsible for this very early clinical union are examined: compression is believed to be the main factor, although fixation is also important. 4. A fallacy is exposed in the use of bone grafts for arthrodesis of the knee; the graft is less osteogenic than the substance of the bones which form the joint, and it provides inefficient internal fixation. 5. A theory is suggested that compression, even in the presence of slight movement, acts by producing a fixed "hinge" without shearing movement; at this point a bridgehead of flexible osteoid tissue is established in which ossification inevitably takes place despite slight bending movement. 6. A second theory is suggested that high compression forces stimulate early union by liberating bone salts at points of maximum pressure through the action of osteoclasts, and that the local excess of bone salts is redeposited under cellular activity within a range of a few millimetres where there is no pressure.

The bone block method for recurrent dislocation of the shoulder joint

Abstract: The purpose of this paper is to call attention to the anterior bone block method of Hybbinette-Eden for recurrent dislocation of the shoulder joint. 1. The operative technique is not difficult, and the after-treatment is short and relatively agreeable for the patient. 2. Sixty of our own cases are described, with four recurrences. The recurrences all occurred as the result of real trauma. In a total of 128 Scandinavian cases there were eight recurrences—that is 6·3 per cent. 3. In our opinion, based on the observations of radiography, arthrography, and operation, it is the compression fracture of the head of the humerus which deserves the name "essential lesion." Destruction of the anterior rim of the glenoid may be very slight, or entirely lacking. No false joint cavity or rupture big enough to receive the head of the humerus was ever observed by arthrography or by inspection during operative exploration. Recurrent dislocation is an intracapsular subluxation, which occurs when the anterior rim of the glenoid slides into the hollow in the humeral head.

Plantar digital neuritis; Morton's metatarsalgia.

Abstract: 1. A series of cases of Morton9s metatarsalgia is reported in which twenty-seven selected patients have had thirty-five operations on the sole of the foot. 2. At operation, degeneration of the plantar digital artery to the cleft between the third and fourth toes has now been found to precede the fibrous thickening of the nerve described by Betts in 1940. Similar changes rarely occur in neighbouring clefts. 3. Local resection of the nerve almost always gives complete relief from pain, and the plantar scar gives rise to no trouble. 4. Histological findings show that the nerve lesion is ischaemic in nature. 5. Acute pain arising as a new event in cases of the deformity of "anterior flat foot" may prove to be due to this condition. 6. Morton9s metatarsalgia is a distinct clinical and pathological entity which can best be described as a plantar digital neuritis.

Arthrodesis of the ankle joint

Abstract: The technique of the transfibular approach for arthrodesis of the ankle joint is described. The results of this operation in a series of thirty cases shows that the procedure is reliable if the technique is carried out faithfully. The two cases in which a first operation failed can both be explained by errors of technique or after-treatment.

The movements of bones and joints

Abstract: 1. Two successive movements at a joint, if not in one and the same plane, constitute a diadochal movement.2. Diadochal movements impose conjunct rotation upon the bone which has been moved. This may be countered by a rotation of opposite sense.3. All muscles of a given joint are, therefore, rotators in some degree.4. Upon the basis of these principles diagnostic and therapeutic suggestions are made.

Paraplegia in cervical spine injuries

Abstract: Twenty-two cases of paraplegia complicating injury of the cervical column have been reviewed. The vertebral injury may be due to flexion or hyperextension violence. Flexion injury —There are three types of flexion injury: 1) dislocation; 2) compression fracture of a vertebral body; 3) acute retropulsion of an intervertebral disc. Evidence is presented in support of the view that disc protrusion is the cause of the cord lesion when there is no radiographic evidence of bone injury, and in some cases at least when there is a compression fracture. Treatment is discussed and the indications for caliper traction and laminectomy are presented. Hyperextension injurv —There are two types of hyperextension injury: 1) dislocation; 2) injury to arthritic spines. Hyperextension injury of an arthritic spine is the usual cause of paraplegia in patients over fifty years of age. The mechanism of hyperextension injury is described. The possible causes of spinal cord injury, and its treatment, are discussed.

Traumatic dislocation of the hip joint

Abstract: 1. One hundred patients with dislocation of the hip joint have been reviewed, many having been re-examined at intervals ranging from two to five years after injury. 2. There were forty-six simple dislocations, forty-three dislocations with fracture of the acetabular rim, seven dislocations with fracture of the acetabular floor, and five dislocations with fracture of the femoral head. 3. Complete recovery, as judged by clinical and radiographic examination, was observed in 76 per cent. of simple dislocations, 63 per cent. of dislocations with fracture of the acetabular rim, and 40 per cent. of dislocations with fracture of the femoral head; in no case of dislocation with fracture of the acetabular floor was recovery complete. 4. Only in one case did myositis ossificans develop, and that was the only case treated by "massage and movements" throughout the first ten weeks after injury. 5. Avascular necrosis of the femoral head was recognised in a smaller proportion of patients than had been expected, but since the follow-up review extended only to four years after injury the results, in this respect, are unreliable. The incidence of this complication after injury to the hip joint cannot be assessed unless the follow-up period is at least five to ten years. 6. Early traumatic arthritis developed in 26 per cent. of patients—in 15 per cent. of simple dislocations, 25 per cent. of dislocations with fracture of the acetabular margin, 60 per cent. of dislocations with fracture of the femoral head, and 100 per cent. of dislocations with fracture of the acetabular floor. 7. When central or posterior dislocations are accompanied by fracture of the acetabular floor, early arthrodesis is the treatment of choice. 8. Displacement of marginal acetabular fragments is usually corrected by manipulative reduction or by traction. 9. Sciatic paralysis in dislocation of the hip joint is nearly always due to damage of the nerve by a displaced acetabular fragment. In such cases, if the fragment is not replaced accurately by manipulation or traction, operative reduction is urgently indicated.

Dislocation and fracture-dislocation of the pelvis.

Abstract: 1. Fifty dislocations and fracture-dislocations of the pelvis have been reviewed. 2. Complications were unusual. Two patients with rupture of the bladder died; two with rupture of the urethra survived. Of eight patients with retroperitoneal haemorrhage four died; the treatment advised is controlled blood transfusion maintaining a blood-pressure of not more than 100 mm. 3. Two types of pelvic disruption should be distinguished: 1) pubic injury with sacro-iliac dislocation; 2) pubic injury with fracture near the sacro-iliac joint. The first is twice as common as the second. 4. In each type, displacement is maintained by extension of the hip and outward roll of the limb. This may be controlled by the Watson-Jones plaster method but the pelvic sling technique is preferred and was used in all cases in this series. 5. The prognosis in fracture-dislocations is very good; nearly all patients went back to heavy work. 6. The prognosis in sacro-iliac dislocations is not so good; only half the patients went back to heavy work and there was often persistent sacro-iliac pain. Sacro-iliac arthrodesis is advised in those cases.

The clinical diagnosis of fat embolism

Abstract: 1. Fat embolism occurs in a high percentage of all cases of injury and it is a relatively frequent complication of fractures of the long bones in civilian accidents as well as battle casualties. 2. The diagnosis can usually be established by the clinical features together with certain physical signs which must however be sought deliberately. 3. Important clinical features are the mental disturbance, alternation of coma with full consciousness, petechial haemorrhages in the conjunctiva and skin, and typical changes in the retina. 4. Evidence is still conflicting as to whether the fat arises by embolism from an injured bone, or by general metabolic disturbance. 5. The fat is harmful not so much by reason of mechanical obstruction of vessels as by erosion and rupture of the vessel wall clue to the liberation of fatty acids. 6. Preventive treatment appears to be of some value but no satisfactory specific treatment is yet available for the established case. 7. Ligation of the profunda vein has been tried in two patients, one of whom recovered and the other died.

Recurrent dislocation of the shoulder

Abstract: A review of the pathology, mechanism, and operative treatment of recurrent dislocation of the shoulder, based on an analysis of 180 cases, with 159 operations, is presented. From this analysis the following conclusions have been made and appear to be substantiated: 1. The pathology comprises two important elements: ( a ) anterior detachment of the glenoid labrum from the bone margin of the glenoid, associated with some degree of stripping of the anterior part of the capsule from the front of the neck of the scapula, found in 87 per cent. of cases examined adequately at operation; ( b ) defect or flattening of the posterolateral aspect of the articular surface of the head of the humerus which engages with the glenoid cavity when the arm is in external rotation and abduction; this defect is demonstrated most readily in antero-posterior radiographs taken with the humerus in 60 to 70 degrees of internal rotation and was shown to be present in 82 per cent. of cases which had been subjected to adequate radiographic examination. 2. The frequency of the humeral head defect has been under-estimated in the past, because of the difficulty of demonstrating it, particularly when the defect is small. 3. Either type of lesion alone may predispose to recurrence of the dislocation. 4. Both types of lesion are often present in the same shoulder. When this is the case the tendency to redislocation is great. 5. The initial dislocation, which results in the development of one or both these persistent structural abnormalities, may be due to very different types of injury, the commonest of which is a fall on the outstretched hand. The factor common to all these injuries is a resultant force acting on the humeral head in the direction of the anterior glenoid margin. 6. In the treatment of recurrent dislocation of the shoulder joint the Nicola operation is unreliable, and it may be associated with a recurrence rate as high as 36 per cent. It is believed that continued instability after this operation is usually due to the presence of a defect of the humeral head. 7. Operative treatment should aim at repairing, or nullifying, the effects of both types of lesion. For anterior detachment of the labrum this involves either suturing the labrum back to the glenoid margin, or constructing some form of anterior buttress, fibrous or bony: for humeral head defects it necessitates some procedure designed to limit external rotation, thus preventing the defect from coming into engagement with the glenoid cavity. Such limitation of external rotation does not constitute a significant disability.

Recurring dislocation of the shoulder

Abstract: Twenty-five years ago I had the honour of presenting to fellows and members of this College a report of various uses made of the principle of transplantation of fibrous tissues. In that report it was suggested that, as recurring dislocation of the shoulder seemed to result from some defect in the ligaments, it should be possible to repair the defect either by plicating the supposedly loose ligaments with living sutures of fascia, or by replacing them with new ones. Soon afterwards an opportunity arose to try out this suggestion and from it there developed the method which I wish to discuss to-day. It is most gratifying that in this Moynihan Lecture I am to have the opportunity of reporting once more to the Royal College a further application of the principles I presented in the Hunterian Lecture of 1924. A Moynihan Lecture would be incomplete without reference to the founder. I had hoped to find that at some period in his distinguished career the great man had said or written something which would indicate that he might have been interested in what we are discussing to-day. I have been unable to find any such reference, and I must content myself with telling you that once, long ago, he came into my operating room while an operation such as I shall describe was going on, and showed great interest in those features of it which to him were novel, and in the anatomical exercise involved. A kindly word of encouragement from the great is a priceless thing to the young. When Le Mesurier and I first became interested in recurring dislocation of the shoulder we were quite ignorant of the cause, and quite without any original idea of how to prevent it. We did notice, however, in performing the various operations that had been recommended, such as Clairmont’s operation, Joseph’s operation, and plication of the capsule, that we were never able to see a defect in the ligaments through which the head of the humerus had passed at the first dislocation. It gradually dawned on us, as the result of watching a dislocation produced on the operating table with the capsule exposed, that the head of the humerus did not pass out through a rent in the ligaments in the lower part of the joint, but that it simply slipped over the anterior rim of the glenoid into a cavity, lined with synovial membrane, which had resulted from detachment of the capsule and glenohumeral ligament. This pathological picture has been clearly and forcibly described by Bankart (1923, 1938) who on many occasions opened the joint and observed that the capsule and the glenoid labrum were not attached to the rim of the glenoid, and that the head of the humerus could slip over its smooth anterior rim with the greatest ease. While the study of our cases did not involve opening the joint, except in a few instances in which we wished to confirm Bankart’s observation, we did notice that in the great majority we could feel the thick edge of the anterior ligaments quite loose from the anterior lip of the glenoid, and occasionally, by rotating the head of the humerus outward, we could see that nothing covered it but synovial membrane. Careful study of the method of production of the first dislocation in a large number of our cases (nearly 200) has led to some definite observations: 1. It occurs chiefly in young men. \Ve have seen only nine women in 200 cases. The great majority have been in healthy athletic young men of nineteen or twenty years of age. 2. It is frequently double.

Fatigue fractures of the fibula

Abstract: 1. A hope expressed in 1940, that further cases of spontaneous fracture of the lowest third of the apparently normal fibula would be described, has been fulfilled. The literature is here reviewed. Five further personal cases are added. 2. The clinical and radiographic features, diagnosis, treatment and results are considered in the light of the information so far available. Special note is made of misleading freedom of ankle and tarsal movements and the occasional absence of tenderness. 3. It is established that fractures of the lowest third occur particularly in two groups of subjects: 1) young male runners and skaters; 2) active and hard-pressed women of middle age and over. 4. In male runners and skaters the fracture usually occurs through slender, mainly cortical bone, two inches or more above the tip of the lateral malleolus; in middle-aged women the fracture is usually distal to the interosseous ligament through thicker, mainly cancellous bone, one and a half inches from the tip of the lateral malleolus. 5. The most convenient name for both groups of fractures in the lowest third is low fatigue fracture of the fibula. 6. A review of the literature of fatigue fracture of the uppermost third of the fibula shows that it is very often precipitated by jumping. The most convenient name for it is high fatigue fracture of the fibula. 7. Like all clinical classifications this distinction between low and high fractures has exceptions (a low fracture of one fibula in a runner was followed later by a high fracture of the other; most military fractures were high, but a few may have occurred at other levels). 8. Fatigue fracture of the fibula, high or low, may be bilateral. 9. A fracture similarly situated to the high fatigue fracture of the fibula has been frequent in parachute schools. It is a speculative possibility that military and parachutist fractures of the upper third of the fibula indicate the link between true fatigue fractures (as exemplified by march fractures with minimal trauma often repeated) and purely traumatic fractures (with adequate trauma applied once only).

Ischaemic necrosis of the anterior tibial muscles due to fatigue

Abstract: 1. Three cases are reported of ischaemic necrosis of the anterior tibial muscles which were not due to injury. In two, ischaemia was the result of strenuous or unaccustomed exercise in young adults; in the third it was an incident in a systemic disturbance. All three cases were probably the result of spasm of a large segment of the anterior tibial artery. 2. The clinical features during the first few hours resemble those of tenosynovitis of the tibialis anterior; and after twelve to twenty-four hours those of cellulitis of the leg. Later there is "drop foot" due to muscle weakness, contracture limiting plantar-flexion movement, and woody hardness of the muscles in the middle third. 3. The morbid histology is similar to that of Volkmann9s ischaemic contracture. 4. The possible explanations—primary arterial disease, arterial occlusion by pressure of the interosseous membrane, occlusion by tension within the fascial space, intraluminary occlusion by embolism or thrombosis, and fatigue arterial spasm, are discussed. 5. The vascular pattern of the anterior tibial muscles has been studied by experimental injections in cadavers. 6. It is concluded that the most likely cause is spasm of the anterior tibial artery due to muscle fatigue, aggravated by increased tension within the anterior fascial compartment due to reaction after strenuous exercise. 7. Treatment is outlined. Exploration of the anterior tibial artery within the first twelve hours is warranted, but late exploration may be dangerous. 8. Although not previously recognised, evidence is shown that regeneration of necrotic muscle is possible in the human being.

Plasma cell tumours

Abstract: 1. Fifteen new cases of plasma cell tumour are reported with a review of the literature. 2. Case examples are quoted to show the gradual merging of the different clinical and pathological syndromes into one entity. 3. A comprehensive analysis of the various manifestations of the disease is made. 4. An attempt is made to correlate the widely differing features of the disease-process and a classification is given. 5. It is considered that metastasis plays no part in this condition. 6. The variety of forms of plasma cell tumours are shown as gradations of an essentially similar disease-process, and are not regarded as separate conditions.

Pressure at the cervico-brachial junction

Abstract: 1. The causes of pressure on the neuro-vascular bundle of the upper limb are many and varied. No one cause such as clavicular pressure can explain all cases. 2. Costo-clavicular pressure is not possible when there is a normal first rib and a normal thoracic outlet, but it is certainly a factor when the costo-clavicular interval is narrowed by the presence of a large cervical rib or an abnormal first thoracic rib. Clavicular pressure can act only during retraction and abduction, not in depression of the shoulder. 3. Temporary alterations in the radial pulse on movements of the shoulder in normal individuals are due to causes distal to the clavicle and have no relation to costo-clavicular pressure. 4. While irritation of sympathetic nerve fibres may explain the majority of cases of thrombosis, there are others in which clotting occurs in an aneurismal dilatation produced by pressure between the clavicle and the abnormal costal element. It is likely that the thrombosis occurs in an aneurism which has been present for some length of time. The cause of the aneurismal dilatation may be vaso-motor paralysis of a segment of the artery, ending distally at a point where a fresh intact leash of nerves is relayed to the vessel. 5. The importance of the scalenus anterior syndrome has been over-emphasised. If operative treatment is limited in all cases to anterior scalenotomy the results will be disappointing. 6. If operation is advised it should be performed without rigid and preconceived ideas, through an adequate incision, and with exploration wide enough to allow thorough investigation of the cause of pressure.

Benign giant-cell synovioma and its relation to "xanthoma"

Abstract: Benign giant-cell synovioma, the most frequent example of which is the well-known myeloid tumour of tendon sheaths, is used as a text for the discussion of the true significance of the so-called "xanthoma" cell. These cells are the result of the phagocytosis of cholesterol esters and are of varied histogenesis. Some are undoubtedly of neoplastic origin; most of them are not, being usually histiocytic, fibrocytic, serosal or endothelial. There is no such thing as a specific xanthoma cell. The term "xanthosis" might well be used to designate this process of infiltration of tissue with cholesterol fat, and the prefix "xantho-" or the adjective "xanthic" in tumour terminology, as for example in "fibro-xantho-sarcoma," "xanthic neurofibroma," and so on.

The intervertebral ligaments as a source of segmental pain.

Abstract: 1. The work of Kellgren (1939) and Lewis and Kellgren (1939) on the production of segmental pain by stimulation of structures near the mid-line of the back has been reviewed, and! a number of experiments have been carried out with the object of testing the validity of their conclusions. 2. On both anatomical and experimental grounds there is reason to believe that pain produced in this manner does not arise, as was assumed by Lewis and Kellgren, from irritation of the interspinous ligaments, but is rather due to the stimulation of nerve trunks in the vicinity. The views of Kellgren (1941, 1942) on the etiology of pain in certain cases of sciatica, and on the part played by intervertebral ligaments in the production of pain in the back, have been discussed. They have been shown to rest on an inadequate foundation. 3. The importance in investigations of this kind of a detailed anatomical survey has been emphasized.