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Seventy unselectcd patients with painful shoulders were examined by a systematic clinical method based on applied anatomy. In every patient except one, the tissue or tissues at fault were identified. Cases of tendinitis, sub-deltoid and sub-coracoid bursitis, ‘frozen shoulder', osteoarthrosis, and acromio-clavicular joint arthrosis were treated by appropriate local methods given to the affected part only. Nearly all of these patients were rapidly relieved of their symptoms to their satisfaction.

The painful periarticular conditions about the shoulder joint-calcific tendinitis, bicipital tendinitis, and frozen shoulder syndrome-are seen commonly in the general practice of medicine or in the practice of orthopedic surgery. Their etiologies are unknown. Their treatment is relatively simple and depends upon a knowledge of the anatomic structures involved and the proper use of rest and exercise. Operative intervention is rarely necessary in any of these conditions. The frozen shoulder syndrome, however, in our experience is best treated in the subacute or chronic stages by infiltration brisement under general anesthesia.

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A technic is proposed whereby the effusion and other signs and symptoms of subacute and chronic traumatic bursitis can be relieved. The operation consists of a simple paracentesis and internal bursotomy of the bursal sac creating a new communication between the sac and the adjacent subcutaneous tissues. The technic is simple, without significant danger and involves no time loss or disability for workmen. It has been used successfully in fourteen cases of traumatic prepatellar and olecranon bursitis.

A case of prepatellar bursitis which, clinically, appeared to be a simple pyogenic infection proved to be an infection with Mycobacterium marinum (balnei). The bacteriology and epidemiology of this acid-fast bacillus is presented. It was one of fifty mycobacterial strains obtained from bone, joint, or other extrapulmonary lesions and cultured at the Mycobacterial Research Laboratory, Veterans Administration Hospital, Salt Lake City, Utah. Each of the fifty strains was readily classified as one of nine species or groups. It is important to search not only for tubercle bacilli but also for other acid-fast species in infections of musculoskeletal and soft tissues.

An additional six cases of mycobacterial infection other than by Mycobacterium tuberculosis and involving synovial structures are reported. Follow-up is included on a previously reported case. Five of the patients in the present series had involvement of tendon sheaths of the hand, wrist, and forearm. The causative microorganism was Runyon Group III (Battey bacillus) in two and Mycobacterium avium in two others; one tendon-sheath infection was due to Mycobacterium kansasii. An elbow was infected with Mycobacterium kansasii and a prepatellar bursa, with Mycobacterium fortuitum. We believe surgical excision of involved synovial tissue to be very important; antibacterial treatment is of importance in selected cases.

The authors emphasize the probable frequency of this calcific process if search is made for it. It actually is of no clinical significance.

1.1. Hydrocortisone has been injected into inflamed joints or other non-infectious locally diseased tissues a total of 3,757 times in 547 patients with various types of rheumatic disease over an eighteen-month period. This includes 249 patients with rheumatoid arthritis and 210 with osteoarthritis. 2.2. Repeated intra-articular or intrabursal hydrocortisone injections at least partially alleviated the local inflammation in 85 per cent of patients treated. An analysis of case results is given. 3.3. Individual injections of the hormone failed to produce appreciable therapeutic benefit in 346 of 3,757 instances (9 per cent). An analysis of the results with individual joints is presented. 4.4. Indications for and contraindications to this method are presented. 5.5. Adverse reactions to this local therapy are few and transient. 6.6. Intra-articular hydrocortisone is a useful adjunct to the usual methods of treatment for rheumatoid arthritis, osteoarthritis, gout, bursitis and other localized rheumatic disorders.

Thirty-seven cases of bursitis have been encountered over a period of six years. These cases were susceptible of classification on an etiologic basis into acute and chronic types, each of which was further subdivided. Forty-one bursae were removed surgically and to our knowledge, only eight of these have recurred since operation. Eight known different diseases affected the forty-one bursae which were removed and trauma was the most common cause of chronic bursitis in this group of cases. Complete excision is the procedure of choice in the treatment of chronic bursitis that is associated with persistent swelling and disability. Chronic subdeltoid bursitis should be treated conservatively, unless such measures have proved to be ineffective. One hundred two cases of ganglion have been encountered over a period of six years. These cases represented 104 ganglions, in the treatment of which 115 surgical procedures were used. The ratio of males to females was 1:3. Of these 102 cases, permanent results of treatment have been determined in seventy-one. From all methods of treatment, good results occurred in 59 per cent of cases. Of the various treatments employed, complete surgical excision of the sac offered the best results.

A TYPE of foot pain which has received IittIe attention from the writers of textbooks on orthopedic surgery is that due to irritation of one or more of the numerous bursae to be found in the foot. These structures occur as adventitious formations such as I have found in eIeven different areas of the foot or as constant sacs, ten of which are known, and, aIthough they are demonstrabIe on the cadaver, they are given scant consideration in current works on anatomy. The Iiterature on the subject is extremeIy meager. Except for two papers by Arthur E. HertzIer of HaIstead, Kansas, there are no contributions in English. My own interest in the subject was awakened severa years ago when, in operating for a caIcanea1 spur, I encountered a we&formed bursa lying between the inferior surface of the OS calcis and theskin. It occurred to me at the time that the symptoms of painfu1 heeI were more Iikely due to bursitis than to pressure of the exostosis on the soft tissues under the hee1. Since then I have observed painfur heeIs without spurs and spurs without painfu1 heeIs, which suggests that the importance of the spur as a pain-producing factor has been overestimated. In a11 subsequent spur operations I have Iooked for a bursa, which, as is rather generaIIy known, frequently deveIops in this situation. If found, it was excised, and if not discovered, a thin Iayer of the subcutaneous tissue on the bottom of the heel was removed, experience having taught me that adventitious bursae not aIways capabIe of demonstration occur in the superficia1 fascia of the soIe in this and various other situations. The individua1 masses of fat are surrounded by deIicate stromata of connective tissue and as these are grouped together membranous partitions are formed of two or more IooseIy connected Iayers between which spaces are seen from time to time which act as Lymph reservoirs. Now, adopting the description of Clarkson, a we11 known English histoIogist, a bursa is nothing more than an enormousIy distended Iymph space, the ceIIs of whose connective tissue walls have through constant friction assumed the function of secreting a ffuid more viscous than Iymph which serves as a friction-reducing medium between two gIiding surfaces. It is conceivable, therefore, that sacs may form in the subcutaneous tissue with waIIs not suffIcientIy dense to be recognized at operation, but which, nevertheless, possess when irritated the pain-producing characteristics of inflamed bursae eIsewhere. Appreciating the possibiIities of bursa1 formations in the superficia1 fascia of the soIe, I have on severa occasions operated for what appeared cIinicaIIy to be a bursitis in this region notwithstanding that the patient’s compIaints were those of “painfu1 arches ” which had been unreIieved by properIy fitted meta pIates. AIthough in onIy two instances have I been abIe to demonstrate we11 formed sacs, in the other cases portions of the subcutaneous tissue corresponding to areas of tenderness found at examination were excised. CompIete reIief from pain foIIowed to the operations and the meta supports were discarded.

When tendo achillis bursitis associated with prominence of the superior part of the tuberosity of the calcaneus does not respond to conservative measures, it may be necessary to excise the prominence. Thirteen patients with twenty symptomatic heels were treated surgically (seventeen excisions and three osteotomies). Good results were obtained in fifteen of the heels so treated. Five patients with retrocalcaneal bursitis in six heels were treated surgically. The initial result was good in all, but in two patients the final result was considered poor because of recurrence of pain as a manifestation of generalized rheumatoid arthritis. Osteotomy to reduce the posterior prominence yielded results rated good in two and fair in one of the three heels with tendo achillis bursitis and results rated poor in two heels (one patient) with retrocalcaneal bursitis. The two poor results were not necessarily secondary to osteotomy. There were too few osteotomies in this series to evaluate the method. However, one disadvantage of osteotomy was the longer convalescence after this procedure.

Evolutionary imperfections render man's shoulder uniquely vulnerable to damage by wear and tear and by trauma. Impingement of the rotator cuff against the tip of the acromion leads to bursitis, attrition and tearing. The instability of the shoulder predisposes to dislocation and subluxation. Awareness of these imperfections can help the physician to localize the source of pain in the shoulder and to give rational and effective treatment.

1. Two patients with high above-the-elbow arm amputation stumps, too short for function, had large areas of soft tissue hanging below tile bone ends. Massive autogenous-bone grafts were imlplanted to elongate the humerus, produce internal rigidity in the end of the stump, and increase the length of the lever arm that could activate a prosthesis. 2. When the graft extended into the subcutaneous space, under moving skin and soft parts, it caused persistent inflammation, fibrinoid degeneration, and painful bursitis. When the graft was shortened to a position deeply recessed in muscle, it was well tolerated and capable of a limited form of function in the use of an artificial limb. 3. The donor tissue was replaced by new bone from the host along a distance of only approximately one centimeter. Beyond this point, on the basis of its roentgenographic characteristics, the bone graft appeared to remain inert and either unreplaced on slowly resorbed. 4. This procedure is of limited value and can be recommended only for unusual stumps having a lange muscle mass in which to bury the transplant.

I LIOPECTINEAL bursitis is not an uncommon occurrence, but apparentIy it is not commonly recognized in its earIier stages. Since the condition was first described by Fricke in 1834 and elaborated by JoIy in 1847, there have been a tota of onIy seventy-three cases reported in the literature. In 1933, O’Connor pubIished a most comprehensive articIe on this subject in which he added thirty-three cases of his own and was the first author to recognize the condition before a tumor mass presented itseIf in the groin. In twenty-one of his cases, there was neither sweIIing nor paIpabIe tumor in the femora1 traingle. Three additional cases have been reported since those of O’Connor, but in a11 three of these rather Iarge tumor masses were present.3$7 It seems noteworthy that of the seventy-three cases recorded, onIy twentyone have been recognized in the acute stage when the most promising results from treatment may be expected.

A collection of 44 cases of malignancy in scars, chronic ulcers, and sinuses, included the following predisposing lesions: a 20-year-old sinus from ischial bursitis, a 23-year-old bed sore, a congenital gumma about 50 years old, three burn scars (average age of scar 56 years), 11 sinuses from chronic osteomyelitis, and 27 chronic ulcers of the leg. The osteomyelitis cases included two rapidly fatal sarcomas, one in a sinus present for 16 years, the other in a 20-year-old sinus. The remaining tumours in this group were squamous carcinomas that developed in sinuses with an average duration of 37 years. In the cases of varicose ulcer, the ulcer had been present on the average for 21 years before the onset of malignancy. One patient in this group, with an ulcer not known to be more than five years old, developed a sarcoma that was fatal in six months. The biopsy diagnosis was difficult in 17 cases, including one of the cases of sarcoma. The difficulty was greatest in cases of osteomyelitis. The conditions discussed are now known as `Marjolin's ulcer'. In the present series, the degree of malignancy in tumours arising in scars may be low but the malignancy of tumours arising in chronic ulcers and sinuses may be high.

Pain over the pisiform bone and weakness of grip are the characteristic symptoms of the clinical syndrome of calcified pisiform bursitis. The calcific deposit is adjacent to the pisiform bone and is located either within the tendon of the flexor carpi ulnaris or within the bursa of the flexor carpi ulnaris muscle. The diagnosis is frequently missed because the calcification is usually demonstrated only on oblique roentgenograms of the wrist. Surgical excision of the calcification should be resorted to only if more conservative treatment fails to give relief. The majority of patients with this condition are promptly cured by local infiltration of the calcified area.