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Background: The purpose of this study was to review the results of the first four years of use of the American Society of Anesthesiologists (ASA) physical status rating system in the New Zealand Joint Registry. Our hypothesis was that patients with a higher ASA score would have an increased mortality rate, an increased early revision arthroplasty rate, and poorer clinical outcomes at six months after total hip or knee arthroplasty.Methods: We prospectively evaluated the preoperative ASA classes for all patients in the registry who underwent primary total hip or knee arthroplasty from 2005 to 2008 with regard to the six-month mortality rate and the Oxford Hip and Knee Scores at six months. Survival curves were constructed with use of revision joint replacement as the end point.Results: Twenty-two thousand six hundred patients who underwent total hip arthroplasties and 18,434 patients who underwent total knee arthroplasties were recorded in the New Zealand Joint Registry. The six-month mortality rate was 0.77% following hip arthroplasty and 0.40% following knee arthroplasty. Significant differences were observed in the mortality rate between all ASA classes following hip arthroplasty (p < 0.001). Similarly, significant differences were observed in the mortality rate between ASA classes after knee arthroplasty, except between ASA classes 1 and 2 and between ASA classes 3 and 4. The mortality rate was significantly higher (p < 0.001) following hip arthroplasty compared with knee arthroplasty. A significant difference (p < 0.001) in Oxford scores was observed when ASA class 1 and ASA class 2 were compared with ASA class 3 and ASA class 4, independent of age and sex, following both hip or knee arthroplasty. A significant difference was observed in the rate of early revision (revision less than two years after the index procedure) following total hip arthroplasty when ASA class 1 (hazard ratio, 1.39 [95% confidence interval (CI), 1.04 to 1.95]; p = 0.015) and ASA class 2 (hazard ratio, 1.24 [95% CI, 1.02 to 1.55]; p = 0.030) were compared with ASA class 3, which was independent of age and sex. No significant difference was observed in the rate of early revision after total knee arthroplasty.Conclusions: The ASA physical status score can be used as a predictor of postoperative mortality and functional status following both hip and knee arthroplasty and may predict early failure of total hip arthroplasty necessitating revision.Level Of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Purpose: Forearm tendon transfer surgery (FTTS) designed to restore independent hand function for tetraplegia is one intervention where assessment has tended to focus on outcomes of hand function and activity. To broaden the scope of assessment and further understanding of outcome following FTTS, this case study was designed to investigate the total life impacts of such surgical interventions from an individual perspective. Method: A single case study design was employed, utilizing a semi-structured interview and grounded theory methods to guide analysis. Results: All life domains described in the International Classification of Function, Disability and Health (ICF) emerged. Improvements were identified up to 2-3 years post surgery. FTTS was identified as the key among a number of rehabilitation facilitators. The participant's ongoing reference to preinjury attitude, ability, and experience highlighted a number of enduring characteristics that appeared to contribute to the positive outcome. Conclusion: Adequate assessment of interventions such as FTTS should encompass the ongoing monitoring of effects across all life domains, with consideration of effects in relation to preinjury status and other life impacts. This case study is considered a forerunner to a future case series investigation. The case series will include a diversity of participants in terms of the perceived positive or negative outcomes of upper limb reconstructive surgery and/or the decision to undergo/not undergo the surgical procedure(s). [ABSTRACT FROM AUTHOR]

Background: Total hip arthroplasty (THA) can be performed using either femoral and acetabular components provided by the same manufacturer (matched components) or components from different manufacturers (unmatched components). We hypothesized that there would be no difference in outcomes following the use of unmatched compared to matched components., Methods: Data from a nationwide joint registry, the New Zealand Joint Registry (NZJR), were analyzed to assess long-term outcomes of using unmatched implants in THA., Results: The NZJR has recorded a total of 108,613 primary THAs. We excluded combinations with less than 50 implantations, leaving 99,732 arthroplasties (90.5%). The unmatched group consisted of 24,537 (24.6%) THAs. Revision procedures were required in 3434 (4.6%) of the matched group, at a rate of 0.72/100 component years and 1078 (4.4%) of the unmatched group, a rate of 0.69/100 component years (P = .049). THAs with metal-on-metal or ceramic-on-metal bearings were overrepresented in the matched group. When analysis was repeated with these implants excluded, there was no longer a difference in revision rate between groups (4.0% revisions, 0.65/100 component years and 4.3% revisions, 0.67/100 component years [P = .742]). Survival analysis showed 17-year survival for matched components and unmatched to be within 95% confidence intervals at all time points. There was a small, statistically significant improvement in Oxford Hip Scores for the unmatched group compared with the matched group., Conclusion: Data from the NZJR confirm that the use of unmatched components in THA has no adverse effect on outcomes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: To assess elbow extension strength and complications after deltoid-triceps transfers using hamstring tendon graft compared with tibialis anterior and synthetic tendon grafts., Methods: A retrospective review of deltoid-triceps transfers in patients with tetraplegia performed between 1983 and 2014., Results: Seventy-five people (136 arms) had surgery performed, with the majority undergoing simultaneous bilateral surgery (n = 61; 81%). Tibialis anterior tendon grafts were used in 68 arms, synthetic grafts in 23 arms, and hamstring tendon grafts in 45 arms. The average age at surgery was 31 years. Sixty-three arms (46%) were assessed between 12 and 24 months after surgery. Seventy percent of the group (n = 54) were able to extend their elbow against gravity (grade 3 of 5 or greater) following surgery. Seventy-nine percent of those with hamstring grafts achieved grade 3 of 5 or more compared with 77% with tibialis anterior and 33% with synthetic grafts. There was a statistically significant difference in postsurgery elbow extension between the tibialis anterior group and the synthetic graft group and the hamstring and the synthetic graft group but not between the tibialis anterior and the hamstring group. Complications occurred in 19 arms (14%), the majority occurring immediately after surgery and associated with the wounds. The remaining complications were with the synthetic graft group in which dehiscence of the proximal attachment occurred in 30% of the arms., Conclusions: Autologous tendon grafting is associated with achievement of antigravity elbow extension in a greater proportion of individuals than with prosthetic grafting., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Study Design: Retrospective audit., Objectives: The objective of this study was to identify the proportion of patients with cervical spinal cord injury who would potentially benefit from nerve transfer surgery to gain active hand opening, and to determine when a safe nerve transfer decision can be made., Setting: Christchurch, New Zealand., Methods: Case note review of the first 12 months following acute cervical spinal cord injury (2007-2012). Neurological assessment at 6 weeks, 12 weeks and 1 year following injury., Results: Fifty-three patients had complete assessments and showed changes in the level of injury and severity of neurological injury between assessments. Forty-two percent of patients had motor complete C5-7 level injuries 12 weeks following injury and would benefit from consideration for nerve transfer to improve hand opening. Fewer (26%) would benefit 1 year following injury owing to a change in the neurological level of injury., Conclusions: Twelve-week neurological assessment identifies patients who may benefit from nerve transfer surgery. This enables referral for comprehensive upper limb assessment and reassessment of motor function to determine suitability for surgical intervention. Nerve transfer within the window of opportunity provides active hand opening for patients following cervical spinal cord injury.

After cervical spinal cord injury, the loss of upper limb function is common. This affects an individual's ability to perform activities of daily living and participate in previous life roles. There are surgical procedures that can restore some of the upper limb function lost after cervical spinal cord injury. Tendon transfer surgery has been performed in the tetraplegic population since the early 1970s. The goals of surgery are to provide a person with tetraplegia with active elbow extension, wrist extension (if absent), and sufficient pinch and/or grip strength to perform activities of daily living without the need for adaptive equipment or orthoses. These procedures are suitable for a specific group, usually with spinal cord impairment of C4-8, with explicit components of motor and sensory loss. Comprehensive team assessments of current functioning, environment, and personal circumstances are important to ensure success of any procedure. Rehabilitation after tendon transfer surgery involves immobilization for tendon healing followed by specific, targeted therapy based on motor learning and goal-orientated training. Outcomes of tendon transfer surgery are not limited to the improvements in an individual's strength, function, and performance of activities but have much greater life affects, especially with regard to well-being, employment, and participation. This article will provide an overview of the aims of surgery, preoperative assessment, common procedures, postoperative rehabilitation strategies, and outcomes based on clinical experience and international published literature., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Study Design: Implementation study., Objectives: To describe the development and potential value of the New Zealand (NZ) upper limb surgery registry and report the demographic and spinal cord injury characteristics of individuals with tetraplegia collated to date., Setting: Multi Center-coordinated from Burwood Spinal Unit, NZ., Methods: Following discussions with eight international units, clinical information and outcomes measures were agreed upon for use in this specific population. To implement this consensus, a web-based upper limb surgery registry was developed in NZ. Inclusion criteria included referral to a hand clinic for clinical assessment for suitability for tendon transfer surgery. Clinical data were collected regardless of acceptance of surgery thereby creating a self-selected control group. Twenty-eight years of retrospective NZ data was entered into the registry, as well as 3 years of prospective data collected in NZ., Results: From 1982 to 2013, a total of 357 persons with tetraplegia were assessed as suitable for surgery. Of those, 223 individuals underwent surgery and 134 declined the intervention(s). The prospective group currently comprises 55 assessments with 23 surgery individuals and 32 who have declined surgery to date., Conclusion: Clinical information is now available within a web-based registry for all individuals reviewed in hand clinics from when upper limb surgery was first introduced. A broad range of outcomes of interest can easily be reported directly from the registry. The self-selected control group will allow comparative studies to be explicitly linked to the specific interventions of interest.

Purpose: To evaluate the effects of aging on hand function among patients with tetraplegia who had forearm tendon transfer surgery between 1982 and 1990., Methods: The study used a longitudinal cohort design that compared hand function outcomes in 2012 with those obtained 11 years earlier. A digital analyzer was used to measure key pinch and grip strength, and results were compared with those obtained in 2001 to determine changes in strength over time. The study also evaluated changes in participant's employment status, wheelchair use, and subjective changes in function using the Lamb and Chan questionnaire., Results: Participants had a mean key pinch strength force between 11.5 N (tenodeses) and 32.9 N (active transfers) and grip strength forces between 23 N (tenodeses) and 59 N (active transfers). Since 2001, people with active transfers either maintained strength or experienced decreased strength of 5% to 14%. Thumb tenodesis power decreased 40% to 51%, whereas finger tenodeses power increased 32% to 70%. Three activities in the Lamb and Chan questionnaire were identified by the majority of participants as being worse or much worse over the past 11 years. These were performing a pressure relief and propelling a manual wheelchair on level ground and up a ramp. These findings correspond with the increased number of participants who used a power wheelchair in 2012 (64%) compared with 2001 (26%). Close to half of the participants (46%) were employed compared with the 90% in 2001., Conclusions: Tendon transfers continued to provide pinch and grip function for individuals with tetraplegia for many years following spinal cord injury. The decrease in strength of those with active transfers over the 11-year period was within the reported aging loss for the normal population. The small number of participants with tenodesis, however, limited our ability to draw meaningful conclusions for this group., Type of Study/level of Evidence: Prognostic III., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

We reviewed the revision rate and functional outcome of all patients who had a total knee arthroplasty (TKA) after an osteotomy or unicompartmental knee arthroplasty (UKA) on the New Zealand Joint Registry. We used these data to compare the results with primary TKA scores, including comparison of age-matched subgroups. There were 711 patients who had undergone TKA as salvage for a failed osteotomy with a revision rate of 1.33 per 100 component years and a mean 6-month Oxford Knee Score (OKS) of 36.9. There were 205 patients who had a failed UKA converted to TKA with a revision rate of 1.97 per 100 component years and a mean OKS of 29.1. The revision rates of TKA for both failed osteotomy and failed UKA were significantly poorer than after primary TKA (0.48 per 100 component years). The mean OKS after revision of a UKA was significantly poorer than both primary TKA and TKA for a failed osteotomy. There was no significant difference in mean OKS between primary TKA and TKA for a failed osteotomy, even among patients younger than 65 years. Revision of a failed osteotomy to a TKA has improved functional results compared with revision of a failed UKA. However, both yield poorer survivorship rates compared with primary TKA., (Crown Copyright © 2012. Published by Elsevier Inc. All rights reserved.)

Study Design: Retrospective case series., Objective: To describe the uptake of upper limb surgery by individuals with tetraplegia in New Zealand (NZ)., Setting: New Zealand., Methods: The clinical notes of all individuals who sustained a cervical spinal cord injury between 1 January 2001 and 31 December 2005 were retrospectively reviewed for those who met the clinical criteria to undergo upper limb surgery. Cases were cross-referenced to the hand surgery record to determine the uptake of upper limb surgery in this cohort., Results: The uptake of upper limb surgery for people with tetraplegia in NZ was 44% of the eligible cohort and 59% of those assessed for surgery. This is notably higher than the reported proportion in other developed countries. The data also suggested that women and those who identified as NZ Maori were less likely to undergo upper limb surgery than were men and those of NZ European ethnicity., Conclusion: Utilization of upper limb surgery in the eligible tetraplegic population in NZ was high. However, it seemed that some groups were less likely to undergo surgery. Further research into the factors that affect an individual's decision to undergo upper limb surgery could explain the observed pattern.

This study evaluated the mortality rate, major complications, and early outcomes of single anesthetic bilateral total hip and knee arthroplasty compared with unilateral and staged procedures. A total of 37,828 total hip and knee arthroplasties were evaluated with 6-month Oxford 12 scores. Major complications and mortality rates were recorded. Analysis of variance tables were used for statistical analysis. The single anesthetic bilateral group were significantly younger (P < .001), with their age-adjusted postoperative Oxford 12 scores significantly better (P < .001) than the other 2 groups. The surgeons involved, in general, performed more than 25 total knee and hip arthroplasties per year. There was 1 death within the first 6 months occurring in the staged bilateral group and was unrelated to the surgery. The complication rate as reported by patients was low in all groups, and there was no significant difference. The results show that, in selected patients, single anesthetic bilateral total knee or hip arthroplasty is a safe, low-risk procedure with very good patient-generated outcome scores at 6 months when performed by an experienced surgeon.

Measurement of upper limb function in persons with tetraplegia poses significant issues for clinicians and researchers. It is crucial that measures detect the small but significant improvements in hand function that may or may not occur as a result of our interventions. Before determining how we measure changes from upper limb interventions, we must establish what outcomes are of greatest interest, and for whom. Many issues have an impact on both the measurement and interpretative process.

Background and Purpose: There have been few reports of large series of ankle replacements. The aim of this study was to document and evaluate the early results of a nationwide series of total ankle replacements (TARs) performed using second- and third-generation implants., Methods: Records of total ankle replacements performed between February 2000 and November 2005 were retrieved from the New Zealand National Joint Registry and retrospectively reviewed at a mean of 28 months after the primary procedure. At 6 months post surgery, patient scores were generated from questionnaires. Comparisons between patient scores and categorical variables were made using ANOVA. Regression analyses using Cox proportional-hazards modeling were performed to determine predictors of failure. A Kaplan-Meier survivorship curve was used to describe the rate of prosthetic survival., Results: 202 total ankle replacements were performed in 183 patients. 14 prostheses (7%) failed. The overall cumulative 5-year failure-free rate was 86%. An unfavorable patient score at 6 months after the initial procedure turned out to be a good predictor of subsequent failure. The cumulative 5-year failure-free rate was 65% at 5 years for patients with an unfavorable score, and 95% for those who had a favorable patient score. Each 1-point increase in the patient score (i.e. poorer outcome) corresponded to a 5% relative increase in the risk of failure (p < 0.05). In addition, longer operative time for the primary procedure was found in the group of TARs that subsequently failed (p < 0.05)., Interpretation: The National Joint Registry appears to be a useful tool for monitoring the trends in TAR surgery.

The release of soluble forms of CD80 (sCD80), CD86 (sCD86), and CD83 (sCD83) provide a potentially powerful immunoregulatory mechanism. We therefore investigated the potential presence and relative levels of these molecules in the synovial fluid (SF) and serum of patients with rheumatoid arthritis (RA) and osteoarthritis (OA). Serum and SF levels were measured by enzyme-linked immunosorbent assay. Serum levels of sCD80, sCD86, and sCD83 in RA and OA patients were similar to those present in normal donor serum (NDS) and the SF of OA patients. In contrast, when compared with NDS and OA SF levels, almost all RA SF samples had elevated sCD83 levels (32/35, >0.63 ng/ml) and a substantial proportion had elevated sCD80 (13/29, >0.22 ng/ml) or sCD86 (16/33, >2.31 ng/ml) levels. Analysis of matched pairs of serum and SF from RA patients demonstrated that the SF/serum ratio for sCD80 (95% CI = 1.7-3), sCD86 (95% CI = 1.5-3.1), and sCD83 (95% CI = 3.6-7.8) levels was >1 in almost all patients. In conclusion, this study shows that the SF from almost all RA patients contain elevated levels of sCD83 and the majority of these samples also contain elevated levels of sCD80 and/or sCD86. These molecules may play a role in modulating immune responses within the rheumatoid joint.

Background: Streptococci cause up to 20% of prosthetic joint infections but this has received little attention in the published literature., Methods: We reviewed retrospectively our experience with treatment of streptococcal prosthetic joint infections. Patients were followed up for up to 15 years after discontinuation of antimicrobial therapy and up to 8.5 years while on continuous antimicrobial therapy., Results: Eighteen cases were diagnosed between 1984 and 1995. These included one group A, seven group B, one group D, seven group G and one viridans-group streptococcal infection as well as one group B and D streptococcal co-infection. All were late-onset infections and most (11 of 18, 61%) were acute. Hip and knee joints were equally affected. Six of seven group G streptococcal infections were associated with skin or soft tissue infections. Sixteen patients were treated primarily with antimicrobial agents including 5 days to 6 weeks given intravenously and 2 weeks to 8.5 years given orally. At latest follow up, 10 patients had been off antimicrobial therapy for at least 18 months without relapse, one patient had been off antimicrobial therapy for 7 months without relapse and four infections were successfully controlled with long-term suppressive antimicrobial therapy. One infection was unable to be controlled with antimicrobial therapy., Conclusions: Our results, and those of others, show that prosthetic joint infections caused by streptococci have a relatively good outcome with primary antimicrobial therapy and, when necessary, drainage, lavage or debridement. Provided the prosthesis is stable and the patient can tolerate long-term antimicrobial therapy, this may be an effective alternative to excision arthroplasty.

Purpose: To perform a 10-year re-review of hand function outcome for 24 tetraplegic persons who had received bilateral tendon transfers and tenodeses., Methods: The Lamb and Chan questionnaire with additional questions, the Quadriplegic Index of Function (QIF), the Swanson sphygmomanometer technique for hook grip, the Preston Pinch Meter (PP) for key pinch, and a digital analyzer (DA) for both hook and key pinch were the test instruments used. The QIF and DA had not been used previously., Results: Levels of functional independence and expectations were maintained. Mean hook grip values were maintained for the right hand but increased significantly for the left to reach right hand values. Mean pinch grip values decreased significantly. DA measurements confirmed similar hook grip values for both hands but key pinch values were significantly higher than the PP values. Active transfers averaged approximately twice the strength of tenodeses., Conclusions: Hand function improvements gained from tendon transfers and tenodeses are maintained over time.

Purpose: The purpose of this study was to measure the extent and timing of elbow extension torque recovery after posterior deltoid-to-triceps tendon transfer., Methods: Elbow extension moment was measured in 40 limbs from 23 patients who underwent surgical restoration using the posterior deltoid-to-triceps tendon transfer at times ranging from 8 weeks to 1 year after surgery. For comparison purposes, elbow extension moment also was measured in healthy controls and persons with C7 spinal cord injuries., Results: Maximum extension moment was 5.89 +/- 0.24 Nm (mean +/- standard error of mean, n = 40), which corresponds to approximately 65% of the predicted posterior deltoid force and provided an adequate moment to oppose gravity. Based on the shape of the moment-joint angle curve and using a biomechanical model, it was predicted that posterior deltoid was inserted at a relatively short muscle length of 123.1 mm and thus operated exclusively on the ascending limb of the length-tension relationship., Conclusions: These observations support an evolving model of muscle architecture in which connective tissue septa restrict muscle fiber elongation during surgical tensioning of the tendon transfer. This relatively short length would result in a significant force loss should any of the repair sites slip or stretch during rehabilitation. These data have implications for the reconstruction and rehabilitation of this patient population.

Two cases of iliopsoas haemophilic pseudotumours are presented. In one patient a fistula developed between a pseudotumour and the large bowel. This resulted in an abscess involving the pseudotumour and adjacent tissues. It resolved after 5 years of therapy involving percutaneous drainage and closure of the fistula. The second patient had a massive pseudotumour that had obstructed both ureters. Later he suffered a fatal mixed Gram negative septicaemia probably related to erosion into the colon.

In 1997, to mark 30 years of joint arthroplasty in New Zealand, the New Zealand Orthopaedic Association agreed to establish a national hip and knee register, to be based in the Department of Orthopaedic Surgery at Christchurch Hospital. This paper details the steps in the development of the Register, the problems encountered and their solutions, and the trial process involved before the national implementation of the data collection process in 42 hospitals throughout New Zealand in April of 1999. The whole process took seventeen months and the special features are the enthusiastic and voluntary involvement of nursing staff and the inclusion of patient generated outcomes data. However, it will be at least five years before there is sufficient data for any meaningful analysis.

A prospective trial was designed to assess the sensitivity and specificity of intrasound vibration for the early detection of scaphoid fracture. We replicated the method described by Finkenburg et al. (J Hand Surg 1993;18A:4-7) in an attempt to corroborate their results. We found the test to be 73% sensitive and 51% specific. Because the test was not 100% sensitive, as claimed by Finkenburg et al., we discontinued the use of this device in our hospital.

Twenty-one consecutive rheumatoid patients (23 hands, 92 joints) who underwent Silastic metacarpophalangeal joint arthroplasty between 1989 and 1993 had the 33-task Baltimore quantitative upper extremity function test prior to surgery and then repeated at intervals from 6 weeks to 1 year for all 23 hands and 3 to 4 years for 14 of the hands. In addition all hands had goniometer measurement of active range of finger joint motion and ulnar drift at each assessment. The average preoperative score was 71 improving rapidly to 89 at 6 weeks, to 91 at 1 year and 92 at 3 to 4 years. Most improvement occurred in functions requiring pinch span or hook grip and could be attributed largely to correction of ulnar drift and the change of metacarpophalangeal arc of motion. These results confirm that the Silastic metacarpophalangeal joint arthroplasty significantly improves hand function and that the improvement is maintained over a 3- to 4-year period.

A simplified technique of the Sauvé-Kapandji (SK) procedure for disorders of the distal radioulnar joint (DRUJ) is described. The DRUJ is transfixed by a screw but is not formally exposed and fused, the periosteum of the distal ulna is not excised, and the pronator quadratus is not advanced into the pseudarthrosis. Stability of the ulna shaft is obtained by suturing the sheath of the extensor carpi ulnaris (ECU) and periosteum as a single layer firmly over the ulnar stump and pseudarthrosis. The operating time averages 20 minutes. Review of 28 wrists demonstrated relief of pain in 27; 80 degrees or greater of pronation and supination in 19 and 20, respectively; fusion of the DRUJ in 18; and ulnar carpal shift in 3. The main complications were related to screw placement and length and prominence of the ECU tendon. The simplified SK procedure reliably relieves pain and restores movement at the DRUJ.

A macroscopic and histologic study has been made on the changes during a 2-year period in a free composite graft of synovium subsynovial fat and periosteum taken from the medial femoral condyle and placed on the cartilage denuded patellar groove of the knee joint in skeletally mature sheep. The results have been compared to a control group which had the same surgical management except that the graft was discarded. The study demonstrated that following "take" and revascularization, the composite graft had converted to a single layer of vascular fibroblastic tissue by 6 weeks and over the ensuing year this had been largely replaced by fibrocartilage of variable differentiation. However, over the next year much of this fibrocartilage would appear to have undergone either redifferentiation into disorganized fibrochondroid tissue or developed secondary degenerative changes. By contrast, the control specimens had profound resorption of the bone plate followed by patchy resurfacing with tissue ranging from a very loose fibrous connective tissue to well differentiated fibrocartilage. The latter had gradually increased in amount of over the 2-year period, but secondary degenerative changes had also developed as in the grafted group. Despite some of the drawbacks, particularly the magnitude of the patello-femoral compression force, the technique has now been refined into a reliable animal model for the study of different parameters either in the graft or the graft environment in the hope that a way can be found to increase the life span of the metaplastic cartilage.

A prospective study of 60 patients with quadriceps hematomas was carried out in an attempt to gain a better understanding of the pathogenesis, characteristics, and morbidity of this condition, including those patients in whom ossification occurs. The patients ranged in age from 15 to 25 years; thirty-six were injured playing rugby football. The knee was the most common site. In ten patients heterotopic ossification developed. The three phases of management are rest, knee mobilization, and restoration of quadriceps function. The average hospitalization period in the 28 inpatients was eight days. The average time away from work in the 40 employed patients was four weeks. Both hospitalization and disability times were greater in those patients in whom ossification developed. 99m-Technetium-diphosphonate scanning, carried out in ten patients, was useful for determining the site and size of the bleed. The study has elucidated the epidemiology and morbidity and has been successfully used in an education program. Investigations to determine the localization of the hematoma and to predict ossification were unsuccessful.

The pseudo-boutonniere deformity is a boutonneire-like deformity resulting from a hyperextension injury to the proximal interphalangeal joint causing tearing of the volar soft tissues. It is seen almost exclusively in the little and ring fingers. The features, pathomechanics and prophylaxis of the condition are described. The treatment is by dynamic splintage and the importance of distinguishing the deformity from the true boutonniere deformity is emphasised.

A haemophiliac patient with crippling degenerative joint disease is described in whom arthrodeses of the left knee and right ankle and total replacement of the left ankle were performed in the course of one operation. The reasons for this and for using a total ankle replacement are discussed.

Severe damage to the deep musculature of the thigh was caused by standardized crushing injuries applied to muscle overlying the femora of anesthetized sheep. The injuries caused an acute inflammatory response, with the formation of granulation tissue and, later, extensive scarring. Periosteal bone formed in all cases, in some instances resulting in a spike of bone that protruded into the overlying soft tissue. Heterotopic bone formed in 16.6% of the legs of sheep within three weeks to three months after trauma by intramembranous ossification within scar tissue replacing muscle tissue.

A technique is described for the repair of the chronic, post traumatic, uncomplicated boutonnière deformity which has given consistently good results. The fundamental steps are: Mobilisation and reefing of the lengthened middle slip; Kirschner wire fixation of the proximal joint in full extension and replacement of the mobilised lateral slips with the distal joint flexed approximately 45 degrees.