Volume I Number 3 REPORTS OF MEETINGS 243

REPORTS OF MEETINGS

S U M M A R Y O F P A P E R S D E A L I N G W I T H I N J U R I E S

Meeting of the British Orthopaedic Association held in London, September, 1969

Alcohol, Steroids, and Idiopathic Necrosis of the Femoral Head: L. SOLOMON, Johannesburg

Having reviewed papers reporting a relationship between alcohol and steroids with apparently spon- taneous crumbling of the head of the femur, the speaker drew attention to the fact that there were cases in which neither of these possible causes could be blamed. African Negroes drank a special beer that contained little alcohol but having been brewed in iron pots had a high concentration of iron in it. This led to osteoporosis with crumbling of the weaken- ed bone under more or less normal loads. Crumbling was not restricted to the hip; it could occur in any of the weight-bearing joints.

Professor Solomon also expressed the opinion that when there was heavy drinking, fat emboli could arise from the fatty liver. He suggested that alcohol, steroids, and aspirin might reduce a patient's aware- ness of pain and so cause him to go on using a joint that needed rest and protection.

The Complications of Fractures of the Femoral Neck in Children: A. H. C. RATCLIFF, Bristol

Most of the 132 fractures collected and studied occurred in children aged 11-15. Complications occurred in nearly three-quarters of the patients with displaced fractures, which were three times as numer- ous as the mild fractures.

The complications were avascular necrosis, delayed union, non-union, coxa yarn, and premature fusion of the epiphysis with consequent shortening of the limb. Forty-five per cent showed signs within a year that the head of the femur was dead; this occurred with the mild as well as the severe fractures and had one of three patterns :--(a) The whole proximal fragment died; (b) Only the epiphysis of the head died; (c) The dead part was in the lower part of the head, adjoining the neck. The first sort always gave bad results, the other two did not always do so. Avascular necrosis could occur with basal as well as with subcapital fractures of the neck.

The best chance of successful treatment occurred when the fracture was reduced and fixed with Moore's or similar pins but Mr. Ratcliff had known non- union to be treated successfully by abduction osteo- tomy and bone-graft. In discussion, Mr. Denys Wainwright showed that timely osteotomy might be followed by more or less reversal of early crumbling.

Geographical Distribution of Senile Osteoporosis: J. CHALMERS, Edinburgh, and K. C. Ho, Hong Kong

Fracture of the neck of the femur was found pro- gressively less often in Sweden, Britain, China, and among African Negroes. Senile osteoporosis showed similar differences and the speakers concluded that

the less active one became the more likely one was to develop osteoporosis and, consequently, fractures.

Osteochondral Fractures and their Relationship to Osteochondritis Dissecans--an Experimental Study: P. M. AICHROTH, London

By cutting pieces of bone of different shapes and positions from the medial femoral condyle of rabbits the speaker has shown that if the resulting fragment either fitted snugly in its bed or was securely fixed with steel pins it would unite but that if it were free to move it was much less likely to do so and might become a loose body. He showed how the area of contact between the patella and the medial condyle of the femur when the knee was flexed, corresponded with the classic site of osteochondritis dissecans, but he gave no details of how this lesion might occur elsewhere.

The Structure of the Meniscus; its Relationship to Tears and to the Forces acting through the Knee: P. G. BULLOUGH and L. R. JORDAN, New York

The articular surface of the tibia that is not covered by meniscus becomes rough before the covered part, but this is not the only weight-bearing part of the tibia. This was shown by tomograms made after treating the knees with silver nitrate, which outlined the free surface of the articular cartilage.

The speakers went on to show that the meniscus was made up largely of collagen fibres that followed its main curve but were bound together by radial, vertical, and more tortuous fibres. The meniscus was one of the weight-bearing components of the knee and degenerated with age. This structure provided a good explanation for the usual patterns of injury in the meniscus.

A Comparison of Two Methods of Postoperative Management of Patients after Meniscectomy: D. ROSBOROUGH, Cambridge

Patients who had undergone meniscectomy were treated in one of two ways:- -

1. A large bandage was applied and reinforced with plaster-of-Paris. The patients were allowed up on crutches and began to walk about a week after operation. Stitches and the dressings were removed after 13-14 days.

2. A smaller dressing was used for 48 hours, without plaster-of-Paris. Treatment was otherwise as for (1).

Seventy-five per cent of those in Group 1 left hospital within a week of operation and had fewer complications than Group 2, which had an average stay of 10"9 days in hospital. There were few effusions in either group and in both the patients were off work for an average of 6 weeks.

244 INJURY" THE BRITISH JOURNAL OF ACCIDENT SURGERY Injury Jan. 1970

Observations of the Fixation of the Femoral Component of Total Hip Prosthesis by Acrylic Cement: D. W. PARSONS, R. H. ANSELL, and D. GODDARD, London

Removing the cancellous bone of the upper end of the femur gave a more strongly embedded mass of cement and prosthesis than merely rasping out the socket, which provided a small area of contact for the cement. It was also shown that there was less risk of seizing of metal-to-metal joints if the ball was well embedded in the socket than if it bore on a ring- shaped area.

Ivory Prostheses for Ununited Fractured Neck of the Femur: U. SAN BAW, Mandalay

The strength of ivory compares well with that of metal; 7 of the 100 prostheses used broke but this was the result of a fault in design, which was corrected by making the prosthesis thick. The shape closely resembled that of Moore's prosthesis. Sepsis occurred in only one case. Bone can grow into ivory and so fix the prosthesis very firmly.

Round Table Conference on Deep Venous Thrombosis V. V. Kakkar described the use of fibrinogen

labelled with 1~5I to identify and locate thrombi and went on to show that thrombolysis was best achieved by streptokinase. In answer to questions he said that isotopic diagnosis was more accurate than phlebo- graphic and that the concentration of I~5I in thrombi was one hundred or so times higher than in the blood and tissues.

IV. A. Matheson: A clinical diagnosis of deep venous thrombosis was right in 23 limbs and wrong in 6 but thrombosis was demonstrated by 125I in 44 limbs, in 31 of which there was no clinical evidence of throm- bosis.

Of anticoagulant substances, dextran 70 increased the volume and flow of blood and reduced both the stickiness of platelets and the tendency for them to settle and clump. Seventy ml. per kg (about 500 ml.) were given during operation and half that amount daily for the next 3 days.

Dextran 40 allowed thrombosis in 4 of 40 patients but warfarin in dosage sufficient to raise the pro- thrombin time to 2-2½ times normal, allowed 6 mild and 6 severe cases of thrombosis in 40 persons. When warfarin was not first given until 36 hours after operation, deep venous thrombosis occurred in 7 of 12 persons.

G. E. Mavor had found iliofemoral thrombosis in I1 of 140 victims of pulmonary embolism and evi- dence of peripheral thrombosis in the other 28. He thought that phlebography was better for diagnosing iliofemoral thrombi and ~25I for peripheral thrombi.

Thrombectomy was well worth undertaking, being much more effectual than plication and much less dangerous than ligation of the inferior vena cava. Of 22 patients, none suffered pulmonary embolism and 1 secondary thrombosis after thrombectomy. The main risk of embolism occurred when embolism had already preceded thrombectomy. Rethrombosis is much more likely to occur if the removal has been incomplete. Ten per cent of the patients had evidence of venous insufliciency from 3 months to 7 years later.

Discussion did not bring out a generally agreed policy but it seemed to be the case that prophylactic anticoagulant measures were by no means generally adopted and that there was still widespread readiness

to disregard thrombosis until it became clinically manifest in one way or another.

Slipped Upper Femoral Epiphysis In the discussion of slipped epiphysis there was little

support for a policy that avoided operation and relied on traction. D. M. Dunn's method of corrective cervical osteotomy was admired but was felt to require more skill than many surgeons could exercise. T.J . Fairbank put in a plea for gentle attempts at manipu- lative reduction in all cases because he had had much more success than many thought possible. P. H. Newman favoured subtrochanteric wedge osteotomy to correct fixed deformity and there was general support for this method.

The Painful Stiff Shoulder: H. F. MOSELEY, Toronto The lecturer showed a film and otherwise described,

in detail, the operation he used to treat recurrent dislocation of the shoulder.

He used a curved incision convex medially over the deltopectoral groove and cut the cephalic vein and the coracoid process. Believing that the essence of the condition is slackness of the anterior capsular mechanism, he screws a vitallium plate close to the inferomedial edge of the glenoid surface and uses it to anchor the capsule firmly to the rawed rim. There had been no attempt to restrict lateral rotation and the film showed that full movement could be regained within a week or so of the operation. No dislocation had recurred after the last 40 or 50 operations of this sort. Dr. Moseley had had cystic and other swellings when he used nylon stitches but no such trouble since he reverted to chromic catgut.

Placing of Pulleys for Flexor Tendons in the Fingers: N. J. BARTON, Oswestry

The speaker showed that it was best to retain one pulley at the neck of the proximal phalanx and another opposite the proximal interphalangealjoint. Two mm. of bow-string displacement occurred with these 2 pulleys and only 3 mm. if the distal pulley was on the shaft of the middle phalanx. Flexor digiti superficialis had no retentive effect on flexor profundus.

A Cause of Limited Flexion and Adduction of the Hip in Children: J. A. F. DE VALDERRAMA, Madrid

Flexion in abduction contracture of the hips could be well hidden by flexing the lumbar spine. This was caused by shortening of gluteus maximus, which was released with much improvement. It was thought likely that the cause was scarring following multiple injections. One British case was notified to the audience.

A Method for demonstrating the Change in Serum Content in Patients with Fat Embolism: A. R. GURD and R. I. WmSON, Belfast

By passing serum through a 10/~ filter it could be shown that the concentration of triglycerides in the filtrate was less than in the unfiltered serum; this was shown to be because fat globules had been held back. Filtration thus offered a sensitive test of fat globul- aemia; it was pointless measuring triglycerides in serum because they varied so much and because this would not distinguish free fatty acids from fat globules.

,P.S.L.