The Gelation of CO(2): A Sustainable Route to the Creation of Microcellular Materials

Compounds with strong thermodynamic affinity for carbon dioxide (CO(2)) have been designed and synthesized that dissolve in CO(2), then associate to form gels. Upon removal of the CO(2), these gels produced free-standing foams with cells with an average diameter smaller than 1 micrometer and a bulk density reduction of 97 percent relative to the parent material.

A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments

OBJECTIVE

To evaluate the effectiveness and cost effectiveness of specially trained physiotherapists in the assessment and management of defined referrals to hospital orthopaedic departments.

DESIGN

Randomised controlled trial.

SETTING

Orthopaedic outpatient departments in two hospitals.

SUBJECTS

481 patients with musculoskeletal problems referred for specialist orthopaedic opinion.

INTERVENTIONS

Initial assessment and management undertaken by post-Fellowship junior orthopaedic surgeons, or by specially trained physiotherapists working in an extended role (orthopaedic physiotherapy specialists).

MAIN OUTCOME MEASURES

Patient centred measures of pain, functional disability and perceived handicap.

RESULTS

A total of 654 patients were eligible to join the trial, 481 (73.6%) gave their consent to be randomised. The two arms (doctor n = 244, physiotherapist n = 237) were similar at baseline. Baseline and follow up questionnaires were completed by 383 patients (79.6%). The mean time to follow up was 5.6 months after randomisation, with similar distributions of intervals to follow up in both arms. The only outcome for which there was a statistically or clinically important difference between arms was in a measure of patient satisfaction, which favoured the physiotherapist arm. A cost minimisation analysis showed no significant differences in direct costs to the patient or NHS primary care costs. Direct hospital costs were lower (p < 0.00001) in the physiotherapist arm (mean cost per patient = 256 Pounds, n = 232), as they were less likely to order radiographs and to refer patients for orthopaedic surgery than were the junior doctors (mean cost per patient in arm = 498 Pounds, n = 238).

CONCLUSIONS

On the basis of the patient centred outcomes measured in this randomised trial, orthopaedic physiotherapy specialists are as effective as post-Fellowship junior staff and clinical assistant orthopaedic surgeons in the initial assessment and management of new referrals to outpatient orthopaedic departments, and generate lower initial direct hospital costs.

Surgery for rheumatoid arthritis of the elbow: a comparison of radial-head excision and synovectomy with total elbow replacement

The results of total elbow replacement (TER) in 45 elbows of 38 patients with rheumatoid arthritis were compared with results of radial head excision with synovectomy (RHES) in 45 age-matched patients treated in the same unit. The groups were similar with respect to duration of disease and preoperative clinical status, although pain was of longer duration and slightly more severe in the TER group. Failure was defined as the onset of moderate or severe pain after surgery or revision surgery for any reason. Reduction in pain was greater after TER than after RHES (P < .05). Recurrence of pain was common after RHES but was not seen after TER. Movement increased by a similar amount in each group. Complications were more frequent and more serious after TER (4 dislocations, 4 ulnar nerve dysfunctions, 1 significant wound breakdown) than after RHES (2 ulnar nerve dysfunctions, 1 transient wound discharge). Complications after TER were most common in patients who had previous RHES. On survival analysis, TER results were better than RHES results in each successive year. Cumulative survival rates at 10 years were 85% for TER and 69% for RHES, but the difference in rates was not statistically significant. In the medium term, TER relieves pain more reliably than RHES and its use is justified despite the greater risk of complications. In view of the paucity of long-term results for TER, RHES may retain a role in younger patients or in those whose symptoms are related mainly to the radiohumeral joint.

Osteoarthritis-susceptibility locus on chromosome 11q, detected by linkage

We present a two-stage genomewide scan for osteoarthritis-susceptibility loci, using 481 families that each contain at least one affected sibling pair. The first stage, with 272 microsatellite markers and 297 families, involved a sparse map covering 23 chromosomes at intervals of approximately 15 cM. Sixteen markers that showed evidence of linkage at nominal P</=.05 were then taken through to the second stage, with an additional 184 families. This second stage confirmed evidence of linkage for markers on chromosome 11q. Additional markers from this region were then typed to create a denser map. We obtained a maximum single-point LOD score, at D11S901, of 2.40 (P=.0004) and a maximum multipoint-LOD score of 3.15, between markers D11S1358 and D11S35. A subset of 196 of the 481 families, comprising affected female sibling pairs, generated a corrected LOD score of 2.54 (P=.0003) for marker D11S901, with evidence for linkage extending 12 cM proximal to this marker. When we stratified for affected male sibling pairs there was no evidence of linkage to chromosome 11. Our data suggest that a female-specific susceptibility gene for idiopathic osteoarthritis is located on chromosome 11q.

Beyond disability: measuring the social and personal consequences of osteoarthritis

OBJECTIVE

Measuring the impact of osteoarthritis has traditionally focused on the disease (measures of impairment), functional disability and latterly, general health status or quality of life. This paper highlights the importance of measuring the wider personal and social consequences of OA both at a population and an individual patient level.

DESIGN

The World Health Organisation definition of handicap is used to describe this wider impact of disease and measures of handicap, both generic and disease-specific are reviewed. The measurement of handicap in OA is illustrated by the use of the Disease Repercussion Profile in a clinical trial of orthopaedic out-patients with OA and low back pain. These data are compared to routine clinical handicap data collected on consecutive patients with rheumatoid arthritis attending a different outpatient clinic.

RESULTS

OA patients reported handicap in six areas of their lives: functional and social activities, relationships, socio-economic status, emotional well-being and body image. The prevalence was similar to that reported by RA patients. OA patients reported more severe handicap than RA patients in each of the 6 areas (F ratios 4. 97-55.67) and the differences were statistically significant (P values 0.03-0.0001) for all dimensions except functional and social handicap. The LBP patients scored slightly more severe handicap on all dimensions than the OA patients but these differences did not reach statistical significance. However, they scored significantly more severe handicap than the RA patients (F ratios 8.49-174.72, P< 0.0001).

CONCLUSIONS

These data suggest that the psychosocial impact of OA may have been underestimated and highlight the importance of going beyond disability in assessing the impact of OA. Measurement of the wider impact of OA can be achieved using disease-specific and generic measures of handicap. The choice of tool will depend upon the setting (research or clinical practice) and the purpose of measurement.

Patients with primary osteoarthritis show no change with ageing in the number of osteogenic precursors

The variation in marrow colony forming unit-fibroblastic (CFU-F) number in 59 patients (14-87 years of age) undergoing corrective surgery (14 controls; 14-48 years of age) or hip arthroplasty for primary osteoarthritis (45 OA; 46-87 years of age) was examined to determine whether marrow CFU-F, derived from marrow stromal fibroblastic stem cells, are maintained with the development of primary osteoarthritis (OA). Total colony number, colony size as well as alkaline phosphatase-positive colonies were determined. The mean fibroblast colony forming efficiency from the whole patient group was 2.4 x 10(-5) +/- 1.4 x 10(-5). Ageing had no effect on the colony forming efficiency or on the alkaline-phosphatase-positive colony forming efficiency, irrespective of gender. Thus precursor cells with the potential for osteogenic differentiation are maintained in OA with ageing. However, colony size showed a significant reduction with age, implying altered proliferation potential of osteogenic progenitors with ageing. This ageing effect may not be as significant in OA as in the rest of the population as bone mineral density is often preserved in osteoarthritis. As there is no apparent deficit in primitive progenitor cells, this preservation may be the result of altered regulation of osteoprogenitor activity in OA.

Aromatic analogs of arcaine inhibit MK-801 binding to the NMDA receptor

Aromatic analogs of arcaine were shown to have inhibitory effects on the binding of the channel blocking drug [3H]MK-801 to the NMDA receptor complex. The most potent compound of the series was an N,N'-bis(propyl)guanidinium which inhibited [3H]MK-801 binding with an IC50 of 0.58 microM and an IC50 of 12.17 microM upon addition of 100 microM spermidine. The increase in IC50 upon addition of spermidine suggests competitive antagonism between the inhibitor and spermidine at the arcaine-sensitive polyamine site of the NMDA receptor complex.

Development of a new synthetic bone graft

A process for the replication of bovine cancellous bone in synthetic bioceramic materials for use as artificial bone graft substitutes is described. The process detailed here may be easily implemented to allow production of large numbers of blocks of material, even on a laboratory scale. The graft material has a pore morphology and interconnectivity identical with that of the original cancellous bone used as a starting material. Strength of the material is adequate, and at lower porosity levels it meets the FDA requirements for coralline materials for spinal applications. The synthetic graft is also shown to have excellent fluid-retention characteristics, making it a potential carrier for morphogenic agents such as solutions of bone morphogenic protein.

A synthetic bone implant macroscopically identical to cancellous bone

Macroporous hydroxyapatite (HA) and beta-tricalcium phosphate (beta-TCP) are widely used as synthetic bone replacement materials due to their high biocompatibility and osteoconductive properties. The level of porosity, pore size distribution, pore morphology, and the degree of pore interconnectivity in such grafts significantly influences the extent of bone ingrowth. It has been hypothesised that an ideal implant macrostructure may be similar in morphological characteristics to the inorganic matrix of the bone it is replacing. However, to date, clinically available synthetic materials differ structurally from cancellous bone. A method is described for the macrostructural replication of cancellous bone. Reproduction involves a multistage process requiring the manipulation of positive and negative forms of the inorganic matrix. By infiltration of a wax negative mould of cancellous bone with a ceramic slip, followed by removal of the wax, and firing, it is possible to produce a positive replica of the original cancellous macrostructure. Optimisation of slip preparation conditions (pH and percentage deflocculant addition) and sintering conditions have allowed successful replication of cancellous bone using several bioceramic compositions including HA, beta-TCP, and HA/beta-TCP.

A quantitative study of the sintering and mechanical properties of hydroxyapatite/phosphate glass composites

Previous work has shown that small additions of a phosphate glass (CaO-P2O5) can significantly enhance the sinterability and strength of hydroxyapatite. However, there are no quantitative phase analyses available for these materials which would provide indicators of biocompatibility and resorbability. Similarly, there is little information available about the mechanical properties, especially with high glass additions. In this study, the effects of sintering hydroxyapatite with phosphate glass additions of 2.5, 5, 10, 25, and 50 wt.% are quantified. Each composition was sintered over a range of temperatures, and quantitative phase analysis was carried out using XRD. In addition, the microstructures were studied using RLOM and SEM, and mechanical properties (Vickers hardness, KIC, and MOR) measured. These results may be used to indicate which compositions and processing conditions may provide materials suitable for use in hard tissue replacement. Composites containing up to 10 wt.% glass additions formed dense HA/TCP composite materials possessing flexural strength and fracture toughness values up to 200% those of pure HA. The HA/TCP ratio was strongly dependent on the percentage glass addition. Higher glass additions resulted in composites containing beta-TCP together with large amounts of alpha- or beta-calcium pyrophosphate, and having similar mechanical strengths to pure HA.

Synovectomy of the elbow and radial head excision in rheumatoid arthritis. Predictive factors and long-term outcome

We carried out a survival analysis of elbow synovectomy (ES) and excision of the radial head (RHE) performed on 171 rheumatoid elbows. The failure criteria were revision surgery (performed or desired) and/or the presence of significant or severe pain. The cumulative survival was 81% at one year which thereafter decreased by an average of 2.6% per year. The strongest predictor for success was a low preoperative range of supination-pronation when corresponding survival curves were compared. A low range of flexion-extension also predicted failure. Combining both factors gave better prediction (failure: 6.3% v 67%), but a long duration of elbow symptoms before surgery predicted failure (72%, p = 0.04). At review, there was a mean gain of 50 degrees in supination-pronation and 11 degrees in flexion-extension; both correlated with success. Failure correlated with recurrence of synovitis, elbow instability, ulnar neuropathy, poor general mobility and poor upper-limb function. The last was independently affected by the severity of RA in the ipsilateral shoulder. Our findings show that although the short-term result of ES and RHE in rheumatoid arthritis is good, the long-term outcome is poor except in a subgroup with more than 50% limitation of forearm rotation.

SYNOVECTOMY OF THE ELBOW AND RADIAL HEAD EXCISION IN RHEUMATOID ARTHRITIS

We carried out a survival analysis of elbow synovectomy (ES) and excision of the radial head (RHE) performed on 171 rheumatoid elbows. The failure criteria were revision surgery (performed or desired) and/or the presence of significant or severe pain.

The cumulative survival was 81% at one year which thereafter decreased by an average of 2.6% per year. The strongest predictor for success was a low preoperative range of supination-pronation when corresponding survival curves were compared. A low range of flexion-extension also predicted failure. Combining both factors gave better prediction (failure: 6.3% v 67%), but a long duration of elbow symptoms before surgery predicted failure (72%, p = 0.04).

At review, there was a mean gain of 50° in supination-pronation and 11° in flexion-extension; both correlated with success. Failure correlated with recurrence of synovitis, elbow instability, ulnar neuropathy, poor general mobility and poor upper-limb function. The last was independently affected by the severity of RA in the ipsilateral shoulder.

Our findings show that although the short-term result of ES and RHE in rheumatoid arthritis is good, the long-term outcome is poor except in a subgroup with more than 50% limitation of forearm rotation.

Genetic influences in end-stage osteoarthritis. Sibling risks of hip and knee replacement for idiopathic osteoarthritis

From a prospective, cross-sectional survey of 402 patients who had a total hip (THR) or a total knee (TKR) replacement for idiopathic osteoarthritis (OA) at a major centre, we determined the prevalence of these replacements for idiopathic OA in their 1171 siblings and 376 spouses. Using spouses as controls, the relative risk of THR in siblings was 1.86 (95% CI 0.93 to 3.69). The relative risk for TKR in siblings v spouses was 4.8 (95 % CI 0.64 to 36.4) whereas the risk for the combined outcome measure of THR or TKR was 2.32 (95% CI 1.22 to 4.43) when siblings and spouses over 64 years of age were compared. Using a threshold liability model (Falconer), the heritability of end-stage OA of the hip was estimated at 27%. The increased risks of joint replacement for severe, idiopathic OA which we found in siblings suggest that genetic influences are important in end-stage OA of the hip and knee.

GENETIC INFLUENCES IN END-STAGE OSTEOARTHRITIS

From a prospective, cross-sectional survey of 402 patients who had a total hip (THR) or a total knee (TKR) replacement for idiopathic osteoarthritis (OA) at a major centre, we determined the prevalence of these replacements for idiopathic OA in their 1171 siblings and 376 spouses. Using spouses as controls, the relative risk of THR in siblings was 1.86 (95% CI 0.93 to 3.69). The relative risk for TKR in siblings v spouses was 4.8 (95% CI 0.64 to 36.4) whereas the risk for the combined outcome measure of THR or TKR was 2.32 (95% CI 1.22 to 4.43) when siblings and spouses over 64 years of age were compared. Using a threshold liability model (Falconer), the heritability of end-stage OA of the hip was estimated at 27%.

The increased risks of joint replacement for severe, idiopathic OA which we found in siblings suggest that genetic influences are important in end-stage OA of the hip and knee.

Measurement of the anteroposterior translation of the humeral head using MRI

Anteroposterior translation of the humeral head within the glenohumeral joint was investigated using MRI. Ten normal shoulders, 11 recurrent anterior dislocations, 10 stabilised shoulders after the Putti-Platt operation and one shoulder with multidirectional instability, were scanned. The arm was positioned in internal and external rotation and in an overhead position. Gradient echo volume acquisition scans were carried out, and 22 were suitable for evaluation. Consistent results were obtained in the normal shoulders. The unstable and unstable shoulders showed higher variance, but there was no significant anterior translation in external rotation in any group. The range of external rotation was significantly reduced in the unstable and stabilised shoulders. A trend towards posterior translation was found in internal rotation with a mean of 1 (+/- 0.44) in normal, 0.89 (+/- 1.67) in unstable and 1.6 (+/- 1.4) in stabilised shoulders.

Reflex muscle contraction in anterior shoulder instability

Reduced proprioception may contribute to recurrent anterior shoulder instability. Twelve patients with unilateral shoulder instability were investigated for evidence of deficient proprioception with an activated pneumatic cylinder and surface electromyography electrodes; the contralateral normal shoulder was used as a control. The latency between onset of movement and the detection of muscle contraction was used as an index of proprioception. No significant difference in muscle contraction latency was detected between the stable and unstable shoulders, suggesting that there was no significant defect in muscular reflex activity. This study does not support the use proprioception-enhancing physiotherapy in the treatment of posttraumatic anterior shoulder instability.

Anatomy of the normal acromion investigated using MRI

The shape of the acromion is strongly associated with impingement syndrome and with rotator cuff tears. It is notoriously difficult to image the acromion with conventional radiography. We have developed MRI techniques to depict the acromion in its longitudinal axis. Furthermore, we have measured the subacromial space in both external and internal rotation. In previous studies, three types of acromial shape have been described with the type III or hooked acromion being present in 66% of cases with rotator cuff tears. We studied 31 normal shoulders in 29 people using MRI. Within this population aged 24-36 years, mean age 31 years, no type III acromions were found. Twenty-one were type I (67.7%) and 10 were type II (32.3%). In addition, we found no difference in subacromial height in external or internal rotation. Low rates of intra- and interobserver error were found. These results imply that the hooked acromion is not present in the normal population and is, therefore, likely to be an acquired abnormality.

Margaret Holroyd Prize Essay. A patient-centred approach to evaluation and treatment in rheumatoid arthritis: the development of a clinical tool to measure patient-perceived handicap

Assessment of patient-centered outcomes is of particular importance in a chronic disease such as rheumatoid arthritis (RA), where a major aim of treatment is a reduction of its disabling and handicapping effects. Rheumatology is reasonably well advanced in its deployment of such outcomes. Measurement of the patient's experience of disease has focused on the ability to perform daily living tasks and, latterly, on the more global effect on quality of life. Neither of these approaches is without conceptual and measurement problems. A new measure of patient-centred outcome in RA has been developed (Carr AJ, Br J Rheumatol 1994;33:378-82). This tool, the Disease Repercussion Profile (DRP), attempts to extend the measurement of outcome to incorporate the individual functional, social, psychological, emotional and economic disadvantage resulting from RA, i.e. patient-perceived handicap. It has been designed for use as a clinical tool, to allow patients to specify the problems and needs of most importance to them, and as such represents a new approach. This paper reviews the development of the DRP in the context of existing health status measures and examines its potential role as a routine measure in an out-patient setting.

Handicap in inflammatory arthritis

Two instruments measuring handicap were evaluated and compared with clinical, laboratory and disability measures. Participants were 133 patients attending a rheumatology follow-up clinic in a district general hospital, of whom 102 were followed up after 3 months. Measurements included acute-phase response, early morning stiffness, pain, wellbeing, joint involvement (impairments), the Stanford Health Assessment Questionnaire (disability), the Disease Repercussion Profile and the London Handicap Scale (handicap). A substantial burden of disability and handicap was recorded. There were moderate correlations between impairments (0.4 < rho < 0.6), and moderate to strong correlations between disability and handicap measures (0.4 < rho < 0.8). Correlations between impairment and disability/handicap were weak (rho < 0.4). Mean changes in all variables over 3 months were small, and none was statistically significant. A comprehensive description of the impact of disease and treatment requires measurements to be made of impairments, disabilities and handicaps. The use of clinical and laboratory variables alone may be misleading.

An evaluation of the Constant-Murley shoulder assessment

We have analysed the Constant-Murley (1987) assessment for 25 patients with shoulder pathology. We found the score easy to use, with low inter- and intraobserver errors, but sufficiently imprecise in repeated measurements to give concern in its use for clinical follow-up of patients. We have calculated 95% confidence limits for a single assessment to be within 16 to 20 points in most cases. In addition, we found that all our subjects with instability as their main problem scored within five points of the maximum; this suggests that the scoring method may need to be revised for use on these patients.

Quality of life measures

Quality of life measures have become increasingly popular as outcome measures despite the lack of consensus on a definition of quality of life. This review describes the most frequently used measures, and discusses the conceptual and measurement issues surrounding quality of life measurement. Finally, it tries to place quality of life in the World Health Organization's model of disease impact.

Fibrogenesis imperfecta ossium

The clinical features, investigation, treatment and outcome of two adults with fibrogenesis imperfecta ossium are described. In this rare acquired disorder of bone, normal lamellar collagen is replaced by structurally unsound collagen-deficient tissue, which leads to extreme bone fragility and ununited fractures. Transmission microscopy and SEM showed striking ultrastructural changes in bone structure and mineralisation. Both patients had monoclonal IgG paraproteins in the plasma and one excreted monoclonal lambda light chains in the urine. No abnormal plasma cells were found in the bone marrow and there was no evidence of amyloid deposition in the tissues. In both patients initial treatment with 1 alpha-hydroxycholecalciferol appeared to be ineffective, but in one, repeated courses of melphalan and corticosteroids over three years together with 1 alpha-hydroxycholecalciferol produced striking clinical and histological improvement. The findings in these and other patients strongly suggest that paraproteinaemia is an integral feature of fibrogenesis imperfecta ossium, and this needs further investigation.

Fibrogenesis imperfecta ossium

The clinical features, investigation, treatment and outcome of two adults with fibrogenesis imperfecta ossium are described. In this rare acquired disorder of bone, normal lamellar collagen is replaced by structurally unsound collagen-deficient tissue, which leads to extreme bone fragility and ununited fractures. Transmission microscopy and SEM showed striking ultrastructural changes in bone structure and mineralisation. Both patients had monoclonal IgG paraproteins in the plasma and one excreted monoclonal lambda light chains in the urine. No abnormal plasma cells were found in the bone marrow and there was no evidence of amyloid deposition in the tissues. In both patients initial treatment with 1 alpha-hydroxycholecalciferol appeared to be ineffective, but in one, repeated courses of melphalan and corticosteroids over three years together with 1 alpha-hydroxycholecalciferol produced striking clinical and histological improvement. The findings in these and other patients strongly suggest that paraproteinaemia is an integral feature of fibrogenesis imperfecta ossium, and this needs further investigation.

Which primary total hip replacement?

To assist surgeons to select a total hip replacement (THR) we present comparative information on all such implants on the market in the UK. We identified 62 different primary THRs, manufactured by 19 companies; half had been introduced in the last five years, and only 30% have any results published in peer-reviewed journals. The prices range from 250 pounds to 2000 pounds, and the two cheapest implants have the longest reported follow-up. The number of THR implants available in the UK, and presumably the rest of the world, is rapidly increasing, but there is little or no scientific evidence that the newer, more expensive, implants are better than established designs. Some will undoubtedly be worse. We believe that this situation is unsatisfactory and make recommendations for improvement, in particular that preference be given to implants with good results in published peer-reviewed long-term clinical trials.

Which primary total hip replacement?

To assist surgeons to select a total hip replacement (THR) we present comparative information on all such implants on the market in the UK. We identified 62 different primary THRs, manufactured by 19 companies; half had been introduced in the last five years, and only 30% have any results published in peer-reviewed journals. The prices range from 250 pounds to 2000 pounds, and the two cheapest implants have the longest reported follow-up. The number of THR implants available in the UK, and presumably the rest of the world, is rapidly increasing, but there is little or no scientific evidence that the newer, more expensive, implants are better than established designs. Some will undoubtedly be worse. We believe that this situation is unsatisfactory and make recommendations for improvement, in particular that preference be given to implants with good results in published peer-reviewed long-term clinical trials.

Day case arthroscopy under local anaesthesia

A prospective study of the effectiveness of local anaesthesia in arthroscopy of the knee was performed in 212 consecutive patients. Arthroscopic surgery was undertaken successfully in 121 cases (57%), including meniscectomy and drilling of osteochondral defects. Dynamic evaluation of the patellofemoral joint articulation was possible and demonstration of pathological abnormalities was felt to be beneficial by some patients. The method described is safe, reliable, confers good postoperative analgesia and enables physiotherapy to begin immediately. Conversion to general anaesthesia was necessary in one case due to pain localised to a stiff and osteoarthritic hip. Intra-articular haemorrhage was found to be a problem in one case with synovitis. Only ten patients complained of moderate pain, none had severe pain. Local anaesthesia is contraindicated in cases with ipsilateral osteoarthritis of the hip or with significant synovitis of the knee. This technique is particularly suited to day case surgery.

Towards a measure of patient-perceived handicap in rheumatoid arthritis

The impact of chronic disease on an individual depends not only on the severity of the disease, but on his/her life role i.e. his/her needs, expectations etc. The World Health Organization expresses the impact of chronic disease in terms of impairment, disability and handicap, where handicap is the social disadvantage resulting from disease. This article argues that the assessment of patient-perceived handicap is essential to the clinical management of chronic disease because it provides the physician with clinically relevant information about the meaning of disease for each patient, enabling treatment and intervention to be tailored to meet individuals' needs. The development of a method for assessing patient-perceived handicap using patient profiles with the object of supplying the physician with a simple clinical tool is described.

The clinical features of Ehlers-Danlos syndrome type VIIB resulting from a base substitution at the splice acceptor site of intron 5 of the COL1A2 gene

The features of a 32 year old woman with Ehlers-Danlos syndrome type VIIB and affected members of her family, resulting from a mutation in one COL1A2 allele, were studied. Her dermal type I collagen contained alpha 2(I) chains and mutant pN-alpha 2(I) chains in which the amino-terminal propeptide remained attached to the alpha 2(I) chain. She was heterozygous for an AG-->AC mutation at the splice acceptor site of intron 5 of the COL1A2 gene. The mutation activated a cryptic AG splice acceptor site corresponding to positions +14 and +15 of exon 6 of the COL1A2 gene. In contrast to previous reports only five, rather than all 18, amino acids encoded by exon 6 were deleted in the proband. The deleted peptide removed the amino-proteinase cleavage site, but not the nearby lysine cross linking site in the amino-telopeptide of the alpha 2(I) chain. She was born with bilateral hip dislocations, knee subluxations, and generalised joint hypermobility. Bilateral inguinal herniae and an umbilical hernia were present at birth. Facial features included a depressed nasal bridge with prominent paranasal folds. The skin was soft, moderately hyperelastic, and sagged over the face. Skin fragility and easy bruising were apparent from childhood. Skin wounds healed slowly and with broad, paper thin scars. Throughout her life, she had multiple fractures of the small bones of her hands and feet following moderate trauma. Electron microscopy of the proband's dermis as well as deep fascia and hip joint capsule from her affected brother showed that collagen fibrils in transverse section were nearly circular but with irregular margins. Light microscopy of bone from her affected brother and son showed normal Haversian systems and lamellar bone. All of these tissues contained approximately equal amounts of the normal and mutant alpha2(I) chains. The findings of this study confirm that loss of the amino-proteinase cleavage site of the pro alpha2(I) collagen chains, owing to anomalous splicing of exon 6 sequences in the conversion of pre-mRNA to mRNA, produces the clinical features of Ehlers-Danlos syndrome type VIIB. The history of frequent fractures found in this family is atypical and indicates an overlap with osteogenesis imperfecta.

The management of isolated distal radius fractures in children

In a consecutive series of 175 forearm fractures requiring manipulation in children who presented to the John Radcliffe Hospital between 1 January 1991 and 30 June 1992, 23 had isolated distal radius fractures, all of which required manipulation for unacceptable angulation or displacement. We had previously noted that these fractures had a high incidence of loss of position leading to malunion. The 23 patients were randomly allocated to one of two treatment groups: either manipulation and cast alone, or manipulation and percutaneous Kirschner wiring with cast. These two groups were followed up clinically and radiographically until union occurred. Those fractures treated by percutaneous wiring had no significant complications, and all had a satisfactory result. The fractures treated by manipulation and casting alone required further manipulation in 10 cases (91%). We conclude that these problematic fractures should be treated by stabilisation with percutaneous wiring.

Survival analysis of joint replacements

Survival analysis is a powerful tool for analysing the results of total joint replacement, but it has major drawbacks when the failure rates are very low. We have reviewed 35 recent survival analyses of joint replacements to assess the magnitude of these problems and make recommendations as to how they may be avoided.

Rupture of the ulnar collateral ligament of the thumb in a 5-year-old girl

Injuries to the metacarpophalangeal joint of the thumb are rare in children and usually involve avulsion of the bone or cartilage. We describe a tear of the ulnar collateral ligament of the thumb with minimal symptoms in a 5-year-old girl.

The Oxford knee. Survival analysis of joint replacement

To evaluate the success of a knee prosthesis, long-term follow-up studies are needed. The best means for this is survival analysis. It would be desirable for a contribution towards the costs of these essential follow-up studies to be included in the sale price of the prosthesis.

Chronic multifocal osteomyelitis

We describe 22 patients who presented between the ages of 4 and 14 years with gradual onset of malaise and pain at the sites of multiple bone lesions. The symptoms from the bone lesions were sometimes sequential in onset and often relapsing. The radiological findings were typical of osteomyelitis. Radioisotope bone scans identified some clinically silent lesions. Bone biopsies were performed in 20 patients and the changes of osteomyelitis were seen in 17; microbiological culture was positive in only one. Seven patients had polyarthritis, two had palmoplantar pustulosis and one had psoriasis. Some symptomatic relief was obtained with anti-inflammatory agents and, to a less extent, with antibiotics. No patient had primary immunodeficiency. The mean duration of symptoms from the bone lesions was two years (1 to 4). When arthritis was present the joint symptoms lasted considerably longer (mean 7 years; range 4 to 10). The long-term prognosis was generally good. There was no evidence of altered bone growth or abnormal joint development. One patient developed a progressive kyphosis requiring fusion, but no other surgical intervention was necessary.

Joint laxity and hip rotation in normal children and in those with congenital dislocation of the hip

We measured the range of rotation in both hips of 397 normal children and in the unaffected hip of 135 children with unilateral congenital dislocation of the hip. Both groups were assessed for generalised joint laxity. Joint laxity was more common in normal children with an internally centred arc of hip rotation than in normal children with a neutral or an externally rotated arc. The children with congenitally dislocated hips had significantly more joint laxity than did the control group and significantly more of them had an internally centred arc of hip rotation. We suggest that the lax joint capsule fails to mould away the neonatal anteversion of the femoral neck during the first few months of life.

Joint laxity and hip rotation in normal children and in those with congenital dislocation of the hip

We measured the range of rotation in both hips of 397 normal children and in the unaffected hip of 135 children with unilateral congenital dislocation of the hip. Both groups were assessed for generalised joint laxity. Joint laxity was more common in normal children with an internally centred arc of hip rotation than in normal children with a neutral or an externally rotated arc. The children with congenitally dislocated hips had significantly more joint laxity than did the control group and significantly more of them had an internally centred arc of hip rotation. We suggest that the lax joint capsule fails to mould away the neonatal anteversion of the femoral neck during the first few months of life.

Family stature in idiopathic scoliosis

The standing heights of 40 children with scoliosis and 110 persons from their immediate families were compared with those of a group of 349 contemporary control subjects. Skeletal bone ages and puberty ratings did not differ from normal, but the children with scoliosis were found to be significantly taller than the controls. They were also taller than their unaffected relatives, suggesting that the increased stature is not due to genetic factors alone. Scoliotic children with an affected immediate-family member were of normal height, which suggests that growth is of less etiological importance in children with a strong genetic susceptibility.

Rupture of extensor tendons due to osteoarthritis of the distal radio-ulnar joint

Extensor tendons ruptured in 12 patients as a result of osteoarthritis of the distal radio-ulnar joint. Rupture occurred without warning in ten cases and was sequential in five. Perforation of the dorsal capsule of the distal radio-ulnar joint, allowing contact between the roughened ulnar head and extensor tendons, was present in every case. The capsular performation was demonstrated by arthrography, which may be used to identify patients who are at risk of extensor tendon rupture. Loss of independent extension of the little finger is a valuable clinical sign because rupture of extensor digiti minimi may be masked by a powerful contribution from the extensor tendon of the ring finger.

The radiographic classification of medial gonarthrosis. Correlation with operation methods in 200 knees

Ahlbäck's classification of gonarthrosis can be applied with improved precision by careful interpretation of anteroposterior varus stress and lateral radiographs of the knee. The tibial lesion in early gonarthrosis is located in the anterior and middle part of the medial plateau. In more advanced disease, when the anterior cruciate ligament is invariably damaged, the lesion extends to the posterior margin of the medial tibial plateau. We studied the preoperative radiographs of 200 knees with arthrosis. We were able to predict the integrity of the anterior cruciate ligament (and the use of unicompartmental arthroplasty) with 95 percent accuracy and rupture or damage to the anterior cruciate ligament (and the use of total condylar arthroplasty) with 100 percent accuracy. We believe that the Ahlbäck classification reflects the anatomic and pathologic progression of medial compartment gonarthrosis, and is of value in allowing more accurate comparisons to be made of different methods of treatment.

Segregation of structural collagen genes in adolescent idiopathic scoliosis

The etiology of idiopathic scoliosis remains unknown. The condition results in a characteristic deformity of the spine and surrounding tissues. Both Types I and II collagen are important constituents of the affected tissues, and thus defective collagens are reasonable candidates for the primary abnormality in adolescent idiopathic scoliosis (AIS). Direct analyses of the amount and solubility of collagen have revealed differences between normal individuals and those with AIS. However, these changes may be secondary to the mechanical effects of the spinal deformity. Segregation analysis was done of genetic markers linked to the structural genes encoding Types I and II collagen to test these candidate loci in four pedigrees with dominantly inherited AIS. In one pedigree, markers linked to both of the Type I collagen loci (COL1A1 and COL1A2) were found to be inherited independently of the abnormal phenotype. Two pedigrees were discordant at one of the Type I loci. The condition also segregated independently of the locus for Type II collagen (COL2A1) in three pedigrees. This is evidence against idiopathic scoliosis generally being caused by mutations in the Types I and II collagen genes.

An analysis of normal back shape measured by ISIS scanning

Two hundred seventy-one school children aged 10-16 years and 72 normal adults aged 21-59 years were scanned by ISIS. Subjects with any evidence of scoliosis were excluded from the study. Characteristic ISIS parameters of back shape showed no statistically significant differences related to age or sex for the children. Back shape in both men and women was not significantly different from that of the children, except for kyphosis angles which were greater.