A little-known aspect of Arthur Conan Doyle (1859-1930): the call of India and a debt to Walter Scott (1771-1832)

This paper recalls the early life of Dr Arthur Conan Doyle when his writing centred briefly on India. The significance of a young female skeleton given to the museum of the Royal College of Surgeons of Edinburgh in 1879 is reviewed. Morphometric and genetic evidence is provided to show that the skeleton originated in the Andaman Islands. It is suggested that Doyle saw it during his undergraduate or early postgraduate years, leading him to introduce an Andaman Islander into his novel The Sign of the Four, published in 1890. Like his inspiring predecessor Walter Scott, Doyle wrote of India but did not visit the country: both authors learned indirectly of the Indian Raj and the Indian Medical Service. Doyle knew of the convict colony established after the Sepoy Mutiny of 1857 at Port Blair, capital of the Andamans, but the reason he chose an Islander to commit murder in London has, until now, remained contentious.

New insights into function of the growth plate

The mammalian growth plate is a complex structure which is essential for the elongation of long bones. However, an understanding of how the growth plate functions at the cellular level is lacking. This review, summarises the factors involved in growth-plate regulation, its failure and the consequence of injury. We also describe some of the cellular mechanisms which underpin the increase in volume of the growth-plate chondrocyte which is the major determinant of the rate and extent of bone lengthening. We show how living in situ chondrocytes can be imaged using 2-photon laser scanning microscopy to provide a quantitative analysis of their volume. This approach should give better understanding of the cellular control of bone growth in both healthy and failed growth plates.

Management of congenital talipes equino varus in Scotland: a nationwide audit

The Scottish Talipes Register is a record of all newly diagnosed cases of idiopathic congenital talipes equinovarus (CTEV) in Scotland over a four.year period. Two hundred and sixteen children were entered into the register, which recorded initial management and all subsequent interventions, both non-operative and operative. The data, therefore, represent a record of the different management regimens used within Scotland highlighting the variations in duration of conservative management and variations in surgical intervention following different methods of conservative management.

Pelvic remodelling after the Chiari osteotomy. A long-term review

Survivorship analysis of 215 medial displacement pelvic osteotomies undertaken for symptomatic, incongruent dysplasia of the hip since 1966 showed that four of every five hips had not required conversion to a total hip arthroplasty. The radiological characteristics of 86 osteotomies were evaluated at a mean of 18 years (5 to 30) after surgery which was performed at the age of 15.9 +/- 9.5 years. Revision was significantly (p < 0.05) more likely in those patients operated on after the age of 25 years. The centre-edge (CE) angle increased from 2.5 +/- 13.9 degrees before to 41.8 +/- 15.0 degrees immediately after operation. The increase in CE angle was maintained at later review (38.5 +/- 16.5 degrees). Even with severe dysplasia with a CE angle less than zero a substantial improvement in the cover of the femoral head was achieved, usually by medial shift of the lower pelvic fragment. However, the head was not invariably medialised by the osteotomy and lateral movement of the ilium was noted when the position of the joint was relatively medial before operation or when the hip was arthritic. In the longer term pelvic remodelling did not reverse the medialisation produced by the osteotomy, and the cover of the femoral head was maintained.

10-16 year results of Leeds-Keio anterior cruciate ligament reconstruction

Following initial enthusiasm in the late 1980s, the use of artificial ligament substitutes for anterior cruciate ligament (ACL) reconstruction has declined. However, the disadvantages of donor site morbidity for autologous graft and concerns about cross-infection from allogenic material have resulted in a maintained interest in prosthetic ligament substitutes. This study presents the outcome of ACL substitution using the Leeds-Keio (LK) polyester ligament at a mean of 13.3 years (range 10-16 years). Outcome was assessed using the International Knee Documentation Committee score, the Lysholm knee score, Tegner activity scale and American Knee Society Score and laxity by clinical examination and the Stryker Knee Laxity Tester. Standardized radiographs were taken to assess for evidence of degenerative change. The objective scoring tests showed that all patients experienced some degree of symptoms from their knee but functional impairment varied widely. Of the group, 28% were known to have ruptured their LK ligament and 56% had increased laxity compared with their opposite knee but no correlation could be shown between rupture, increased laxity and poor function. Of particular concern, all post-operative knees had radiographic signs of degenerative change compared with a rate of 39% in the contralateral knees.

Identification of the saphenous nerve at arthroscopy

Injury to the saphenous nerve can be a troublesome complication of arthroscopic procedures to the posterior half of the medial meniscus. In this article, we outline a technique for accurately identifying saphenous nerve position using transillumination of the saphenous vein.

Osteochondritis dissecans of the femoral head in Perthes disease: a cause for concern?

Osteochondritis dissecans (OCD) and loose body formation are rare following Perthes' disease. We have reviewed the literature about clinical presentation, treatment and outcome and added a further three cases of the condition. Cases mentioned in the literature were poorly documented. We feel that a thorough documentation should be carried out as soon as the diagnosis is made. Conservative treatment should be given when the disability is moderate. The loose body should only be removed surgically when it is mobile, when it bulges into the joint space or when there are signs of early arthritis.

Growth arrest lines and recurrent patellar dislocation: a new sign

The phenomenon of growth arrest lines has been widely described in the medical literature. They are usually found at the metaphysis of growing long bones and are the result of short periods of partial growth arrest. Recurrent dislocation of the patella is a well-recognised problem, particularly in adolescents. Several radiological features have been reported in association with patellar dislocation or instability. We have reported a hitherto undescribed radiological sign of patellar growth arrest lines on the skyline radiographs of two patients with this condition. The shape of the patella when symptoms were at their worst corresponded remarkably closely to the outline of the subsequent growth arrest line. We postulated that repeated dislocations adversely affect the process of normal maturation of the patella. With the resolution of symptoms, patella ossification resumes, leaving the telltale sign of previous injury in the form of a growth arrest line and an improvement in bone density once the patella has been stabilised and tracks normally.

Osteomyelitis of the pelvis and proximal femur: diagnostic difficulties

Osteomyelitis of the pelvis or proximal femur may still be diagnosed late because the infection is deeply placed and investigations may concentrate solely upon the possibility of septic arthritis. Periacetabular infection was diagnosed in 16 children between 1994 and 1998. A high index of suspicion and the use of appropriate imaging will ensure that the condition is not allowed to progress, although in this series one child underwent an unnecessary appendectomy, and a subsequent sepsis of the hip joint was drained in another case. Radiographs of the pelvis were rarely abnormal within 7 days of the onset of symptoms and an ultrasound scan focused on the hip joint may miss the periarticular changes.

Functional results of surgical treatment in congenital talipes equinovarus (clubfoot): a comparison of outcome measurements

A total of 151 children with 234 grade 2 or grade 3 congenital talipes equinovarus were treated by lateral-posteromedial peritalar release utilizing the Cincinnati incision. The feet were reviewed independently after a mean follow-up period of 10 years (5-19 years), using a modified rating scale, and the results compared to the severity of the initial deformity. An excellent or good result was achieved in 196 feet (84%) and a modest correlation (r = 0.48) noted between the preoperative grading of the foot and the functional result at later review. Both gender and bilaterality were also influential since a boy with bilateral deformity has a 1 in 4 chance of only a fair result, compared to a girl with a unilateral clubfoot where the chance is 1 in 10. The total range of ankle movement and the talocalcaneal index correlated strongly with the eventual surgical outcome [r = 0.69 and 0.65 (P = 0.001 and 0.01) respectively].

Somatosensory evoked potentials as a means of assessing neurological abnormality in congenital talipes equinovarus

Somatosensory evoked potentials (SSEPs) are a very sensitive measure of the functional integrity of the neuroaxis, including peripheral and central structures. When used in diagnostic mode they can provide additional information regarding the probable areas of dysfunction. SSEPs were recorded from 44 children (64 feet with congenital talipes equinovarus, CTEV), between the ages of 2 to 15 years, who had structural CTEV deformity previously treated by surgery, with no clinical evidence of neurological deficit. SSEPs were elicited after sequential and bilateral stimulation (0.1 ms/5 Hz/10 to 20 mA) of the posterior tibial nerve and the common peroneal nerve and were recorded cortically (P40). In half the children, additional recordings were conducted at the knee (N5), the first lumbar spinous process (N14), and the seventh cervical spinous process (N20). Eighteen children had abnormal responses, four children had non-reproducible responses, and 22 children had normal responses. Analysis of the data at different levels of the nervous system showed that eight children had abnormality at the spinal level. The surgical outcome was influenced by the neurological abnormality, with an excellent or good outcome in 34 of 36 feet with normal neurology and 19 of 28 feet where a deficit was present (p<0.05). These findings support the neurological theory as an etiological factor in CTEV deformity.

Evaluation of the deformity in club foot by somatosensory evoked potentials

Somatosensory evoked potentials (SSEPs) measure the conduction pathways from the periphery to the brain and can demonstrate the site of neurological impairment in a variety of locomotor conditions.

SSEPs were studied in 44 children (64 feet) with surgically corrected club feet. Four children had unreproducible responses, 18 showed abnormal recordings and 22 showed normal responses. In a further 31 feet (21 children) subjected to motor electrophysiological tests, 16 (52%) were abnormal.

Overall, 44 of 95 feet (46%) showed abnormal SSEPs or motor electrophysiological tests. Neurological abnormality was related both to the severity of the deformity and the surgical outcome. It was seen in 38% of feet with grade-2 and in 53% of feet with grade-3 deformity. A fair surgical result was obtained in 36% of feet with a conduction deficit and in only 6% with no abnormality. These results suggest an association between neurological abnormality as demonstrated by SSEPs or motor electrophysiological studies and the severity of deformity in club foot and its response to surgical treatment.

Evaluation of the deformity in club foot by somatosensory evoked potentials

Somatosensory evoked potentials (SSEPs) measure the conduction pathways from the periphery to the brain and can demonstrate the site of neurological impairment in a variety of locomotor conditions. SSEPs were studied in 44 children (64 feet) with surgically corrected club feet. Four children had unreproducible responses, 18 showed abnormal recordings and 22 showed normal responses. In a further 31 feet (21 children) subjected to motor electrophysiological tests, 16 (52%) were abnormal. Overall, 44 of 95 feet (46%) showed abnormal SSEPs or motor electrophysiological tests. Neurological abnormality was related both to the severity of the deformity and the surgical outcome. It was seen in 38% of feet with grade-2 and in 53% of feet with grade-3 deformity. A fair surgical result was obtained in 36% of feet with a conduction deficit and in only 6% with no abnormality. These results suggest an association between neurological abnormality as demonstrated by SSEPs or motor electrophysiological studies and the severity of deformity in club foot and its response to surgical treatment.

The Scottish incidence of traumatic dislocation of the hip in childhood

Traumatic dislocation of the hip was reviewed over a 20-year period in Scotland. The incidence of the condition was 0.8 cases per million children annually. Posterior dislocation predominates and the presence of an associated femoral fracture must always be considered. Avascular necrosis developed in two of the 15 cases (13.3%) and is more likely if the injury is severe or if there is an appreciable delay in reduction.

Arrest of the growth plate after arterial cannulation in infancy

Seven children who had partial arrest of the growth plate after neonatal arterial cannulation, developed obvious skeletal changes in adolescence. Cannulation of the femoral artery produced ischaemia which led to four cases of ipsilateral shortening of the lower limb and one of partial arrest of the proximal femoral physis with subsequent coxa valga. The two arrests in the upper limb affected the humerus, ulna and radius, and the radius alone, after cannulation of the brachial and radial arteries, respectively. These late effects of cannulation are not widely appreciated, and may occur as a result of thrombosis rather than extravasation.

Arrest of the growth plate after arterial cannulation in infancy

Seven children who had partial arrest of the growth plate after neonatal arterial cannulation, developed obvious skeletal changes in adolescence. Cannulation of the femoral artery produced ischaemia which led to four cases of ipsilateral shortening of the lower limb and one of partial arrest of the proximal femoral physis with subsequent coxa valga. The two arrests in the upper limb affected the humerus, ulna and radius, and the radius alone, after cannulation of the brachial and radial arteries, respectively. These late effects of cannulation are not widely appreciated, and may occur as a result of thrombosis rather than extravasation.

Just a pulled hamstring?

Images

Calcaneocuboid malalignment in clubfoot

In a series of 179 clubfeet treated surgically with a follow-up of 3 to 14 years, the clinical significance of calcaneocuboid malalignment was assessed on the basis of a standardized anteroposterior radiograph. The revision rate was 15% and the clinical requirement for a further soft tissue release was related to the talocalcaneal and calcaneocuboid angles. Calcaneocuboid malalignment does not have an adverse effect on the good prognosis of an otherwise well-corrected foot and does not alter the surgery needed to improve a clearly uncorrected foot. When talocalcaneal correction is doubtful, calcaneocuboid malalignment should tilt the balance toward a revision and is of value when the navicular has yet to ossify. Surgical release of the calcaneocuboid joint is unnecessary, particularly the lateral dissection, provided that the medial and subtalar dissection is complete.

Focal fibrocartilaginous dysplasia of the femur

Two additional cases of femoral fibrocartilaginous dysplasia are reported. The condition produces such significant angulation of the articular surfaces of the knee that progressive deformity is of concern to parents and surgeon alike. In both the reported cases, corrective distal femoral osteotomy confirmed the histologic diagnosis and ensured satisfactory gait in later childhood.

Finger flexion sign for ulnar neuropathy

We report a diagnostic sign of ulnar neuropathy. Function of the interossei is tested by asking the patient to hold a sheet of paper between the middle and ring fingers, by adducting the fingers while the examiner pulls it firmly away. The metacarpophalangeal joints will flex more on the affected side as the flexor tendons are recruited. This test can easily detect muscle weakness in the early stage of ulnar neuropathy, and is produced by a similar mechanism to that of Froment's sign.

Prognosis in Perthes’ disease

We compared the prognostic value of the Catterall grouping, the Salter-Thompson grading, the arthrographic shape of the femoral head, and the Herring lateral pillar grouping during the fragmentation stage of Perthes’ disease in 73 patients with 81 affected hips. Radiographs were available for study from the onset of the disease until skeletal maturity. We used the Stulberg classification to assess outcome.

The Herring grade and arthrographic sphericity proved to be the best predictors of final outcome. Combining these two values further increased the predictive value. All but one patient in Herring group A achieved an excellent outcome. In Herring group B, the age of the child and the sphericity of the femoral head influenced the end result. If the child was less than seven years old at the onset of symptoms the prognosis was invariably good and all spherical hips in group B had a good outcome with Stulberg grades 1 or 2. Moderately and severely deformed hips on arthrography resulted in Stulberg 3 and 4 hips. None of the hips in Herring group C had a normal appearance at maturity and the outcome was not significantly influenced by the age at onset or the arthrographic appearance.

Prognosis in Perthes' disease: a comparison of radiological predictors

We compared the prognostic value of the Catterall grouping, the Salter-Thompson grading, the arthrographic shape of the femoral head, and the Herring lateral pillar grouping during the fragmentation stage of Perthes' disease in 73 patients with 81 affected hips. Radiographs were available for study from the onset of the disease until skeletal maturity. We used the Stulberg classification to assess outcome. The Herring grade and arthrographic sphericity proved to be the best predictors of final outcome. Combining these two values further increased the predictive value. All but one patient in Herring group A achieved an excellent outcome. In Herring group B, the age of the child and the sphericity of the femoral head influenced the end result. If the child was less than seven years old at the onset of symptoms the prognosis was invariably good and all spherical hips in group B had a good outcome with Stulberg grades 1 or 2. Moderately and severely deformed hips on arthrography resulted in Stulberg 3 and 4 hips. None of the hips in Herring group C had a normal appearance at maturity and the outcome was not significantly influenced by the age at onset or the arthrographic appearance.

EPIPHYSIODESIS USING A CANNULATED TUBESAW

A technique for epiphysiodesis using a cannulated tubesaw has been developed to combine the precision of the original Phemister method with newer percutaneous methods. The approach is unilateral, and requires minimal access. Reinsertion of the removed core of bone reduces haemorrhage from the defect and augments arrest of the growth plate.

In 35 patients treated by this method predicted discrepancies of 2 to 4.5 cm were reliably reduced to 0.7 ± 0.6 cm, with no serious complications. The timing of surgery is critical, and relies upon careful monitoring of the pattern of discrepancy over several years, using clinical and radiographic measurements. Undercorrection of the disparity in three patients was the direct result of late referral.

Epiphysiodesis using a cannulated tubesaw

A technique for epiphysiodesis using a cannulated tubesaw has been developed to combine the precision of the original Phemister method with newer percutaneous methods. The approach is unilateral, and requires minimal access. Reinsertion of the removed core of bone reduces haemorrhage from the defect and augments arrest of the growth plate. In 35 patients treated by this method predicted discrepancies of 2 to 4.5 cm were reliably reduced to 0.7 +/- 0.6 cm, with no serious complications. The timing of surgery is critical, and relies upon careful monitoring of the pattern of discrepancy over several years, using clinical and radiographic measurements. Undercorrection of the disparity in three patients was the direct result of late referral.

Congenital insensitivity to pain: orthopaedic implications

We report two children in one family with congenital insensitivity to pain, anhidrosis, and mental retardation with behavioural disturbance. Orthopaedic manifestations of this condition include recurrent fractures, osteomyelitis, and neuropathic joints. The differential diagnoses and difficulties in the management of this rare disorder are discussed.

A prospective study of nonoperative and operative management for Perthes' disease

Two groups of children with Perthes' disease, randomized according to their source of referral, were treated by bed rest and skin traction, followed by either use of a weight-relieving caliper or a proximal femoral varus osteotomy. The outcome was similar in both groups and could be predicted more effectively by the arthrographic shape of the femoral head at presentation than by the Catterall grouping. The principal influences were the age of the child when treated and the sphericity of the femoral head. Walking speed at time of review was related to the height of the child and, at this age, was not affected by the shape of the healed femoral head.

Distal transfer of the greater trochanter

After congenital dislocation of the hip, Perthes' disease and some other conditions, the femoral neck may be short and the greater trochanter in a relatively proximal position. Distal transfer of the greater trochanter is an effective and relatively simple operation to correct this deformity. We have reviewed 26 patients (27 hips) at a mean follow-up of eight years. Pain relief and improvement in gait were maintained in 74%, and the poor results were largely due to progression of osteoarthritis. We describe a 'gear-stick' sign of trochanteric impingement, which is useful in the pre-operative assessment of patients.

Early results of the Leeds-Keio anterior cruciate ligament replacement

We report the two- to four-year results following the insertion of the Leeds-Keio prosthetic ligament for chronic anterior cruciate deficiency. Virtually all the 20 patients were less disabled by instability, but objective results were good or excellent in only two-thirds and under anaesthesia the pivot shift sign was still positive in half. Arthroscopic and histological assessment in 16 patients failed to show the development of a functional neoligament, and the common appearance of a synovitic reaction to polyester particles gave concern.

Results of a 25-year screening programme for neonatal hip instability

From 1962 to 1986, 117,256 neonates were screened for congenital dislocation of the hip (CDH). When the primary physical examination was performed by the junior paediatric staff there was a persistent late diagnosis rate of 0.5 per 1000 live births. When the primary examination was undertaken by experienced orthopaedic personnel (1982 to 1984) the late diagnosis rate fell and fewer infants were splinted.

Idiopathic meralgia paresthetica

Idiopathic meralgia paresthetica was treated surgically in 14 men and 11 women, the latter group were a decade older on average. Treatment was unsatisfactory if symptoms had been present for longer than 18 months. Reexploration of the nerve was not therapeutic in those cases in which the initial decompression provided no relief. The usual course of the lateral femoral cutaneous nerve is deep to the lateral end of the inguinal ligament but superficial to the sartorius muscle. However, the nerve may overlie the anterior iliac wing or pass between two slips of the inguinal ligament and may also be compressed if it passes deep to or through the sartorius muscle.

Acrodysostosis and protrusio acetabuli. An association

Progressive protrusio acetabuli in a patient with acrodysostosis (peripheral dysostosis Type 12) has not, as far as we know, been reported previously. It is recognised that epiphyseal dysplasias may lead to disturbances of acetabular growth, but generally this results in a shallow socket with associated changes in the proximal femoral epiphysis.

The Chiari pelvic osteotomy. A long-term review of clinical and radiographic results

We have reviewed a series of 94 Chiari pelvic osteotomies carried out from 1966 to 1982. In 83 hips the indication for surgery had been pain, and of these patients 73 (88%) had appreciable relief within one year of operation. The other 11 hips were all in children and were painless; in them the osteotomy had successfully stabilised progressive subluxation of the hip. At review after a mean follow-up of 10 years (range, 2 to 18 years) 68 previously painful hips were reassessed. Although function of the hips had deteriorated slowly with time, four of the seven cases with 18 years' follow-up had good function and only minor symptoms. A detailed analysis of the radiographic changes produced by the Chiari osteotomy was made, using computerised analysis of variance. The beneficial effects of the osteotomy resulted from complex changes, among which the provision of a stable fulcrum for the hip seemed to be the most important.

Hemophilic arthropathy of the upper limb

Little has been written about the effects of hemophilic arthropathy on the function and radiography of the upper limb. Therefore, 14 moderate and 19 severe hemophiliacs between the ages of 10 and 57 years were examined clinically and radiographically. The extent of the arthropathic changes in the shoulders, elbows, wrists, and hands were classified according to the system proposed by the World Federation of Hemophilia. The severity of the arthropathy increased with the age of the patient and with the number of hemarthroses recorded, although the correlation between these parameters was variable. The elbow joints were the site of recognizable arthropathy in 87% of the cases, with a slight preponderance for the nondominant side. The glenohumeral and wrist joints were affected in a small proportion of patients, although symptoms were rarely experienced. Hemorrhages affecting the hands were uncommon and produced arthropathy infrequently.

Pulmonary insufficiency after long bone fractures: significant correlation with the catabolic response

Twelve young men between the ages of 17 and 25 years had their metabolism investigated over the first 5 days after sustaining multiple fractures involving at least one femoral shaft. Five patients developed respiratory distress and three of these required varying periods of ventilatory support. The lowering of arterial oxygen tension following injury was directly proportional to the excretion of urinary urea (a convenient index of protein catabolism). Pulmonary insufficiency was rectilinearly related to the degree of thrombocytopenia. The relationship between hypoxaemia and protein catabolism following long bone fractures has not been reported previously. It is important to appreciate that metabolic alterations are more severe in those patients with overt pulmonary insufficiency and that the metabolic response does not appear to be directly related to the severity of skeletal injury.

Symptomatic calcaneonavicular bars. The results 20 years after surgical excision

Eleven patients were reviewed an average of 23 years after they had been treated by excision of a symptomatic calcaneonavicular bar in 16 of their feet. Of these feet 69% (11 feet) had a good or excellent result. Of the five failures, three feet had good results after subsequent triple arthrodesis, but two treated by repeated excision of the bar were still unsatisfactory. Beaking of the talus seen before operation correlated with poor results.

Pulmonary insufficiency after long bone fractures. Absence of circulating fat or significant immunodepression

Twenty young men with displaced fractures of one or more long bones in the lower limb, but with no evidence of cranial, thoracic or abdominal injury, were studied prospectively. Although all the patients became hypoxaemic, the six who developed signs of respiratory distress (Group 1) were found to have a significantly lower arterial oxygen tension and a significantly higher rate of urinary urea excretion than the remaining 14 patients whose pulmonary function appeared to be clinically normal (Group 2). Circulating fat macroglobules were identified in three cases, only one of whom was in Group 1, and hence the tests for fat embolism were not of prognostic value. Although an immunodeficient state is considered to contribute to the pulmonary insufficiency which occurs after major trauma, convincing evidence of a lymphocyte-suppressive agent was found in only one patient.

Foot deformities associated with onycho-osteodysplasia. A familial study and a review of associated features

A family, of which thirteen members suffered from hereditary onycho-osteodysplasia (HOOD), is presented. Four of the thirteen patients also had foot deformities, and it is postulated that this anomaly may be a true part of the HOOD syndrome, and not just an incidental finding.

The open palm technique for Dupuytren's contracture

The results of subtotal palmar fasciectomy employing an open palm technique have been reviewed. Full correction of the metacarpophalangeal flexion deformity was achieved in the majority of 120 hands which were followed up for between one and nine years after operation, but the results from associated digital dissection were less satisfactory. Leaving the transverse distal palmar wound open lessens many of the hazards inherent in a palmar dissection, and the approach is therefore relatively safe for the less experienced surgeon. Efficient supervision of the hand after surgery is of paramount importance and may influence the outcome as significantly as the operation itself.

Surgical treatment of the symptomatic accessory navicular

The accessory navicular is occasionally the source of pain and local tenderness over the instep. If conservative measures fail, surgical treatment may be required and the results of 62 operations to one or both feet in 47 patients are reported. Twenty-six patients were treated by the Kidner operation, in which the main insertion of the tibialis posterior is re-routed; in the remaining 21 the ossicle was merely excised. Excision was as effective as the Kidner technique, provided that the medial surface of the main navicular bone was contoured to prevent any residual prominence. Both procedures were successful in relieving symptoms in the majority of cases and failures resulted from errors in the selection of patients or in the surgical technique. Correction of any associated flat foot was secondary to growth and maturation of the foot rather than to the operation; hence the Kidner procedure does not confer any particular advantages over simple excision.

Common peroneal nerve entrapment in a hemophiliac

Traumatic neuropathies of the common peroneal nerve at the head of the fibula are relatively common, but nerve entrapment at this site is rarely encountered. A 55-year-old man with hemophilia A in whom common peroneal nerve entrapment occurred secondary to a probable muscle hematoma is described.