1. Double osteotomy was performed on 1 50 knees between 1961 and 1969. The first fifty-seven cases were assessed independently. 2. The operation of osteotomy of the upper end of the tibia and the lower end of the femur is described. it is emphasised that the osteotomy sites are close to the bone ends and well within the cancellous expansion. 3. The indications for the operation are pain and loss of function in a mobile arthritic knee joint. 4. Flexion of the knee is important during the operation to allow the popliteal artery to be moved away from bone. Arteriograms at necropsy show the danger of damaging the popliteal artery when the knee is extended. 5. The operation appears to be equally effective in osteoarthritis and rheumatoid arthritis. The proliferated synovium of the active rheumatoid knee regresses rapidly following operation. 6. The operation has resulted in relief of pain and increase in function in many knees which had no deformity. When a deformity did exist before operation recurrence of the deformity did not appear to influence the result. 7. The cause of relief of symptoms after osteotomy is not known, and it is suggested that answers to the following questions should be sought: Why are some arthritic knees painful and some not ? Why does physiotherapy relieve pain ? Why does osteotomy relieve pain? Why is double osteotomy followed by regression of synovial proliferation ? Why does osteotomy sometimes fail ? Would osteotomy of one bone (tibia or femur) be sufficient?

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In 1967, eighty double osteotomies of the knee and thirty double osteotomies of the metacarpophalangeal joints had been carried out. The results had been dramatic in two respects: ( a ) relief of pain, and (b) disappearance of exuberant rheumatoid synovium.Only a week after double osteotomy of the metacarpophalangeal joints, some patients remarked that wrinkles on the back of the hand were visible for the first time for years. The possibility of the shoulder joint responding to this procedure was considered, as arthrodesis of the shoulder is difficult and tedious, both for patient and surgeon. In 1967, a painful, rheumatoid arthritic shoulder was referred to me for arthrodesis. Instead, I did a double osteotomy through an anterior approach. The humerus was osteotomised through the surgical neck and the scapula through the neck of the glenoid. The postoperative treatment was 10 days in a sling only. The pain relief was so dramatic that the patient wanted to remove the sling earlier. I have operated on two such shoulders and George Arden from Windsor has operated on three recently. This is a preliminary report of this procedure. All 5 patients have relief of pain, including the first after 5 years. In each case there is an apparent increase in movement, though this may be due to pain relief only. X-ray improvement appears to occur. Although this may be significant, it could however signify mere reversal of disuse atrophy. The aavantages of this procedure are that it is simple, it is quick, there are few complications, it is financially attractive as no prosthesis is required, there is no plaster of Paris, and the patient need stay in hospital only 2 to 3 days. It seems worthwhile undertaking a series, which George Arden and I now intend to start. It is ofinterest to note that double osteotomy appears to be successful in the metacarpophalangeal joints and in the shoulder joint in rheumatoid arthritis. These are non-weight-bearing joints and thus the effect of this procedure is unlikely to be due purely to a mechanical effect of the operation. From 1960 to the present I have performed this operation on 300 knees, approximately equally divided between rheumatoid arthritis and osteoarthritis. A detailed analysis of the results in the first 57 was given in November 1969 in The Jour-I nal of Bone and Joint Surgery. The percentage of good and poor results has remained the same in the subsequent series. A further 60 cases at Windsor and a similar number at The London Hospital have been reported to me, showing similar results.A 6-year follow-up revealed some recurrence but still 60% were satisfactory and those who suffered a recurrence felt that the 6 years' pain relief made the operation justifiable. I still perform this operation because more recent and sophisticated methods can end in catastrophe. -741865There are few serious complications and nothing but time is lost by the operation. If it should prove unsuccessful, prosthetic replacement can still be undertaken.[A film was shown of the technique of the operation and o...

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