IN my work in the orthopredic department of Salford Royal Hospital I have now met with three instances in which cystic changes had occurred in the external semilunar cartilage. The condition has been recorded previously by several German observers. In 1904 Ebnerl reported one case in great det,ail ; in 1906 Schmidt2 recorded a case, and in 1918 Riede13 described 6 cases upon which he had operated. Eden4 also reported 2 cases in 1911. I n 1909 Mr. Furnivall, who was then a member of the honorary staff of the London Hospital, told me of a recent example and referred t o another case with which he had dealt. He presented a specimen to the museum of the Royal College of Surgeons. I have examined this specimen, which shows precisely the same condition as is seen in my own cases.The museum catalogue describes it as follows : " The chief portion of a right semilunar cartilage removed by operation from the knee-joint. Projecting from the outer attached border there is a somewhat hemispherical swelling which extends for about half a n inch along the cartilage and attains a maximum eminence of half a n inch. As seen in the divided surfaces, the swelling consists of a series of well-defined spaces which, in the recent state, were filled with a thick, transparent, ntucoid material. The smallest spaces appear as clefts between the bundles of white fibrous tissue a t the periphery of the fibrocartilage, and seem to have arisen from a mucoid softening of the tissues and not in any way t o be connected with the attached portions of synovial membrane. From a man, age 30, who slipped and fell, injuring the right knee four months before coming under observation. About a month later he noticed a swelling on the outer side of the joint; this slowly increased and troubled him in walking; i t was especially uncomfortable at night and in the morning, without ever causing actual pain. On examination, there was found a swelling as large as a small filbert over the region of the external semilunar cartilage, just in front of the external lateral ligament : it was fixed to, and moved with, the tibia, and was unaffected by contraction of the biceps. The movements of the joint were smooth, and the other structures of the knee were normal. There was no affection of any other joint, and there was no history of gout or rheumatism. The parts shown were removed by longitudinal incision over the swelling." Tllc swelling was wholly inside the capsule of the joint. The wound healed by first intention, and the function of the joint was afterwards perfect." Fig. 261 shows a drawing which Mr. Sewell has made of this specimen. The clinical history of all the cases seems t o be similar; all have a history of a n injury, iisually not severe, with gradually increasing pain and lameness, and with the development of
HON. SURGEON IY CHARLE O F THE ORTHOPADIC D s P A R r M r c v r , SALFORD ROYLLHOSPITAL, X L \ C H I S T E R IN 1921 I described in the B R I T I~H JOIJRNAL OF SURCERY~ three cases upon which I had operated because of persistent pain in the knee associated with a cystic change in the external semilunar cartilage. These were the first instances of the condition recorded in this country, although four cases had already been described in the German literature.2 5 Since 1921 I have met with eighteen additional cases in my own practice, and, in the light of this unique experience, I propose to review my original description of the condition and its pathology. A number of isolated cases have been reported in American and British journals, but as these are readily available to everyone. and as no fresh points have been brought out by them, they will not be discussed.In my former paper I referred to the fact that the cysts were found in the external cartilage, and up to that time my own (three) cases and all those reported in Germany had been on that sidc of the joint (Figc. 420, 421). In FIGS. 420, 421.-Cnse 20. 'J'yp~cal appearance nf cyit of external cartilage ( a ) Lateral vleu-. ( b ) Aritrrlor xlen.niy prescnt series four out of the eighteen have occurred in the internal cartilage, so that, although the lesion prcsents itself chiefly in the external cartilage (seventeen times out of twenty-one in my own cases), it may be found in the internal cartilage also. The pathology of the lesion has received
SINcE the days of Pott and Dupuytren fractures involving the ankle-joint have received much consideration, though not too much, in view of the disabilities which may follow in their train. Apart from the classical fractures, as usually described, the great importance of the anterior and posterior marginal fractures of the tibia was emphasized by Cotton in 1915,1 and more recently by Ashurst.2 It should always be remembered, however, that Astley Cooper described the posterior marginal fracture in 1822. TYPrEs OF ANKLE FRACTURE. Three vears ago the British Orthopaedic Association, at its meeting 'in Manchester, discussed ankle fractures at some length, and I fear that it is not possible for anyone to break much new ground today. In considering my contribution to this discussion it seemed to me that an outline of the treatment adopted and the results obtained in a series of my own cases would be of most use. Beyond this, I propose to review a number of isolated cases which have offered more than the usual difficulties in their treatment. The incidence of the various types of fractures-at the ankle is shown by the following summary of 100 cases radiographed at Salford Royal Hospital between December, 1927, and November, 1928.
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