David A. Macdonald

Reamed against unreamed nailing of the femoral diaphysis: a retrospective study of healing time

In order to assess the results of the AO unreamed femoral nail (URFN), and specifically its effects on healing, 147 consecutive patients treated were reviewed. These included 50 reamed femoral nails (RFN) and 97 unreamed femoral nails. Exclusion of pathological fractures, revisions and fractures outside the femoral diaphysis left 51 procedures in which the healing process could be studied. Twenty-four unreamed and 27 reamed femoral nails in patients with diaphyseal fractures AO (32) were followed up by clinical review and radiographically until union or death. There were two deaths from multiple injuries (one in each group) and two non-unions (at 52 weeks), one in each group. There were no cases of infection, angular deformity of leg length discrepancy; two cases required early rotational correction. There was a single broken distal locking screw in the URFN group but no other implant failures. The fractures in the URFN cases took longer to heal with a mean of 26.9 weeks as opposed to 20.5 weeks in the RFN group (P = 0.009). This did not cause a significant clinical problem. The URFN proved easy to use with a much shorter operation time.

Variation in the TNF Gene Promoter and Risk of Osteolysis After Total Hip Arthroplasty

Genetic factors may influence implant failure caused by osteolysis after THA. In an association study of 481 subjects after THA, we found that carriage of the TNF‐238A allele was associated with an increased incidence of osteolysis versus noncarriage (odds ratio, 1.7) and was independent of other risk factors. Genetic and environmental factors influence implant survival after THA.

Exchange nailing for femoral shaft aseptic non-union

Although rare, non-union of femoral shaft fractures is a cause of significant morbidity. In aseptic non-union, excellent union rates have historically been reported following reamed exchange femoral nailing. However, recently, a high incidence of failure requiring additional procedures has been reported. In light of these concerns and a recent change in our practice to the use of thin solid nails we undertook a retrospective study to determine the efficacy of exchange nailing with these modern nails in our hands. We reviewed records and radiographs of 25 patients who had a reamed exchange femoral nailing for established aseptic non-union. 24 patients (96%) united after exchange without the need for an additional procedure. The mean time to union was 29.75 weeks. Patients who had open bone grafting performed at the same procedure tended to unite quicker, but this did not achieve statistical significance (p = 0.14). Union times were not affected by smoking habits or nail type. This study demonstrates that reamed exchange nailing for aseptic femoral non-union remains an effective treatment. We believe that the nail type is less important than the biological effects of reaming, bone grafting and dynamization.

Segmental tibial fractures: an assessment of procedures in 27 cases

Twenty-seven patients (two women) with segmental tibial fractures (19 open) were treated in our institution with a mean age of 38.9 years (range 22-67 years) and a mean Injury Severity Score of 11.5 (9-34). Sixteen fractures were stabilised initially with an interlocking nail, seven with an external fixator, one with a hybrid external fixator, two cases were plated and one was treated in plaster. The mean size of the segment was 11.5 cm (range 4-20 cm). Soft tissue coverage was required in 17 cases. There were three cases of compartment syndrome, six cases of superficial infection and four deep infection cases (two of which required amputation). In four cases, excision of the non-viable segment was necessary. Overall, 13 patients were subjected to a second operative procedure (OP) (four external fixators were replaced with the AO solid tibial nail, two Ilizarov bone transports following excision of the dead bone segment, 2 below knee amputations, 3 exchange reamed nailings, 1 LISS plate application for stability and 1 ring fixator for compression of a fracture). Five patients underwent third procedure (two Ilizarov for bone transport, two exchange nailing, and one bone grafting). The mean time to union of the proximal segment was 38.8 weeks (range 10-78 weeks) and 41.4 weeks (range 12-65 weeks) for the distal segment, respectively. The treatment of segmental tibial fractures poses many problems to the surgeon due to the precarious blood supply of the intermediate segment. The risk of non-union delayed union, infection and additional procedures is high as seen in this series of patients.

Knee dislocation with ipsilateral femoral shaft fracture: A report of five cases

We report the management and outcome of 4 patients with 5 knee dislocations associated with ipsilateral femoral shaft fractures. All patients were managed by immediate reduction of the knee dislocation, intramedullary nailing of the femur, and angiography, followed by postoperative immobilization of the knee (brace or external fixation) for a minimum of 6 weeks. Four of the 5 dislocations underwent a secondary ligament reconstruction. At the 2-year follow up, the mean Knee Society Score was 133 (range 99-170).

Spontaneous isolated rupture of popliteus tendon presenting as locked knee: case study and literature review

Traumatic isolated rupture of the popliteus tendon has been described as a rare cause of haemarthrosis of the knee. There has been only one reported case of spontaneous rupture of the popliteus tendon in the English literature before. We present the case of a 70-year-old lady who had spontaneous rupture of the popliteus tendon without history of significant trauma. She presented with a painful locked knee without any features of instability. The diagnosis was made on arthroscopy of the knee and she made a complete recovery after partial excision of the torn tendon. Our literature review looks at treatment options in relation to best functional outcome.RésuméLa rupture traumatique isolée du tendon poplité a été décrite comme une cause rare d’hémarthrose du genou. Il n’y a eu qu’un seul cas de rupture spontanée de tendon poplité rapporté jusqu’à présent dans la littérature anglo-saxonne. Nous présentons le cas d’une femme de 70 ans qui a eu une rupture spontanée du tendon poplité sans histoire traumatique évidente. Elle s’est présentée avec un genou douloureux bloqué sans aucun signe d’instabilité. Le diagnostic a été fait par arthroscopie du genou et elle récupéra complètement après excision partielle du tendon déchiré. Notre revue de la littérature a été orientée sur la recherche des options thérapeutiques qui ont permis d’obtenir le meilleur résultat fonctionnel

i) Risks versus rewards of total hip replacement

Abstract • • 95% of THRs give long-term pain relief. • • One in twenty patients may/will be worse off within one year due to early complications. • • Early failures are surgical errors. • • All joint replacements will fail if the patient lives long enough. • • A painful THR is a failure and must be investigated. • • Patients must be told if they are being given a ‘new design’.