Introduction: There is an increasing number of total hip replacements (THR) being carried out primarily on patients with a sub capital fracture reflecting the change of opinion nationally towards a more positive view on replacement as the initial choice of treatment for these fractures. A number of randomised trials have shown that THR results in better function and improvement in health-related quality of life (HRQoL) and has a lower failure rate than internal fixation.

Purpose. To review patients with proximal femoral nails (PFNs) in our hospital that developed complications and needed revision. Methods. Between January 2000 and June 2006, records of 216 patients with PFN fixations for traumatic extracapsular trochanteric fractures (n=160), pathological fractures (n=23), and as a prophylactic measure for metastasis (n=33) were retrospectively reviewed. The injury mechanism, reduction technique and quality, and time to and cause of implant failure were recorded. Results. 12 PFNs failed: 8 in the trauma group, 3 in the pathological group, and one in the prophylactic nailing group. Two PFNs broke at the proximal lag screw level at a later stage secondary to non-union of the pathological fractures. One broke at the level of the distal locking screw at an early stage, as the locking holes were too close to the fracture. Conclusion. Poorly reduced fractures tend to fail early, whereas late failures are due to non-union. Good reduction with minimal dissection, the use of appropriate nail length, and proper positioning of the nail and screws are necessary to avoid failure or revision.

Serial swabs were taken from the inner and outer surfaces of a new Rhys-Davies exsanguinator before and after use on the limbs of patients to exsanguinate limbs prior to tourniquet inflation and surgery. Both surfaces of the exsanguinator showed increasing levels of contamination with bacterial colonisation with use starting from the first use. The organisms grown included potentially harmful bacteria such as Pseudomonas sp. The Rhys-Davies exsanguinator can harbour potentially harmful organisms and, thus, may raise the risk of infection transmission between patients when used without cleaning between uses. Methods of effective cleaning of the exsanguinator between uses are discussed.

When patients have been seen by multiple hospital specialities over the same complaint, it is important to start at the beginning with an open mind, obtain a full history and perform a comprehensive clinical examination. We report the case of one such patient with a long history of complex and sometimes invasive investigations whose diagnosis was reached by a simple clinical examination and a plain radiograph. A 71-year-old man was referred to the knee clinic with a 4-year history of severe progressive left knee pain. The severe constant unremitting pain in his knee radiated down the anterior aspect of his left shin. He complained of sleep disturbance and he was virtually wheelchair-bound. An x-ray ten years previously showed Paget’s disease as affecting his left proximal tibia. In the previous 4 years, numerous medical teams had extensively investigated his Paget’s disease and knee pain. Alkaline phosphatase levels and urinary markers for Paget’s disease were all within normal limits. The local metabolic bone unit performed a bone scan, which showed increased uptake in the proximal left tibia in keeping with Paget’s disease. A magnetic resonance (MR) scan of this area showed no evidence of sarcomatous change. The patient was treated with courses of IV pamidronate and calcitonin without improvement and an intra-articular injection of local anaesthetic and steroid provided no relief. His pain continued to worsen and he was referred to the pain clinic, where he was given a TENS machine and commenced on opiate analgesia. The patient was then referred to an orthopaedic team. Plain x-rays showed Paget’s disease in the tibia but a well-preserved knee joint. A further MR scan was performed, which confirmed Paget’s disease but no sarcomatous changes or stress fractures of the proximal tibia. An MR scan of his lumbar spine was performed which revealed no obvious cause for the leg pain. Knee arthroscopy revealed only minor degenerative changes but these could not account for the severity of the symptoms. A second orthopaedic opinion was requested and an open tibial biopsy was performed. Histological examination of the 10 samples showed evidence of active Paget’s disease but no evidence of osteosarcoma. The patient was subsequently referred to a clinical biochemist and underwent a further course of IV pamidronate without any relief of his pain. By this time, 130 mg of MST was required twice daily for pain relief. The patient’s daughter, concerned at her father’s deterioration, consulted the Paget’s Disease Society and obtained a further opinion from another clinical biochemist. His opinion was that the Paget’s disease could not be responsible for the severe nature of the pain and suggested a further orthopaedic opinion from a knee specialist. When we saw him, we felt his symptoms had an organic basis. Clinical examination proved to be somewhat difficult, as any limb movement caused severe pain. However, it was possible to determine that in addition to knee limitation, there was also marked limitation of hip movements, with a fixed flexion deformity of the left hip. Further radiographs showed minor degenerative changes in the knee with Paget’s disease affecting the proximal tibia (Figures 1 and 2). An AP radiograph of his pelvis (Figure 3) showed severe degenerative changes in the left hip with almost complete loss of joint space superiorly. To determine whether the hip pathology was the cause of his pain, he was admitted as a day-case for local anaesthetic infiltration of his left hip under x-ray control. The result was remarkable with immediate (but temporary) relief of his pain. He was able to walk unaided for the first time in 4 years! Age and Ageing 2002; 31: 67–69 # 2002, British Geriatrics Society

We report a case of subclavian vein obstruction caused by a chronic unreduced posteriorly displaced type II Salter Harris injury of the medial clavicular physis, which required excision of the first rib to decompress the thoracic outlet. We emphasize the importance of acute reduction of this type of injury to prevent the possible serious complications.

A case of medial foot pain caused by an apparent stress fracture of an accessory navicular is presented in a patient with a long-standing history of flat feet. Radiographs support the diagnosis. After excision of the fractured ossicle the patient was pain free.