Intramedullary Nailing is now accepted as the standard treatment for most femoral diaphyseal fractures. Most intramedullary nails are designed for proximal and distal locking with screws. We describe our experience with the Brooker Wills femoral nail. This nail is unique as distal fixation is achieved with as transverse fixator deployed through slots in the nail, a concept first enunciated by deCamargo in 1952. The fins of the fixator pierce the distal cortex when deployed thereby conferring rotational stability. The entire nail (including the proximal and distal fixation devices) can be inserted through a single proximal incision in the skin. We treated 17 patients with femoral shaft fractures using this system. 93% of the patients were males. Motor vehicle accidents accounted for 80 % of the fractures. Most fractures involved the middle third of the femur (54%), followed by distal third (33%) and proximal third (13%). 67 % of the fractures showed Winquist and Hansen Grade 3 or 4 comminution. All the nailings were performed in the supine position. Static locking was done in 16 cases. Post operative weight bearing was individualized with 86% of the patients bearing full weight before the end of 16 weeks. The average time to full weight bearing was 14 weeks. The mean time to union was 17.1 weeks, with proximal, middle and distal third fractures showing average healing times of 19, 15.6 and 18.8 weeks respectively. All the fractures united. There was one case of delayed union. Intra-operative complications included–inability to deploy the distal fixator in one case and unwinding of the reamer in another case. There was one case of superficial infection where a patient developed a sinus over the metallic fin of the distal fixation device, which had penetrated the cortex. This healed after the distal fixation device was removed. There was one case of proximal nail migration, but the fracture went onto union with some limb shortening. Results were evaluated using the scoring system devised by Sanders etal (1991). The functional criteria in their scoring system include- knee flexion, presence of pain, femur deformity, walking distance, stair climbing and pre injury functional status. We achieved excellent results in 53% of patients, good- 27%, fair–13 % and poor-7%. We feel that the main advantage of the Brooker Wills Nail is the ease of distal locking. This saves time and also leads to lower level of radiation exposure, as the image intensifier is sparingly used for distal locking. In fact, this nail is an attractive option in centres which lack an image intensifier. We achieved good results with this nailing system and feel that it is an acceptable alternative to other nailing systems with conventional locking systems with screws.
Carpal Tunnel Syndrome is the most common entrapment neuropathy encountered in clinical practice. Previous studies have suggested that the disease has a higher prevalence in the elderly(Stevens JC etal, Neurology 1988;) and that this sub group also tends to have a higher prevalence of severe CTS.(Seror P, Ann Hand Surg 1991; Bland etal, J Neurol Neurosurg Psychiatry). Surgical decompression of the median nerve is the treatment of choice with a reported success rate of between 53 and 97 %.(Katz et al, J Hand Surg 1998). There has been some controversy regarding the effectiveness of surgery in elderly patients. The aim of our study was to evaluate the results of carpal tunnel release in patients over the age of 75 years at the time of surgery. A literature search revealed few studies carried out in elderly patients–Weber etal-(mean age 75 years), Porter etal (mean age 59.8 years) and Leit et al (mean age 79 years). The average age of our patient group (80.4 years) is the highest reported in literature so far. We posted questionnaires to all patients who were over 75 years at the time of their surgery. There were a total of 49 patients (65 hands) operated over the last 10 years who belonged to this age group. We used the Brigham And Women’s Hospital Questionnaire devised by Levine et al. (1993). In addition, we added some questions to assess patient satisfaction with the procedure. 65% of the patients were females. The average age was 80.4 years. The completed questionnaires were used to calculate the Pre and Post operative scores. The mean pre operative score was found to be 3.18, which improved post operatively to 1.8. (Scale of 1 to 5, with 1 being the best and 5 the worst). Importantly, although all symptoms improved, some such as pain and numbness showed a much greater improvement than grasping power. On the Visual Analogue Scale, pain scores improved from 6.4 to 2.3 post surgery. 82 % of patients had no scar tenderness, 12 % had mild to moderate tenderness, while 6 % reported severe scar tenderness. Overall 79% of patients showed improvement, 15 % felt that the surgery had made no difference, while 6% reported worsening of their symptoms after surgery. Our study showed that 8 out of 10 elderly patients will improve after carpal tunnel release, though all symptoms are unlikely to improve. The symptom least likely to improve is weakness of the hand. The results of this study are important to counsel this sub group of elderly patients, so that they may take an informed decision on whether to proceed with the surgery.
Patella instability can be a disabling condition predominately affecting younger patients, restricting activity and potentially leading to premature osteoarthritis. We describe and evaluate a new technique of stabilising the joint. Between November 2000 and January 2002 we operated on 24 unstable knees (belonging to 23 patients). All patients had failed a course of conservative treatment and the average number of dislocations pre-operatively was 7. All patients had an extra-synovial lateral release and stabilisation by harvesting the semitendinosus tendon which was then tunnelled through a vertical hole in the patella, under the vastus medialis, wrapped around the adductor magnus and tied to itself at the lower border of the patella. The patients were assessed clinically and radiologically at an average of 19 months, following the procedure. There were 19 knees assessed: 13 female /6 male, 10 left /9 right, average age 22 years. 13 patients had retro-patella chondral damage none had meniscal or cruciate pathology. The visual analogue score increased from 4 pre-op to 7.5 after operation. The Kujala patello-femoral score was 74 post procedure. 53% of patients described their knee as excellent, 47% as good. Only one patient has re-dislocated to date (single event). There were no specific risk factors.
