Aims: Review the results of Long Gamma nail in the treatment of a select group subtrochanteric meta-static lesions of femur. Methods: From 1996 to 2002, 34 patients with subtrochanteric metastatic lesions of femur treated with Long Gamma Nail were included in this retrospective study. Hospital records and x-rays were reviewed for collecting the data. Results: 37 met-astatic femoral subtrochanteric lesions (3 bilateral) in 34 patients, 17 male and 19 female, with an average age of 65 yrs, had reconstruction with Long Gamma Nail. Right femur was affected in 15 and left in 22. Most common primary cancer was breast in 15, prostrate in 5, lung in 5, and others in 9 cases. Prophylactic nailing was preformed in 28 femurs (75%) and nailing of actual fracture in 9 femurs (25%). All femurs had distal locking bolts except in 2. Postoperatively pain relief was achieved and pre-op mobility was regained in all patients. 5 patients (13.5%) had medical complications including a death due to chest infection. 4 patients (10%) had implant related complications but none required any further surgery. There were no implant failures. From the time of surgery 20 patients (60%) died with a mean survival of 9 months, and 13 patients (40%) are alive, pain free and independent with a mean survival of 18 months. The overall patient survival rates after operation are 73% at 6 months, 56% at one year and 40% at 4 years. Conclusion: Reconstruction of met-astatic subtrochanteric femoral lesions with long gamma nail is highly effective in achieving local pain control, restoring limb function and better quality of remaining life with acceptable rate of complications.

Introduction

Inclusion of foot dominance in clinical examination of foot disorders is not routinely practised. The existence of foot dominance is not reported in the orthopaedic literature. We have evaluated foot dominance in a normal population and correlated it with hand dominance to highlight its existence and also to bring it into common practice.

Materials and methods

Demographic data was obtained from 468 healthy adult subjects. Those with pre-existing lower limb pathology were excluded from the study. Hand dominance was noted and each subject was then assessed for foot dominance by a blinded method. During the study all subjects were invited to come and stand on a set of weighing scales, and the leading foot was regarded as the dominant one. This was repeated three times for each subject.

Results

Two hundred and fifteen (46%) were males. Two hundred and fifty-three (54%) were females. Three hundred and ninety (83%) were right handed and 78(17%) were left-handed. Three hundred and fifty (75%) were right footed and 118 (25%) were left footed. Eighty-four per cent (328) of the right-handed lead with their right foot and 16% (62) lead with their left foot. Seventy-seven per cent (60) of the left-handed lead with their left foot and 23% (18) lead with their right foot.

Conclusion and Discussion

Foot Dominance seems important to recognise in the same way that we always ask about hand dominance. Further study obviously needs to be carried out to relate foot dominance with lower limb pathology. Are we more likely to injure or stress the dominant lower limb and is this reflected in the incidence of conditions such as fractured necks of femur, lower limb arthritis or foot disorders? We would certainly expect a correlation with the speed of rehabilitation of lower limb disorders depending on which limb is affected, and some existing evidence and the experiences of our physiotherapists support this. Further research is being undertaken to investigate this.

A prospective study of 142 consecutive patients admitted with fracture of the neck of femur was performed. 42 patients were operated within 24 hours of time of fracture (group 1), 46 within 24 to 48 hours (group 2) and 47 more than 48 hours later (group 3). Three patients were treated conservatively and in four patients the exact time of fracture was not known.

The reason for delay of the operation was lack of theatre space in the majority of cases (64 patients). Medical problems accounted for delay in only 10 patients.Seven patients out of 42 in group 1 died within four month (16.7%), compared to 11 of 46 in group 2 (23.9%), and 6 out of 47 in group 3 (12.8%). This difference was not statistically significant.

There was no significant difference in requirement for pre- and postoperative blood transfusion between the three groups. No patient operated within 24 hours developed pressure sores. Three patients in group 2, and six patients in group 3 developed pressure sores. Chest infections occurred in three patients in group 2, and in three patients in group 3. None of the patients operated on within 24 hours developed a chest infection, wound infection or urinary tract infection. Two patients who had a Girdlestone procedure for deep infection were operated more than 48 hours after the fracture. One patient requiring drainage for wound infection had the operation 47 hours after the fracture.There were no superficial or deep wound infections, pressure sores, or chest infections if operated on within 24 hours of fracture. There was no difference in the requirement for blood transfusion. Patients operated within 24 to 48 hours of fracture had the highest mortality, although this was not statistically significant.