Introduction: While recent guidelines for the treatment of such fractures do not recommend load-bearing devices, there is little evidence actually condemning them, and there is still a lack of literature on the reconstruction nails now generally used.

Aim: To evaluate the clinical outcome of pathological (metastatic) proximal femoral fractures treated by either a long Gamma nail, an AO nail with a spiral blade plate (AO-SBP), or a dynamic hip screw (DHS).

Method: Eighty-six operations in 80 patients with average age 63.9 years were followed for 18 months or until death. Thirty-one procedures were prophylactic.

Results: Thirty Gamma nails (three bilateral), 28 AO SBP rods (three bilateral) and 28 DHS were implanted. The DHS had complications in 10 cases (35%), all occurred in less than 14 months; three implants fractured, four cut out, and three failed to relieve symptoms. The Gamma nail group had two (7%) complications, both after 20 months; one nail fractured and the other lost fixation. The AO-SBP group had two (7%) complications, with one SBP misplacement, and one postoperative death after bilateral nailing. Pain relief and function were greatly improved by the nailing procedures in 57 out of 58 cases. Survival averaged 5.5 months, and was related to primary disease, and presence of visceral metastases.

Conclusion: Both the long Gamma and AO- SBP nails reliably treated metastatic proximal femoral fractures, but loss of fixation occurred with long-term survival. The DHS had a high complication rate when used in these cases, and we do not recommend its use.

Aim: To investigate the efficacy of the Insall tube realignment procedure when used to treat osteoarthrosis of the lateral facet of the patello-femoral joint. This procedure has not been reported before for this indication.

Methods: The operation is a quadricepsplasty that tilts the patella to enable it to articulate on its intact medial facet, decreasing the loading of the damaged lateral surface. An independent retrospective review was performed with clinical examinations and a score of pain and activity. The mean period of follow-up was 3.6 years with a minimum of one year.

Results: There were 43 operations in 30 patients (12 males), with a mean age of 54 years. The patients graded their overall pain relief and functional change as being good to excellent in 32 knees, unchanged in four knees and worse in seven knees. The overall pre- and postoperative pain scores for sitting, walking, running and stair climbing all showed improvements. Ten patients felt some quadriceps weakness on descending stairs, but only one was clinically weak. There was an increase in the number of patients with severe pain on kneeling. Three patients with unsuspected tibio-femoral degenerative change seen at surgery all had poor results.

Discussion: We recommend this relatively simple and effective operation for the surgical treatment of isolated lateral facet patello-femoral osteoarthritis.