The management of a significant bony defect following excision
of a diaphyseal atrophic femoral nonunion remains a challenge. We
present the outcomes using a combined technique of acute femoral
shortening, stabilized with a long retrograde intramedullary nail,
accompanied by bifocal osteotomy compression and distraction osteogenesis with
a temporary monolateral fixator. Eight men and two women underwent the ‘rail and nail’ technique
between 2008 and 2016. Proximal locking of the nail and removal
of the external fixator was undertaken once the length of the femur
had been restored and prior to full consolidation of the regenerate.Aims
Patients and Methods
We prospectively assessed the diagnostic accuracy
of the gravity stress test and clinical findings to evaluate the stability
of the ankle mortise in patients with supination–external rotation-type
fractures of the lateral malleolus without widening of the medial
clear space. The cohort included 79 patients with a mean age of
44 years (16 to 82). Two surgeons assessed medial tenderness, swelling
and ecchymosis and performed the external rotation (ER) stress test
(a reference standard). A diagnostic radiographer performed the
gravity stress test. For the gravity stress test, the positive likelihood ratio (LR)
was 5.80 with a 95% confidence interval (CI) of 2.75 to 12.27, and
the negative LR was 0.15 (95% CI 0.07 to 0.35), suggesting a moderate
change from the pre-test probability. Medial tenderness, both alone
and in combination with swelling and/or ecchymosis, indicated a
small change (positive LR, 2.74 to 3.25; negative LR, 0.38 to 0.47),
whereas swelling and ecchymosis indicated only minimal changes (positive
LR, 1.41 to 1.65; negative LR, 0.38 to 0.47). In conclusion, when gravity stress test results are in agreement
with clinical findings, the result is likely to predict stability
of the ankle mortise with an accuracy equivalent to ER stress test
results. When clinical examination suggests a medial-side injury,
however, the gravity stress test may give a false negative result. Cite this article:
