Aims

Patients undergoing femoral lengthening by external fixation tolerate treatment less well when compared to tibial lengthening. Lengthening of the femur with an intramedullary device may have advantages.

Incomplete avulsion of the proximal hamstrings can be a severely debilitating injury that causes weakness, pain while sitting and inability to run. The results of the surgical treatment of 23 consecutive patients with such injuries at least two years after surgery are described. The surgery consisted of the repair of the hamstrings directly onto the ischial tuberosity. At review, using a visual analogue scale (VAS, 0 to 100), pain while sitting improved from a mean of 40 (0 to 100) to 64 (0 to 100) (p = 0.024), weakness from a mean of 39 (0 to 90) to 76 (7 to 100) (p = 0.0001) and the ability to run from a mean of 24 (0 to 88) to 64 (0 to 95) (p = 0.0001). According to a VAS, satisfaction was rated at a mean of 81 (0 to 100) and 20 patients (87%) would have the same procedure again. Hamstring strength measured pre- and post-operatively had improved significantly from a mean of 64% (0% to 95%) to 88% (50% to 114%) compared with the normal side. Most of these patients with symptomatic incomplete hamstring avulsions unresponsive to conservative treatment had an improved outcome after surgical repair

We tested four types of surgical repair for load to failure and distraction in a bovine model of Achilles tendon repair. A total of 20 fresh bovine Achilles tendons were divided transversely 4 cm proximal to the calcaneal insertion and randomly repaired using the Dresden technique, a Krackow suture, a triple-strand Dresden technique or a modified oblique Dresden technique, all using a Fiberwire suture. Each tendon was loaded to failure. The force applied when a 5 mm gap was formed, peak load to failure, and mechanism of failure were recorded. The resistance to distraction was significantly greater for the triple technique (mean 246.1 N (205 to 309) to initial gapping) than for the Dresden (mean 180 N (152 to 208); p = 0.012) and the Krackow repairs (mean 101 N (78 to 112; p < 0.001). Peak load to failure was significantly greater for the triple-strand repair (mean 675 N (453 to 749)) than for the Dresden (mean 327.8 N (238 to 406); p < 0.001), Krackow (mean 223.6 N (210 to 252); p <  0.001) and oblique repairs (mean 437.2 N (372 to 526); p < 0.001). Failure of the tendon was the mechanism of failure for all specimens except for the tendons sutured using the Krackow technique, where the failure occurred at the knot.

The triple-strand technique significantly increased the tensile strength (p = 0.0001) and gap resistance (p = 0.01) of bovine tendon repairs, and might have advantages in human application for accelerated post-operative rehabilitation.

A silver-containing hydroxyapatite (Ag-HA) coating has been developed using thermal spraying technology. We evaluated the osteoconductivity of this coating on titanium (Ti) implants in rat tibiae in relation to bacterial infection in joint replacement.

At 12 weeks, the mean affinity indices of bone formation of a Ti, an HA, a 3%Ag-HA and a 50%Ag-HA coating were 97.3%, 84.9%, 81.0% and 40.5%, respectively. The mean affinity indices of bone contact of these four coatings were 18.8%, 83.7%, 77.2% and 40.5%, respectively. The indices of bone formation and bone contact around the implant of the 3%Ag-HA coating were similar to those of the HA coating, and no significant differences were found between them (bone formation, p = 0.99; bone contact, p = 0.957). However, inhibition of bone formation was observed with the 50%Ag-HA coating.

These results indicate that the 3%Ag-HA coating has low toxicity and good osteoconductivity, and that the effect of silver toxicity on osteoconductivity depends on the dose.

Fragility fractures of the ankle occur mainly in elderly osteoporotic women. They are inherently unstable and difficult to manage. There is a high incidence of complications with both non-operative and operative treatment.

We treated 12 such fractures by closed reduction and stabilisation using a retrograde calcaneotalotibial expandable nail. The mean age of patients was 84 years (75 to 95). All were women and were able to walk fully weight-bearing after surgery. There were no wound complications. One patient died from a myocardial infarction 24 days after surgery. The 11 other patients were followed up for a mean of 67 weeks (39 to 104).

All the fractures maintained satisfactory alignment and healed without delay. Six patients refused removal of the nail after union of the fracture. The functional rating using the scale of Olerud and Molander gave a mean score at follow-up of 61, compared with a pre-injury value of 70.

Diabetes mellitus is considered an indicator of poor prognosis for acute ankle fractures, but this risk may be specific to an identifiable subpopulation. We retrospectively reviewed 42 patients with both diabetes mellitus and an acute, closed, rotational ankle fracture. Patients were individually matched to controls by age, gender, fracture type, and surgical vs non-surgical treatment. Outcomes were major complications during the first six months of treatment. We contrasted secondarily 21 diabetic patients with and 21 without diabetic comorbidities. Diabetic patients and controls did not differ significantly in total complication rates. More diabetic patients required long-term bracing. Diabetic patients without comorbidities had complication rates equal to their controls. Diabetic patients with comorbidities had complications at a higher rate (ten patients; 47%) than matched controls (three patients; 14%, p = 0.034). A history of Charcot neuroarthropathy led to the highest rates of complication. An increased risk of complications in diabetic patients with closed rotational fractures of the ankle are specific to a subpopulation with identifiable related comorbidities.