We reviewed 155 consecutive patients who were treated with a proximal femoral nail from 1997 to 2001 to determine the rate of implant specific complications. Results were stratified according to fracture type and surgeon experience to determine which problems occurred in these groups. One year postoperative followup was available for 129 of 132 surviving patients (98%). Failure of fixation occurred in three patients (2%), and a femoral shaft fracture occurred in one patient (0.7%). Fixation failures included one cutout, one delayed fracture healing, and one lateral displacement of the antirotation screw. The total reoperation rate was high (12%) mainly because of hardware removals, which occurred in 13 patients (8.6%). Stratification of results showed that hematomas and iliotibial tract irritation occurred more commonly with lesser surgical experience. General complications and intraoperative problems were seen more often with subtrochanteric fractures. Because the high reoperation rate with the proximal femoral nail is a concern, extramedullary devices continue to be the preferred implants for treatment of stable trochanteric fractures. The low rates of femoral shaft fractures and failure of fixation suggest the proximal femoral nail is useful for treatment of unstable trochanteric and subtrochanteric fractures.

A prospective evaluation of 98 patients who had undergone a total hip or knee arthroplasty was conducted to assess the effect of postoperative suction drainage. Sixty-six patients undergoing elective total hip arthroplasty and 32 patients undergoing total knee replacement were randomly allocated to undergo either suction drainage or no drainage of the wound. Statistical analysis of the results showed no difference in wound healing, severity of wound haematoma, postoperative blood transfusion requirement, range of motion and duration of the hospitalization between the two groups. We conclude that the use of closed suction drainage provides no apparent advantage after uncomplicated total hip or knee arthroplasty.

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Ruptures of the lateral ligaments of the ankle joint occur very frequently in young persons and this subject is therefore one which deserves more attention. Once a fracture or avulsion of a ligamentary insertion has been excluded the nature and extent of the ligamentary lesion should be precisely assessed. The only objective criterion of rupture of a ligament is demonstrable instability of the joint. Since the anterior talo-fibular ligament is always found to be torn immediately following supination-inversion injury to the ligaments the talar drawer sign will be demonstratable both clinically and radiologically in such cases. This test causes almost no pain and can be carried out without anesthesia. The radiological visualization of ligamentary instability with the aid of a simple jig which stresses the ankle joint provides diagnostic information which is definitely superior to that obtained from an a-p roentegenogram of the stressed joint. This conclusion was reached by statistical analysis of 384 roentgenograms.

We report four cases with very unusual manifestations of tophaceous gout. All patients were male, aged between 29 and 67 years. Only one patient had an acute gouty arthritis in his medical history, whereas the other three had never developed clinical symptoms from their hyperuricemia. Two patients had gout tophi in the patella, while the others showed gout tophi in the space of bipartite bones, one in a bipartite patella and one in a tripartite sesamoid bone of the first toe. To our knowledge, gout tophi in the space of bi- or tripartite bones has never been described before.