We treated 108 patients with a pertrochanteric femoral fracture using either the dynamic hip screw or the proximal femoral nail in this prospective, randomised series. We compared walking ability before fracture, intra-operative variables and return to their residence. Patients treated with the proximal femoral nail (n = 42) had regained their pre-operative walking ability significantly (p = 0.04) more often by the four-month review than those treated with the dynamic hip screw (n = 41). Peri-operative or immediate post-operative measures of outcome did not differ between the groups, with the exception of operation time. The dynamic hip screw allowed a significantly greater compression of the fracture during the four-month follow-up, but consolidation of the fracture was comparable between the two groups. Two major losses of reduction were observed in each group, resulting in a total of four revision operations.Our results suggest that the use of the proximal femoral nail may allow a faster postoperative restoration of walking ability, when compared with the dynamic hip screw.The incidence of pertrochanteric femoral fractures has increased significantly during recent decades, and this tendency will probably continue in the near future due to the rising age of the population.

No abstract

We analysed the time-dependent mean changes in the femoral neck length, neck-shaft angle and hip offset in a randomised study comprising 48 patients who were treated with the dynamic hip screw (DHS) or the proximal femoral nail (PFN) for an unstable intertrochanteric femoral fracture. As a consequence of fracture compression, the mean post-operative neck length was significantly shorter in patients treated with the DHS. During the first 6 weeks after the operation, a mean decrease of 4.6°w as observed in the neck-shaft angle, but there was not a significant difference between the treatment groups. The radiographic measures remained virtually unaffected during the interval from 6 weeks to 4 months in both groups. When the operated hip was compared to the opposite hip, patients who had received the DHS showed significantly greater medialisation of the femoral shaft at 4 months than those treated with the PFN. We thus recommend that unstable intertrochanteric fractures should be initially reduced in a slight valgus position in order to achieve an outcome after healing that is as normal as possible. As a result of differences in operative technique and implant stability, the PFN may be superior to the DHS in retaining the anatomical relations in the hip region in unstable intertrochanteric fractures.Résumé Nous avons analysé les modifications, en fonction du temps, des valeurs moyennes de la longueur du col fémoral, de l'angle cervico-diaphysaire et du bras de levier de la hanche dans une étude randomisée qui comprenait 48 malades traités avec une Vis Dynamique (DHS) ou un Clou Fémoral Proximal (PFN) aprés une fracture intertrochantérienne instable. Par suite de la compression de la fracture, la longueur du col était nettement plus courte chez les malades traités avec une DHS. Pendant les premières six semaines après l'opéra-tion, une baisse moyenne de 4.6°de l'angle cervicodiaphysaire a été observée mais il n'y avait pas de différence notable entre les groupes de traitement. Les mesures radiographiques sont restées pratiquement non affectées pendant l'intervalle de six semaines à quatre mois dans les deux groupes. Comparé à la hanche opposée, les malades qui avaient reçu une DHS ont montré à 4 mois une nettement plus grande médialisation de la diaphyse que ceux traités avec le PFN. Nous recommandons que ces fractures intertrochantériennes instables soient réduites en léger valgus pour avoir une situation aussi normale que possible après consolidation. Par suite de différences dans la technique opératoire et dans la stabilité de l'implant, le PFN semble supérieur au DHS pour rétablir l'anatomie de la région de la hanche dans les fractures intertrochantériennes instables.

The most common cause for heel pain is plantar fasciitis. The diagnosis can usually be made by clinical examination, but sometimes ENMG (electroneuromyography), ultrasound, and magnetic resonance imaging examinations are helpful. Other reasons for heel pain, e.g., nerve entrapments, atherosclerosis/ischemia, and fat pad degeneration, should be excluded. Plantar fasciitis can also present a symptom of chronic seronegative spondyloarthropathies or reactive arthritis. In the case of common plantar fasciitis, three different modes of treatment can be administered, namely, (1) anti-inflammatory and analgesic treatment, (2) rest and diminution of the strain at the insertion, and (3) maintenance of the tension and flexibility of the soft tissues. A simple four-step treatment plan algorithm, based on symptoms, their duration, and response to treatment, is presented. Operative treatment is seldom needed if the algorithm is correctly followed. Operative treatment is recommended only when the pain remains resistant to conservative treatment after more than 1 year. For operative treatment, partial release of the fascia close to insertion to avoid flat foot and secondary strain on the calcaneocuboid and midtarsal (Lisfranc) joints is our preferred option.