The aim is to report a rare technique for correction of intramedullary nail acute angular deformity. Intramedullary tibial nail fixation of diaphyseal tibial fractures is the gold standard treatment allowing early mobilisation whilst preserving the soft tissues around the fracture site. Most commonly, intramedullary nails fail by metal fatigue secondary to non union, without significant deformity of the metalwork. Plastic deformity of the nail can result following new acute trauma, particularly before bone union has occurred. This is a clinical challenge as a reamed intramedullary nail is designed to achieve three point fixation with close anatomical fit, such that removal of a bent nail is technically difficult and also risks further damage to bone and soft tissues. We report a case of a 20 year old patient treated with intramedullary nail fixation of a diaphyseal right tibial fracture who was subsequently assaulted 4 weeks post operatively. This produced an unacceptable deformation of the nail into 25 degrees valgus and procurvatum. To remove the nail, the authors used a previously reported but rare technique of partial (up to 50%) nail division on the convex surface of the apex using Midas Rex High Speed Drill to weaken the nail then manipulation to correct deformity with minimal stress. The technique produced minimal metal debris and allowed simple exchange nail replacement without further complication. The authors believe this is the first reported use of the technique from the United Kingdom

When a constrained liner is used in a non-cemented cup it is advisable to add screw fixation to the cup even if the cup has an excellent press-fit because there is more pull-out pressure on the liner with a constrained cup. It also is necessary for the cup to be in the correct anteversion/inclination. It is not advisable to use a constrained liner to “make up” for poor cup position. The patient can still dislocate and then that will require an open reduction. Our most common use with constrained sockets is to cement a liner into a well fixed cemented cup. We also will cement the liner into two-stage infections to keep it stable between those operations. Failure with the cemented liner into a non-cemented cup only occurs with poor surgical technique. There is only one correct surgical technique and violation of this can cause disassociation of the liner from the cup or dislocation of the head from the liner. The correct technique is: 1.) Preferably there is no hood on the liner because that can increase impingement. 2.) The liner size must have a press-fit of the liner edge to the edge of the metal shell. This is absolutely critical. The liner size cannot sink into the shell or be proud of the shell. 3.) The liner cannot be tilted in the shell to change anteversion or inclination. 4.) The backside of the polyethylene liner must be roughened with a high speed bur preferably in a spider web design. 5.) The inside of the cup should be roughened with a carbide bit of a high speed drill. The screw holes should be cleared of fibrous tissue. 6.) The cement thickness is not a critical factor and 1–2mm is always sufficient. 7.) Maintain pressure on the liner with one size smaller pusher (28mm for 32 inner diameter liner) until the cement is hard

Introduction: Surgical removal by means of curettage is the mainstay of treatment of enchondromas of the hand. Methods of reconstruction after tumor removal usually entail no reconstruction or filling of the tumor cavity with a bone graft. These techniques necessitate a prolonged period of protected activity until bone healing of the tumor cavity occurs. The authors have utilized hardware and bone cement for the purpose of reconstruction of the tumor cavity. This technique provides immediate mechanical stability and allows early mobilization. Methods: Between 1986 and 1999 the authors treated 13 patients (8 females, 4 males) who ranged in age from 23 to 58 years (median, 32 years) and diagnosed with enchondroma of the hand. Eight patients presented with a pathological fracture. Anatomic locations included: metacarpal bones – 5, proximal phalanx – 4, and middle phalanx – 4. Tumors were approached through the retained thinned or destroyed cortex to minimize additional bone loss. Surgery included removal of all gross tumor with hand curettes; this was followed by high speed burr drilling of the inner reactive bone shell. Reconstruction included intramedullary metal wire along the longitudinal axis of the cavity and polyme-hylmethacrylate (PMMA). Full activity as tolerated was allowed immediately after surgery. All patients were followed for more than 2 years. Follow-up included physical and radiological evaluation and functional evaluation. Results: Following surgery, all patients returned to their presurgical functional capability within two weeks. At the last follow-up, none of the patients had local tumor recurrence and although three patients had 15° to 20° decrease in flexion of the metacarpophalangeal joint, none reported a functional limitation. There were no postoperative infections or fractures. Conclusions: Reconstruction of the tumor cavity, remaining after curettage of enchondroma of the hand, with intramedullary hardware and PMMA provides immediate mechanical stability and allows early mobilization. This technique is associated with good short- and long-term functional outcomes