The reduction for unstable femoral intertrochanteric fracture should be extramedullary, which means that the proximal fragment protrudes for the distal fragment. However, only few articles have compared extramedullary and intramedullary reductions in a biomechanical study. Thus, we created unstable femoral intertrochanteric fracture models using imitational bone (extramedullary and intramedullary groups, each with 12 cases) and evaluated their biomechanical stabilities. The fracture type was 31-A2 according to the AO-OTA Classification of Fractures and Dislocations and greatly lacked bone on the posterior side. We performed compression examination and evaluated stiffness. The implant used for fixation was TFNA (DePuy Synthes). We applied axial compression with 20 adduction in the standing position. Statistical analysis was performed using the Mann-Whitney U test. No significant difference in initial loading force was found between the two groups. However, the axial stiffness of the extramedullary bone showed a significant increase (p < 0.05) in high loading force (800–1000 N). This means that the stability of the extramedullary reduction was superior to that of the intramedullary reduction in terms of high loading force in the standing position. We suggest that antero-medial bony buttress is important for unstable femoral intertrochanteric fractures. These data indicate that extramedullary reduction and fixation for unstable femoral intertrochanteric fractures increase stability

Patients with a femoral shaft fracture requiring intra-medullary nailing were recruited to investigate if the femoral canal could be a potential source of inflammatory cytokines, previously implicated in the pathogenesis of life-threatening inflammatory complications. Femoral and peripheral blood samples were obtained at the time of surgery from patients with a femoral shaft fracture requiring intramedullary nailing. The local femoral intramedullary and peripheral release of a group of ten Th1 and Th2 cytokines concentrations (IL-1b, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, GM-CSF, TNF-a and IFN-g) after femoral shaft fracture and intramedullary reaming, if performed, was measured using a Human Cytokine Antibody 10-plex Bead Kit. A control group of patients(n=3) undergoing hip replacement was established to allow comparison with the normal femoral intramedullary cytokine environment. 21 patients with a femoral shaft fracture were recruited. Femoral shaft fracture caused a significant increase in the local femoral concentrations of IL-6 (median 3967pg/ml; range 128–25,689pg/ml) and IL-8 (median 238pg/ml; range 8–8,288pg/ml) compared to the femoral control group(p=0.0005 and p=0.001 respectively). No significant local femoral release of the other cytokines was demonstrated. In the patients who underwent intramedullary reaming of the femoral canal (n=6), a further significant local release of IL-6 (median post-ream 15,903pg/ml; range 1,854–44,922pg/ml) and IL-8 (median post-ream 1,443pg/ml; range 493–3,734pg/ml) was demonstrated (p=0.01 and p=0.03 respectively), thus showing that intramedullary reaming can cause a significant local inflammatory response. Femoral shaft fracture produces a local inflammatory response releasing large amounts of the cytokines IL-6 and IL-8 into the local femoral environment but not of the other Th1 and Th2 cytokines studied. Reaming, produced significant elevation in local femoral IL-6 and IL-8 concentration, suggesting a local femoral response as a result of this procedure. Possibly, local femoral environment may act as a cell-priming or stimulating zone, for circulating inflammatory cells

Introduction. The use of intramedullary lengthening devices is becoming increasingly popular. There are no published data regarding the incidence of venous thromboembolism following intramedullary lengthening and no reports or guidance for current practices on use of thromboprophylaxis. Following a case of post-operative deep vein thrombosis in our institution, we felt that it is important to assess best practice. We conducted this survey to collect data that would describe current practice and help guide consensus for treatment. Materials and Methods. We have identified surgeons across the UK that perform intramedullary lengthening through the British Limb Reconstruction Society membership and a Precise Users database. Surgeons were contacted and asked to respond to an online survey (SurveyMonkey - SVMK Inc.). Responses to thromboprophylaxis regimes employed in their practice and cases of venous thromboembolism were collated. Results. 24 out of 54 surgeons identified responded with a total of 454 cases of intramedullary lengthening (352 femoral and 102 tibial nails) performed over the last 5 years. Only one case of DVT following femoral lengthening was reported. There is wide variability in practice both in terms of thromboprophylaxis risk assessment, choice of medications (20% no pharmacological treatment, 75% Low molecular Weight Heparin, 5% Aspirin) and duration of treatment (0–42 days). The vast majority of surgeons (85%) felt that there was insufficient evidence available to guide their practice. Conclusions. Intramedullary lengthening is a relatively recent and novel surgical treatment. As a result there is limited data available to guide decision making regarding aspects of treatment such as thromboprophylaxis. This is reflected in the wide variation in practice reported in this study. There is both a need and a desire to gather data that will allow us to come to a consensus and to guide safe practice

Introduction. Coronal malalignment and leg length discrepancies (LLD) are frequently associated. Temporary hemiepiphysiodesis (tHED) is commonly employed for the correction of limb malalignment in skeletally immature patients. For treatment of LLD greater than 2 cm, lengthening with intramedullary legnthening nails is a safe and reliable technique. However, the combined application of these approaches in skeletally immature patients has not yet been investigated. Materials & Methods. Retrospective radiological and clinical analysis of 25 patients (14 females, 11 males) who underwent intramedullary femoral lengthening with an antegrade PRECICE® lengthening nail as well as tHED of the distal femur and / or proximal tibia between 2014 and 2019. tHED was conducted by implantation of flexible staples (FlexTack™) either prior (n = 11), simultaneously (n = 10), or subsequently (n = 4) to femoral lengthening. The mean follow-up period was 3.7 years (±1.4). Results. The median initial LLD was 39.0 mm (35.0–45.0). 21 patients (84%) presented valgus and 4 (16%) showed varus malalignment. Leg length equalization was achieved in 13 patients at skeletal maturity (62%). The median LLD of patients with a residual LLD > 10 mm was 15.5 mm (12.8–21.8). Limb realignment was obtained in nine of seventeen skeletally mature patients (53%) in the valgus group, and in one of four patients (25%) in the varus group. Conclusions. The combination of antegrade femoral lengthening and tHED can efficiently correct LLD and coronal limb malalignment in skeletally immature patients. Nevertheless, achieving limb length equalization and realignment may render difficult in cases of severe LLD and angular deformity. Furthermore, the reported techniques ought to be thoroughly planned and executed and require regular clinical and radiological examinations until skeletal maturity to avoid - or timely detect and manage - adverse events such as overcorrection and rebound of deformity

Introduction. Management of deformity involving limb length discrepancy (LLD) using intramedullary devices offers significant benefits to both patients and clinicians over traditional external fixation. Following the withdrawal of the PRECICE nail, the Fitbone became the primary implant available for intramedullary lengthening and deformity correction within our service. This consecutive series illustrates the advantages and complications associated with the use of this device, and describes a novel technique modification for antegrade intramedullary lengthening nails. Materials & Methods. A retrospective cohort review was performed of patient outcomes after treatment with the Fitbone nail at two tertiary referral limb reconstruction services (one adult, one paediatric) between January 2021 to December 2023. Aetiology, indications, initial and final LLD, use of concomitant rail assisted deformity correction (ORDER), removal time and healing index were assessed. Complications of treatment were evaluated and described in detail, alongside technique modifications to reduce the rate of these complications. Results. 21 nails (18 femoral, 2 tibial, 1 humeral) were inserted in 6 adult and 13 paediatric patients. Post-traumatic and congenital/developmental LLD were the most common indications for surgery in the adult and paediatric cohorts respectively. ORDER was employed in 11 cases (9 femurs and 2 tibias). Treatment goals were achieved in all but one case. Complications included superficial infection, locking bolt migration, periprosthetic fracture and component failure. Seven patients required unplanned returns to theatre. Conclusions. The Fitbone nail is an established option for intramedullary limb lengthening, however its use in the UK has been relatively limited compared to the PRECICE until 2021. Our data helps to define its place for limb lengthening and complex deformity correction in both adult and paediatric patients, including in humeral lengthening and retrograde femoral insertion across an open physis. We have identified important potential risks and novel techniques to simplify surgery and avoid complications

Introduction. The use of vascularised fibula grafts is an accepted method for reconstructing the distal femur following resection of malignant childhood tumours. Limitations relate to the mismatch of the cross-sectional area of the transplanted fibula graft and thel ocal bone, instability of the construct and union difficulties. We present midterm results of a unique staged technique—an immediate defect reconstruction using a double-barrel vascularised fibula graft set in in A-frame configuration and a subsequent intramedullary femoral lengthening. Materials & Methods. We retrospectively included 10 patients (mean age 10 y)with an osteosarcoma of the distal femur, who were treated ac-cording to the above-mentioned surgical technique. All patients were evaluated with regards to consolidation of the transplanted grafts, hypertrophy at the graft-host junctions, leg length discrepancies, lengthening indices, complications as well as functional outcome. Results. The mean defect size after tumour resection was 14.5 cm, the mean length of the harvested fibula graft 22 cm, resulting in a mean (acute) shortening of 4.7 cm (in 8 patients). Consolidation was achieved in all cases, 4 patients required supplementary bone grafting. Hypertrophy at the graft-host junctions was observed in78% of the evaluable junctions. In total 11 intramedullary lengthening procedures in 9 patients had been performed at the last follow up. The mean Muskuloskeletal Society Rating Scale(MSTS) score of the evaluable 9 patients was 85% (57% to 100%)with good or excellent results in 7 patients. Conclusions. A-frame vascularised fibula reconstructions showed encouraging results with respect to defect reconstruction, length as well as function and should therefore be considered a valuable option for reconstruction of the distal femur after osteosarcoma resection. The surgical implementation is demanding though, which is emphasized by the considerable high number of com-plications requiring surgical intervention, even though most were not serious

Introduction. At Sheffield Children's Hospital, treatment of leg length discrepancy is a common procedure. Historically, this has been done with external fixators. With the development in intramedullary technology, internal nails have become the preferred modality for long bone lengthening in the adolescent population. However, it is important to review whether this technology practically reduces the known challenges seen and if it brings any new issues. Therefore, the aim of this review is to retrospectively evaluate the therapeutic challenges of 16 fit-bone intramedullary femoral lengthening's at Sheffield Children's Hospital between 2021–2022. Materials & Methods. The international classification of function (ICF) framework was used to differentiate outcomes. The patient's therapy notes were retrospectively reviewed for themes around structural, activity and participation limitation. The findings were grouped for analysis and the main themes presented. Results. There were 8 males, mean age 17.4 years (range 17–18) and 8 females, mean age 15.9 years (range 14–18). 5 right and 11 left femurs were lengthened. Underlying pathology varied amongst the 16 patients. All patients went into a hinged knee brace post operatively. Structural limitations included: pain, fixed flexion deformity of the knee, loss of knee flexion, quadriceps muscle lag, muscle spasms and gluteal weakness. The primary activity limitation was reduced weight bearing with altered gait pattern. Participation limitations included reduced school attendance and involvement in activities with peers. Access to Physiotherapy from local services varied dramatically. Five of the cohort have completed treatment. Conclusions. Anecdotally, intramedullary femoral lengthening nails have perceived benefits for families compared to external fixators in the adolescent population. However, there remain musculoskeletal and psychosocial outcomes requiring therapeutic management throughout the lengthening process and beyond. Therefore, quantifying these outcomes is essential for measuring the impact on each patient for comparison. To interpret these themes, we need to evaluate the outcomes objectively, this was not done consistently in this review. Future research should look at outcome measures that are sensitive to all aspects of the ICF. With an aim of improving the therapeutic treatment provided and the overall outcome for the children treated

Aim. Intramedullary osteomyelitis remains a challenge in the treatment of bone infections, requires organized, sequential and effective management to prevent its spread and subsequent recurrence. Errors are often made in the comprehensive treatment of this type of infection classified as type 1 of Cierny-Mader, where you can perform an insufficient treatment or in some cases perform very extensive and unnecessary bone resections. A rigorous protocol is proposed, by stages to achieve the total eradication of the infection and a surgical tactic that avoids diffusion of the infection or recurrences. Method. In the prospective case series study, 16 patients with type 1 intramedullary infection of Cierny Mader, diagnosed by radiology, TAC or MRI were included. The microbiological protocol is carried out, with the germ typing and the corresponding antibiogram, at least 3 samples of deep tissues, the biofilm and segments of dead bone are taken. In the surgical tactic, intramedullary sequestrations are resected, the intramedullary canal is cleaned by stages, initially in the most inflammatory focus detected, the medullary canal is accessed through a planned and defined bone window, with round edges to avoid fractures and allowing access To the flexible reamer and cleaning guides, an additional window is made that avoids the blood dissemination of the infection, the septic embolisms or the contamination of the underlying soft tissues. It is defined if it requires stabilization of the bone with internal or external devices, therapies are applied locally to avoid recolonization, using Bioglass or absorbable substitutes with selective antibiotic. The treatment is associated with intravenous antibiotic therapy between 2 and 6 weeks according to the type of germ and if it is multiresistant. It guarantees skin coverage and protection of structures at risk such as nerves, tendons and exposed bone. Results. Successful treatment results are obtained, infection eradication in 100% of cases, the healing of osteomyelitis is achieved by applying an integral management of the intramedullary canal Osteomyelitis and a complete protocol is established. Conclusions. The tactic and surgical technique applied in the integral management of intramedullary bone infection is essential to obtain definitive results in the eradication of bone infection. Care must be taken that the debridement is complete of the intramedullary canal and additionally, segmental or exaggerated resection of viable bone must be avoided, which survives and heals after the integral management of the infection with effective antibiotic therapy

Introduction. The management of fracture-related infection has undergone radical progress following the development of international guidelines. However, there is limited consideration to the realities of healthcare in low-resource environments due to a lack of available evidence in the literature from these settings. Initial antimicrobial suppression to support fracture union is frequently used in low- and middle-income countries despite the lack of published clinical evidence to support its practice. This study aimed to evaluate the outcomes following initial antimicrobial suppression to support fracture union in the management of fracture-related infection. Materials & Methods. A retrospective review of consecutive patients treated with initial antimicrobial suppression to support fracture healing followed by definitive eradication surgery to manage fracture-related infections following intramedullary fixation was performed. Indications for this approach were; a soft tissue envelope not requiring reconstructive surgery, radiographic evidence of stable fixation with adequate alignment, and progression towards fracture union. Results. This approach was associated with successful treatment in 51/55 (93%) patients. Fracture union was achieved in 52/55 (95%) patients with antimicrobial suppression alone. Remission of infection was achieved in 54/55 (98%) patients following definitive infection eradication surgery. Following antibiotic suppression, 6/46 (13%) pathogens isolated from intra-operative samples demonstrated multi-drug resistance. Conclusions. Initial antimicrobial suppression to support fracture healing followed by definitive infection eradication surgery was associated with successful treatment in 93% of patients. The likelihood of remission of infection increases when eradication surgery is performed in a healed bone. This approach was not associated with an increased risk of developing multi-drug-resistant infections compared to contemporary bone infection cohorts in the published literature

To determine the gross structural alterations of the nailed bone (femur or tibia) after the removal of an intramedullary nail (IMN). Eighteen patients (14 femoral and 4 tibia nail) underwent an IMN removal from their femur or tibia. Every patient had a spiral computed tomography scan and a plain X-ray study, immediately after the nail removal and also at their latest follow-up (24–30 months). The 4 patients with a tibia nail were additionally examined using a peripheral quantitative computed tomography study at their latest follow-up. All patients were asymptomatic. An intramedullary shell of compact bone was demonstrated around the nail track. This new bone was apparent on plain radiographs in all of the patients. Peripheral quantitative computed tomography study revealed that the density of the bony ring was similar to that of subcortical bone. The histologic examination of the intra-medullary shell of one of our patients suggested that the bony ring was made of cortical bone. Intramedullary nailing may enhance new cortical bone formation within the bone marrow cavity. This “cortical bone” still exists more than 2 years after implant removal. Nail insertion also causes thickening of the normal cortex at the sites of nail–cortex contact where loads are transferred from the nail to the cortex. This new finding could probably lead the research of intramedullary nailing biomechanics toward new directions as to understand the body’s reaction to IMNs

Aims. This study aims to enhance understanding of clinical and radiological consequences and involved mechanisms that led to corrosion of the Precice Stryde (Stryde) intramedullary lengthening nail in the post market surveillance era of the device. Between 2018 and 2021 more than 2,000 Stryde nails have been implanted worldwide. However, the outcome of treatment with the Stryde system is insufficiently reported. Methods. This is a retrospective single-centre study analyzing outcome of 57 consecutive lengthening procedures performed with the Stryde nail at the authors’ institution from February 2019 until November 2020. Macro- and microscopic metallographic analysis of four retrieved nails was conducted. To investigate observed corrosion at telescoping junction, scanning electron microscopy (SEM) and energy dispersive x-ray spectroscopy (EDX) were performed. Results. Adjacent to the nail’s telescoping junction, osteolytic changes were observed in bi-planar radiographs of 20/57 segments (35%) after a mean of 9.5 months (95% confidence interval 7.2 to 11.9) after surgery. A total of 8/20 patients with osseous alterations (40%) reported rest and ambulation pain of the lengthened segment during consolidation. So far, 24 Stryde nails were retrieved and in 20 (83%) macroscopic corrosion was observed at the nail’s telescoping junction. Before implant removal 11/20 radiographs (55%) of lengthened segments with these 20 nails revealed osteolysis. Implant retrieval analysis by means of SEM showed pitting and crevice corrosion. EDX detected chromium as the main metallic element of corrosion. Conclusion. Patients are exposed to the risk of implant-related osteolysis of unclear short- and long-term clinical consequences. The authors advocate in favour of an early implant removal after osseous consolidation. Cite this article: Bone Joint Res 2021;10(7):425–436

Introduction. The practice of limb lengthening using intramedullary nails has surged in popularity in recent years. Our study explores the relationship between femur lengthening and overall height gain in adults undergoing cosmetic limb lengthening with telescoping magnetic intramedullary lengthening nails (MILNs). Materials & Methods. Demographic information, pre- and postoperative radiographic data, and secondary outcomes, such as mechanical angles and sagittal alignment, were analyzed for 42 adult femurs MILNs (PRECICE 2, NuVasive, Inc.). Height was assessed with a digital stadiometer. Limb lengthening was defined as the amount of nail distraction seen on a calibrated weight bearing X-ray at consolidation. mLDFA, mMPTA, MAD, AMA, and femoral sagittal bow were evaluated as secondary outcomes. Results. Mean starting height was 163.5 cm (SD 10.4, range 137–179) Post -lengthening mean height increased to 171.1 cm (SD 10.1, range 146.7–185.3). Average height gain was 7.5 cm (SD 1.3 cm, range 5.1–9.5). Average femoral lengthening was 7.3 cm (SD 1.14, range 4.1–10.1). There were no statistically significant difference between height gain and femur lengthening. Secondary outcomes showed reductions in femoral sagittal bow and AMA. Conclusions. We conclude that measuring femur lengthening is a reliable and accurate method of measuring gained height in deformity-free patients undergoing limb lengthening. We further reason that straightening of both femoral and spinal sagittal bow counteracts potential lengthening loss over the anatomical axis, versus mechanical axis lengthening

Introduction. The condition of the soft tissues surrounding an ankle fracture influences timing and treatment of injuries. Conventional treatment used an open approach to facilitate anatomical reduction and rigid internal fixation. Intramedullary devices for fibular fractures provide a safe alternative in patients in which the condition of the soft tissue envelope or the patient's co-morbidities may benefit from a less invasive approach. We compared outcomes for patients treated with open reduction internal fixation (ORIF) with those undergoing treatment with fibular nails (FN). Methods. 13 consecutive patients treated with fibular nails (FN) were compared with 13 age-matched patients that underwent open reduction and internal fixation (ORIF). All patients were followed to union. Study outcomes were time from admission to surgery, length of stay, wound failure, implant failure, revision surgery, OMAS and SF-36. Results. There was no difference in age or sex distribution between groups. There was no difference in OMAS at 1 year (83 ± 9 in FN group; 80± 21 in ORIF group) and SF-36 (94 ± 11 and 90 ± 20). There were 2 implant failures in the ORIF group and none in the FN group. There was one wound failure in the ORIF group and none in the FN group. Patients treated with FN had a shorter time to surgery (1 day ± 24 hours vs 3 days ± 24 hours) and shorter length of stay (1 day ± 24 hours vs 4 days ± 96 hours). Conclusion. FN is a safe method to treat patients with displaced distal fibular fractures that may have a poor soft tissue envelope and risk factors for wound healing. FN reduces the time to surgery and overall length of stay compared with similar patients treated with conventional ORIF

Tip-apex distance (TAD) has long been discussed as a metric for determining risk of failure in fixation of peritrochanteric hip fractures. This study seeks to investigate risk factors including TAD for hospital readmission one year after hip fixation surgery. A retrospective review of proximal hip fractures treated with single screw intramedullary devices between 2016 and 2020 was performed at a 327 bed regional medical center. Patients included had a postoperative follow-up of at least twelve months or surgery-related complications developing within that time. 44 of the 67 patients in this study met the inclusion criteria with adequate follow-up post-surgery. The average TAD in our study population was 19.57mm and the average one year readmission rate was 15.9%. 3 out of 6 patients (50%) with a TAD > 25mm were readmitted within one year due to surgery-related complications. In contrast, 3 out of 38 patients (7.9%) with a TAD < 25mm were readmitted within one year due to surgery-related complications (p=0.0254). Individual TAD measurements, averaging 22.05mm in patients readmitted within one year of surgery and 19.18mm in patients not readmitted within one year of surgery were not significantly different between the two groups (p=0.2113). Our data indicate a significant improvement in hospital readmission rates up to one year after hip fixation surgery in patients with a TAD < 25mm with a decrease in readmissions of over 40% (50% vs 7.9%). This result builds upon past investigations by extending the follow-up time to one year after surgery and utilizing hospital readmissions as a metric for surgical success. With the well-documented physical and financial costs of hospital readmission after hip surgery, our study highlights a reduction of TAD < 25mm as an effective method of improving patient outcomes and reducing financial costs to patients and medical institutions

Objectives. The Precice nail is the latest intramedullary lengthening nail with excellent early outcomes. Implant complications have led to modification of the nail design. The aim of this study was to perform a retrieval study of Precice nails following lower-limb lengthening and to assess macroscopical and microscopical changes to the implants and evaluate differences following design modification, with the aim of identifying potential surgical, implant, and patient risk factors. Methods. A total of 15 nails were retrieved from 13 patients following lower-limb lengthening. Macroscopical and microscopical surface damage to the nails were identified. Further analysis included radiology and micro-CT prior to sectioning. The internal mechanism was then analyzed with scanning electron microscopy and energy dispersive x-ray spectroscopy to identify corrosion. Results. Seven male and three female patients underwent 12 femoral lengthenings. Three female patients underwent tibial lengthening. All patients obtained the desired length with no implant failure. Surface degradation was noted on the telescopic part of every nail design, less on the latest implants. Microscopical analysis confirmed fretting and pitting corrosion. Following sectioning, black debris was noted in all implants. The early designs were found to have fractured actuator pins and the pin and bearings showed evidence of corrosive debris. The latest designs showed evidence of biological deposits suggestive of fluid ingress within the nail but no corrosion. Conclusion. This study confirms less internal corrosion following modification, but evidence of titanium debris remains. We recommend no change to current clinical practice. However, potential reuse of the Precice nail, for secondary limb lengthening in the same patient, should be undertaken with caution. Cite this article: V. C. Panagiotopoulou, K. Davda, H. S. Hothi, J. Henckel, A. Cerquiglini, W. D. Goodier, J. Skinner, A. Hart, P. R. Calder. A retrieval analysis of the Precice intramedullary limb lengthening system. Bone Joint Res 2018;7:476–484. DOI: 10.1302/2046-3758.77.BJR-2017-0359.R1

Background. Clavicle development occurs before the age of 9 in females and 12 in males. Children below the age of 10 with displaced midshaft clavicle fractures recover well with conservative management. However adolescents are more demanding of function and satisfaction following clavicle fractures and may benefit from operative management. Study aims: 1) Perform a systematic review of the current evidence supporting intramedullary fixation of adolescent clavicle fractures. 2) Review current management in a major trauma center (MTC) with a view to assess feasibility for a randomised controlled trial (RCT). Methods. The MEDLINE, EMBASE and AMED databases were searched in October 2014 to identify all English language studies evaluating intramedullary fixation in children aged 10–18 years using MeSH terms. Data was extracted using a standardised data collection sheet and studies were critically appraised by aid of the PRISMA checklist. All patients aged 9–15 attending an MTC receiving clavicle radiographs in 2014 were retrospectively reviewed for type of fracture, management and outcome. Results. Literature search identified 54 articles. After application of exclusion criteria 3 studies were selected for final review. 47 adolescent patients received intramedullary clavicle fixation from a prospective and two retrospective case series. 61 adolescents presented to our unit with a clavicle fracture in 2014, 2 were lost to follow-up, 54 were managed non-operatively, 3 received titanium-elastic nailing, 1 plate osteosynthesis and 1 bone suture. 0 and 19 patients reported a palpable lump, mean time to pain resolution was 4 and 6 weeks and time to full range of motion was 4 and 5 weeks following operative and conservative management respectively. All patients reached radiographic union. Conclusion. Current evidence supporting intramedullary fixation of clavicle fractures in adolescents is poor. There remains clinical equipoise on the best management of these patients, however they are predominantly treated conservatively. A future multi-center RCT may be feasible. Level of Evidence. 1

Introduction. Muscle stiffness and joint contractures are common complications of limb lengthening. Authors have demonstrated less permanent soft tissue complications with intramedullary lengthening than external fixation. Our aim was to evaluate the joint response following intramedullary femoral lengthening and need for physiotherapy and alteration to rate/rhythm of lengthening. Method. A retrospective review of documentation for all femoral Precice nails in our centre inserted between 2012 and 2017. This involved 98 nails (68 antegrade, 30 retrograde) in 88 patients (59 males, 29 females) with a mean age of 32 years (range 12–69 yrs). We excluded cases where there was no documentation regarding Range of Movement (ROM). Bilateral lengthenings were recorded as separate cases. This left 50 antegrade, 16 retrograde cases with hip ROM data and 55 antegrade, 26 retrograde cases with Knee ROM data. Results. Hip. In the antegrade group 20 cases (39%) developed no stiffness throughout treatment. ROM decreased in 61% (n=30) of cases and the median length at which this occurred was 3cm. Where a retrograde nail was inserted 62.5% of cases (n=10) maintained normal range of motion. The median length at which ROM decreased was 3.25cm, this occurred in 6 cases (37.5%). . Knee. Where the antegrade nail was inserted, 22 cases (40%) did not develop stiffness. There was reduced ROM in 33 cases (60%), occurring at a median distance of 2cm. The median distance at which reduced ROM occurred with the retrograde nails was 1.5cm, this occurred in 23 cases (88.5%). 3 cases did not develop stiffness. All cases regained full ROM. Conclusion. Although there was no permanent loss, Joint Stiffness still occurs with intramedullary limb lengthening and there remains the need for regular physiotherapy. There are no data from other institutions for comparison. Rehabilitation guidelines and a proforma to accurately monitor patients ROM throughout treatment have been developed

Introduction. Pixel Value Ratio (PVR) is a radiographic measure of the relative density of the regenerate to the adjacent bone. This has been reported as an objective criterion for regenerate healing and a guide for when to allow full weight bearing (FWB) in lengthening with intramedullary telescopic nails. The threshold for which magnitude of PVR is adequate to allow bearing full weight is not yet agreed. The aim of this study was to identify from our cohort of adult limb lengthening patients the time to FWB following lengthening, the PVR at this point, and how this compared with the recommended values in the literature. Materials and Methods. A retrospective database review identified 30 adult patients treated with the PRECICE femoral nail by two senior authors. Time from completion of lengthening to instruction to fully weight bear was noted. The PVR was calculated for each cortex on plain radiographs taken at each postoperative visit following completion of lengthening. Significance was set at p <0.05. Results. The median age was 30.5 years (IQR 22.5 – 42.5), 19 male and 11 female patients were included. The underlying cause of shortening was post traumatic in 12 (40%) with the remaining due to a wide variety of causes including congenital, infective, and idiopathic leg length discrepancies. Twenty-two nails were antegrade and the mean distance lengthened was 42 mm. Median time from completion of lengthening to full weight bearing was 42 days (IQR 28 – 69). The overall mean PVR at FWB was 0.79. Each surgeon had differing protocols for weightbearing, however there was no statistical difference between time to weight bearing, nor the mean PVR at FWB. There were no implant failures, shortening, or regenerate fractures. Conclusions. We report on our cohort of adult patients treated with intramedullary lengthening nails with a mean PVR of 0.79 at time of full weightbearing. This is considerably lower than the values reported in the literature ranging from 0.90 to 0.93. We therefore suggest that weightbearing following lengthening nails can be permitted earlier than previously reported without an increased risk of complication

Purpose: Axial alignment with restoration of mechanical axis is a major determinant of outcome in Total Knee Replacement. Two perceived weaknesses of Intramedullary Referencing of Tibia are crucial:. difficulties in understanding where centre of medullary canal projects on the plateau to plan entry hole. in bowing of tibia, technical axis differs from anatomical axis, resulting in varus placement of tibial tray. We evolved two technical pointers for optimal Tibial Intramedullary Referencing. We undertook a retrospective study to analyse feasibility of our technique of Tibial Intramedullary Referencing. Methods and Results: The study included 206 consecutive Total Knee Replacements between 2000 and 2008. Two – significant tibia vara and maluited tibial fracture- were excluded. Two techniques were used to avoid poor selection of entry hole and eccentric rod placement. Entry Drill Hole is made to a depth of 2–3 cm only and intramedullary rod is passed to find its own way into canal. This avoids tilted position of rod forced by a deeper drill hole and minimises tilted or wrongly sloped position of tibial tray. Identification of Entry Point is facilitated by clearing soft tissue at tibial attachment of ACL over intercondylar eminence and confirmed by placing distal phalanx of surgeon’s thumb over bare area of anterior tibial plateau. Entry point is usually at the tip of thumb. We encountered no problems by our technique in Tibial Intramedullary Referencing in 204 Total Knee Replacements. Conclusion: The two technical pointers help to overcome perceived drawbacks of Intramedullary Tibial Referencing

Introduction. Locking plates can provide greater stability than conventional plates; however, reports revealed that fractures had a high incidence of failure without medial column support; the mechanical support of medial column could play a significant role in humeral fractures. Recent studies have demonstrated the importance of intramedullary strut in proximal humeral fracture fixation, the relationship to mechanical stability and supporting position of the strut remain unclear. The purpose of this study was to evaluate the influence of position of the intramedullary strut on the stability of proximal humeral fractures using a locking plate. Materials and methods. Ten humeral sawbone (Synbone) and locked plates (Synthes, cloverleaf plate), with and without augmented intramedullary strut (five in each group) for proximal humerus fractures, were tested using material testing machine to validate the finite element model. A 10 mm osteotomy was performed at surgical neck and a strut graft (10 cm in length) was inserted into the fracture region to lift the head superiorly. Each specimen was statically tested at a rate of 5 mm/min until failure. To build the finite element (FE) model, 64-slices CT images were converted to create a 3D solid model. The material properties of screws and plates were modeled as isotropic and linear elastic, with an elastic modulus of 110 GPa, (Poisson's ratio, n=0.3). The Young's moduli of cortical and cancellous bones were 17 GPa and 500 MPa (n=0.4), respectively. Three alter shifting toward far cortex by 1, 2, and 3 mm in humeral canal were installed in the simulating model. Results and discussion. The test result showed stiffness for only locked plate was 149.2±21.3 N/mm; and the plating combined with an intramedullary strut was 336.5±50.4 N/mm. On average, the stiffness was increased by 2.2 times in the augmented fixation relative to the only locking plate fixation. The finite element analytical results showed stiffness of 162 N/mm for fixation without strut, and 372 N/mm for those with strut augmentation. The stiffness between experiment and FE analysis agreed in 8.6% for the only locking plate case; and agreed in 10.5% for the case fixed with intramedullary strut. FE analysis showed the stability of construct increased 7%, 11% and 20% as the strut shift by 1, 2, and 3 mm, respectively. Gardner (2007) reported the importance of mechanical support at the medial region for maintenance of reduction when proximal humerus fracture treated with locking plates. Conclusion. The intramedullary strut may provide superior stability than the only locking plate fixation. The FE model provides a useful implement to find the optimal configuration of plate fixation. Acknowledgements. All authors thank the funding support from National Science Council (NSC 102-2628-B-650-001) and E-Da Hospital (EDPJ1020027)