Introduction. Non-union is debilitating, costly and affects 2–8% of intramedullary fixed fractures. Clinical data suggest that percutaneous interfragmentary screws offer a less invasive alternative to exchange nailing. This study aimed to assess their efficiency with biomechanical analyses. Materials and Methods. A tibia was prepared for finite element analysis by creating a fracture of AO classification 42A2b, prior to reaming and insertion of an intramedullary nail. A callus was modelled as granulation tissue and gait loads were applied. The model was validated against published data and with sensitivity studies. The effects of weightbearing, fracture gap and angle, percutaneous screws and exchange nailing were compared through quantification of interfragmentary motion and strain, with the latter used to gauge healing performance via mechano-regulation theory. Results. Axial interfragmentary motion increased with increasing weightbearing, however, shear decreased at 25–50% weightbearing, leading to superior healing performance. Fracture gap had minimal effect on axial motion, but larger gaps gave greater shear, compromising healing. Elevated fracture obliquity culminated in more shear and inferior healing. Exchange nailing reduced axial motion by ∼30%, but had little effect on shear. Conversely, percutaneous screws had negligible effect on axial motion, but reduced shear by ∼15%, with three screws having a similar net effect on healing as exchange nailing from 10 to 11mm. Conclusions. This study provides new insight into fracture healing biomechanics and discovered that partial weightbearing, less oblique fractures and percutaneous screws all reduce shear, enhancing healing

Aim. The aim of this study was to determine whether the absence of periosteal reaction on plain radiographs was predictive of exchange nail failure in lower limb diaphyseal fracture non-unions. Methods. A consecutive cohort of 20 femora and 35 tibiae undergoing exchange nailing for diaphyseal aseptic (n=39) and septic (n=16) fracture non-union at a single centre from 2003 to 2010. Multiple causes of non-union were found in 29 patients (53%) with infection present in 16 cases (29.1%). Of this cohort 49 fracture non-unions had complete radiographic records (19 femora and 30 tibiae) allowing evaluation of the periosteal callus. The primary outcome was the number of number of revision procedures required to achieve union. Failure was defined was as the requirement of >two revision procedures to achieve union. Results. The absence of periosteal callus from the fracture site on all four cortices conferred a relative risk ratio (RRR) 5.00 (p=0.006) of exchange nail failure in septic fracture non-unions. Receiver operator characteristic curve analysis of number of cortices with periosteal reaction for predicting exchange nail (>two exchange nail procedures) failure in both septic and aseptic cases found an area under the curve of 0.79 (95% confidence interval 0.675–0.904, p<0.0001). The complete absence of callus within 5 mm of the fracture site had a 75% chance of requiring 3 or more exchange nails to obtain union. Conversely the presence periosteal callus on at least one cortex within 5mm of the fracture site had a 100% chance the fracture would unite following 1 or 2 exchange nail procedures. Conclusion. Careful radiographic analysis of lower limb diaphyseal non-union should be undertaken before exchange nailing. The absence of periosteal reaction on plain radiographs in septic fracture non-union is predictive of exchange nail failure

The aim of this study was to identify risk factors for failure of exchange nailing for femoral diaphyseal fracture non-unions. The study cohort comprised 40 patients with femoral diaphyseal non-unions treated by exchange nailing. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union. The mean age of the patients at exchange nail surgery was 37 years. The median time to exchange nailing from primary fixation was 8.4 months. Multiple causes for non-union were found in 14 (35.0%) cases, with infection present in 12 (30.0%) patients. Further exchange procedures were required in nine (22.5%) cases, one patient (2.5%) required the use of another fixation modality, to achieve union. Union was ultimately achieved in 35 (94.5%) patients. The median time to union was 9.4 months after the exchange nail procedure. Univariate analysis confirmed that cigarette smoking and infection were predictive of failure (p<0.05). Multi-regression analysis found that Gustilo-Anderson grade, presence of dead bone or a gap and infection were predictive of exchange nail failure (p <0.05). Exchange nailing is an effective treatment for aseptic femoral diaphyseal fracture non-union. Patients with infection required more than one procedure. Smoking, infection and the presence of dead-bone or a gap at the fracture site were associated with an increased risk of further fixation surgery

The aim of this study was to identify risk factors for failure of exchange nailing in tibial diaphyseal fracture non-unions. The cohort comprised 99 tibial diaphyseal fracture non-unions treated by exchange nailing. The mean age of the patients at exchange nail surgery was 36 years. The median time from primary fixation to exchange nailing was 6.4 months. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union. Multiple causes for non-union were found in 31.3% cases, with infection present in 32.3%. Further exchange procedures were required in 35.4%, 7.1% required the use of other fixation modalities. Union was ultimately achieved in 97.8%. The median time to union was 8.7 months. Univariate analysis revealed that cigarette smoking, an atrophic pattern of non-union and infection were predictive for failure of exchange nailing (p<0.05). Multi-regression analysis found that only infection was statistically significantly predictive (p<0.05) of exchange nail failure. Exchange nailing is an effective treatment for tibial diaphyseal non-unions even in the presence of infection. Smoking, atrophic pattern of non-union and infection are associated with an increased risk of further fixation surgery

The treatment of femoral non-union, especially femoral exchanged nailing, has had mixed results in the recent literature. A review of the literature has suggested that exchanged nailing may be the gold standard for the treatment of femoral non-union. Is femoral exchange nailing an acceptable method of treatment of femoral fracture non-union? What is the evidence? In this systematic review we compare four different methods for the treatment of femoral non-union. English speaking literature from 1970 to 2007 was searched using Pubmed. ®. and OVID™ databases and a manual reference search to reveal the original research, presenting the results of the treatment of femoral non-union with exchange nailing, plating, external fixation, and isolated bone grafting. Outcome parameters chosen were union rate and speed of union. The baseline variables chosen were age, number of surgeries, infection and the type of non-union. In total, fifty six case series were identified containing 861 patients treated with exchange nailing (31 studies), 214 patients treated with plating (11 studies), 140 patients treated with external fixation (13 studies), 81 patients treated with bone grafting (4 studies). The average union rate was 89% for exchange nailing, 93% for plating and external fixation and 62% for bone grafting. Speed of union was 7.3 months for exchange nailing, 8.6 months for plating and 9.15 months for external fixation. Study of baseline variables showed patients to be older in plating and external fixation groups (range 32–44 years, P< 0.001). There were more previous operations performed in the external fixation and plating groups (3 and 1.8 vs. 1.2, P< 0.001), significantly more infected non-unions in the plating and external fixation groups as compared to the exchange nailing group (40% vs. 11.5% P< 0.001) and significantly more atrophic non-unions in the plating and external fixation groups as compared to the exchange nailing group (85% vs. 65%, P< 0.001). The literature suggests that femoral exchange nailing has an equivalent or poorer outcomes when compared to external fixation and plating in spite of having been performed in potentially less complex cases. Plating of non-union in the literature has a higher rate of associated bone grafting than femoral exchange nailing which may be responsible for marginally better union rate in the external fixation and plating groups. Isolated bone grafting without revision of fixation does not provide adequate union rate and hence may be of questionable treatment value

Aim: The purpose of this study was to investigate the validity of exchange intramedullary nailing for the treatment of infected tibial non-union. Patients and Methods: Between 1994 and 2001 14 (10 male) patients with tibial fractures were treated in our institution with exchange nailing for infected tibial non-union. The mean age of the patients was 34.3 years (range 18–60) and the mean ISS was 17.5 (range 9–57). Road traffic accidents was the causative mechanism in 10 cases. Seven fractures were originally open (grade IIIb). Initial stabilisation was with intramedullary nailing in 7 cases, external fixator in 3, open reduction internal fixation in 2, Ilizarov frame in 1 and POP in 1. All patients had clinical and radiological evidence of non-union and in each case there was clinical and microbiological evidence of intramedullary infection. All the patients subsequently had an exchange intramedullary nail performed together with debridement and antibiotics. The mean time between original nailing and exchange nailing was 28 weeks. At exchange nailing, the old incisions were reopened and the in situ nail was then removed. Following this, the canal was swabbed and then reamed 1½ mm. more than the diameter of the new nail. The swab and reamings were sent for culture and microscopy. The canal was also irrigated with at least 3 litres of normal saline prior to the insertion of the exchange nail. Antibiotics were then continued for a minimal period of 6 weeks, or longer as the clinical situation warranted. Following discharge from the hospital the patients were seen in the outpatient clinics with regular clinical, haematological and radiographic investigations. The average length of follow-up was 24 months following exchange nailing. Results: There were 7 positive cultures of MRSA, 4 of staph. aureus and in 3 cases multiple bacteria were grown from the samples. No further treatment was required following exchange nailing in 5 (35.7%) cases out of 14. 4 patients required further soft tissue debridement and a free flap to secure union within a week of the exchange nailing procedure. Of the remaining 5 patients, 1 required dynamisation to encourage union; another required incision and drainage of peri-fracture abscess and proceeded to union uneventfully; the third patient needed iliac crest bone grafting which eventually resulted in union. The penultimate patient had numerous operations after the exchange nailing before finally uniting with bone morphogenic protein. Unfortunately the last patient developed overwhelming sepsis which necessitated below knee amputation. Overall, the mean time to union was 11.3 months (4–24). Conclusion: In this series of patients the success rate of exchange nailing for septic tibial pseudarthrosis was 78.5% (11/14). However, some of the patients, especially those originally sustaining open fractures required additional procedures to secure union. We believe that exchange tibial nailing remains an effective method of treatment in the presence of deep bone sepsis

The purpose of this study was to investigate the validity of exchange intramedullary nailing for the treatment of infected tibial non-union. 14 (10 male) patients with tibial fractures were treated in our institution with exchange nailing for infected tibial non-union. The mean age of the patients was 34.3 years (range 18–60) and the mean ISS was 17.5 (range 9–57). Seven fractures were originally open (grade IIIb). All patients had clinical and radiological evidence of non-union and in each case there was clinical and microbiological evidence of intramedullary infection. Following initial stabilisation, all the patients subsequently had an exchange intramedullary nail performed together with debridement and antibiotics. The mean time between original nailing and exchange nailing was 28 weeks. Antibiotics were then continued for a minimal period of 6 weeks, or longer as the clinical situation warranted. The average length of follow-up was 24 months following exchange nailing. There were 7 positive cultures of MRSA, 4 of staph. aureus and in 3 cases multiple bacteria were grown from the samples. No further treatment was required following exchange nailing in 5/14 (35.7%) cases. 4 patients required further soft tissue debridement and a free flap to secure union. Of the remaining 5 patients, 1 required dynamisation, another required incision and drainage of peri-fracture abscess, the third patient needed iliac crest bone grafting which eventually resulted in union. The penultimate patient had numerous operations after the exchange nailing before finally uniting with bone morphogenic protein. Unfortunately the last patient developed overwhelming sepsis which necessitated below knee amputation. Overall, the mean time to union was 11.3 months (4–24). In this series of patients the success rate of exchange nailing for septic tibial pseudarthrosis was 78.5% (11/14). We believe that exchange tibial nailing remains an effective method of treatment in the presence of deep bone sepsis

Introduction. Metabolic bone disease encompasses disorders of bone mineralization, abnormal matrix formation or deposition and alteration in osteoblastic and osteoclastic activity. In the paediatric cohort, patients with metabolic bone disease present with pain, fractures and deformities. The aim was to evaluate the use of lateral entry rigid intramedullary nailing in lower limbs in children and adolescents. Materials and Methods. Retrospective review was performed for an 11-year period. Lower limb rigid intramedullary nailing was performed in 27 patients with a total of 63 segments (57 femora, 6 tibiae). Majority of patients had underlying diagnoses of osteogenesis imperfecta or fibrous dysplasia (including McCune Albright disease). Mean age at surgery was 14 years. Indications for surgery included acute fractures, prophylactic stabilisation, previous nonunion and malunion, deformity correction and lengthening via distraction osteogenesis. Results. All fractures healed. Correction of deformity was successfully achieved in all segments. Delayed union occurred in 4 segments in 1 patient and was successfully treated with nail dynamization. Other complications included prominence, cortical penetrance and loosening of locking screws. One patient who had lengthening performed had nonunion and was managed with exchange nailing and adjunctive measures. Conclusions. Rigid intramedullary nailing is very effective in stabilisation and deformity correction of long bones in adolescent patients with pathological bone disease. The technique has low complication rates. We recommend the use of this technique in paediatric units with experience in managing metabolic bone conditions

Non-union of femoral and tibial shaft fractures is a serious complication, prolonging patient morbidity and ultimately influencing functional recovery. The aim of the study was to assess the effectiveness of different surgical options in the treatment of non-union of femoral shaft fractures after initial intramedullary nailing. Between January 1995 and November 2003, 320 patients with femoral or tibial shaft fractures were treated with closed intramedullary nailing. The mechanism of injury, fracture pattern, concomitant injuries, subsequent surgical treatment and complications were prospectively recorded and retrospective analysis was performed. 16 of the 157 patients (10%) with femoral fractures and 31 of the 161 patients (19%) with tibial fractures developed non-union after initial primary intramedullary nailing. This group of patients had 2–3 further operations before union was established. 26 patients had initial dynamisation and 11 had exchange nailing alone. The remaining patients had autologous bone grafting and/or internal fixation with a plate. Subsequently a further 3 patients required dynamisation, 2 required exchange nailing and another 3 bone grafting. Finally 2 patients required a fourth procedure to reach solid union. Our experience showed that exchange nailing and dynamisation are the most effective method of treatment of non-union of femoral and tibial shaft fractures after intramedullary nailing

Percutaneous grafting of non-union using bone marrow concentrates has shown promising results, we present our experience and outcomes following the use of microdrilling and marrowstim in long bone non-unions. We retrospectively reviewed all patients undergoing a marrowstim procedure for non-union in 2011–12. Casenotes and radiographs were reviewed for all. Details of injury, previous surgery and non-union interventions together with additional procedures performed after marrowstim were recorded for all patients. The time to clinical and radiological union were noted. We identified 32 patients, in sixteen the tibia was involved in 15 the femur and in one the humerus. Ten of the 32 had undergone intervention for non-union prior to marrowstim including 4 exchange nailings, 2 nail dynamisations, 3 caption graftings, 2 compression in circular frame and 1 revision of internal fixation. Three underwent adjunctive procedures at the time of marroswstim. In 18 further procedures were required following marrowstim. In 4 this involved frame adjustment, 5 underwent exchange nailing, 4 revision internal fixation, 2 additional marrowstim, 2 autologous bone grafting and 3 a course of exogen treatment. In total 27 achieved radiological and clinical union at a mean of 9.6 months, of these ten achieved union without requiring additional intervention following marrowstim, at a mean of 5.4 months. There were no complications relating to marrowstim harvest or application. Marrowstim appears to be a safe and relatively cheap addition to the armamentarium for treatment of non-union. However many patients require further procedures in addition to marrowstim to achieve union. Furthermore given the range of procedures this cohort of patients have undergone before and after marrowstim intervention it is difficult to draw conclusions regarding it efficacy

Ankle fractures represent the third most common fragility fracture seen in elderly patients following hip and distal radius fractures. Non-operative management of these see complication rates as high as 70%. Open reduction and internal fixation (ORIF) has complication rates of up to 40%. With either option, patients tend to be managed with a non-weight bearing period of six weeks or longer. An alternative is the use of a tibiotalocalcaneal (TTC) nail. This provides a percutaneous treatment that enables the patient to mobilise immediately. This case-series explores the efficacy of this device in a broad population, including the highly comorbid and cognitively impaired. We reviewed patients treated with TTC nail for acute ankle fractures between 2019 and 2022. Baseline and surgical data were collected. Clinical records were reviewed to record any post-operative complication, and post-operative mobility status and domicile. 24 patients had their ankle fracture managed with TTC nailing. No intra-operative complications were noted. There were six (27%) post-operative complications; four patients had loosening of a distal locking screw, one significant wound infection necessitating exchange of nail, and one pressure area from an underlying displaced fracture fragment. All except three patients returned to their previous domicile. Just over two thirds of patients returned to their baseline level of mobility. This case-series is one of the largest and is also one of the first to include cognitively impaired patients. Our results are consistent with other case-series with a favourable complication rate when compared with ORIF in similar patient groups. The use of a TTC nail in the context of acute, geriatric ankle trauma is a simple and effective treatment modality. This series shows acceptable complication rates and the majority of patients are able to return to their baseline level of mobility and domicile

Aims: The purpose of this presentation is to report our protocol for staged exchange nailing of delayed-unions and non-unions of the tibia complicated by multifocal osteomyelitis from infected pin tracts. Methods: Twenty-four patients with delayed or non-union of the tibia initially treated by external þxation were retrospectively reviewed. Fifteen males and 9 females with an average age of 40 years (range 20–74) and at least 1 year of follow up (range 1–7). External þxation was maintained until the soft tissues healed. External þxation time averaged 116 days (range 28–288). Multiple gross pin tract infection developed in all the casesl. Non-unions and delayed-unions were treated by exchange reamed intramedullary nailing. The exchange protocol consisted in the removal of the external þxator, debridement and culture of bone from the pin sites, cast immobilization, speciþc IV antibiotics for 6 weeks, and a negative post-antibiotics biopsy. Outcome measurements included recurrence of infection and healing of the delayed union or non-union. Results: Twenty-three of the fractures healed at the þrst nailing attempt on an average time of 4 months (range 2–7). One case required re-nailing at 4 months and þnally healed at 6 months from the initial procedure. No recurrence of deep infection was identiþed. Two patients developed superþcial infections, suppressive antibiotics were used until complete bone healing and subsequent nail removal. Discussion: By using our staged protocol we were able to perform exchange nailing for non-unions and delayed unions of the tibia complicated by multiple foci osteomyelitis from infected pin tracts with a considerable rate of success

Introduction. The management of a significant bone defect following excision of a diaphyseal atrophic femoral non-union remains a challenge. Traditional bone transport techniques require prolonged use of an external fixator with associated complications. We present our clinical outcomes using a combined technique of acute femoral shortening, stabilised with a deliberately long retrograde intramedullary nail, accompanied by bifocal osteotomy compression and distraction osteogenesis to restore segment length utilising a temporary monolateral fixator. Method. 9 patients underwent the ‘rail and nail’ technique for the management of femoral non-union. Distraction osteogenesis was commenced on the 6. th. post-operative day. Proximal locking of the nail and removal of the external fixator was performed approximately one month after length had been restored. Full weight bearing and joint rehabilitation was encouraged throughout. Consolidation was defined by the appearance of 3 from 4 cortices of regenerate on radiographs. Results. 7 males and 2 females of adult age underwent treatment between 2009 and 2016. The mean lengthening was 6.6cm (3–10cm). The external fixator was removed at a mean 123 days (57–220), with an external fixation index of 20 days/cm. The regenerate healing index was 28 days/cm. There were no deep infections. Significant complications were seen in 4 patients including knee stiffness, a foot drop, delayed union of the non-union osteotomy (requiring exchange nailing and bone grafting) and revision nailing due to a prominent proximal tip. Conclusion. The combined over-sized intramedullary nail and external fixator enables compression of the femoral osteotomy, alignment of the bone and controlled lengthening. Once the length has been restored, removal of the external fixator and proximal locking of the nail reduces the risk of complications associated with the fixator and stabilises the femur with the maximum working length of the nail. This small retrospective study demonstrates encouraging results for this complex clinical scenario

Background:. Closed femoral shortening (CFS) is a recognised procedure for managing leg length discrepancy (LLD). Method:. We report twenty-nine consecutive patients with LLD who underwent CFS using an intramedullary saw and nail. Mean age was 29.2 years (16.1–65.8). The primary outcome was accuracy of correction. Secondary outcomes were complications, union, ASAMI score and re-operation, alongside Patient Reported Outcome Measures (PROMs), using EQ5D-5L and GROC. Results:. Mean pre-operative limb length discrepancy was 3.4 cm (1.5–6.5). Mean planned and achieved shortening was 2.9 cm (1.7–5.0). Mean follow-up was 2.0 years (0.2–8.4). Minimal access surgery was possible in all cases but careful technique is essential. All patients achieved a correction within 5mm of the planned shortening (range 0–5mm). 28 patients (97%) achieved uncomplicated union. One patient had a non-union requiring exchange nailing and subsequent compression plating. 13 patients had nail removal at a mean of 1.7 years and 3 had locking screw removal. Patients had an overall positive experience with 81% reporting high PROM scores. Discussion:. This technique offered accurate limb length correction with few complications. Patients rehabilitated well with good functional outcomes. Conclusion;. CFS with an intramedullary saw is a well-tolerated and effective technique when managing LLD up to 5cm

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

Femoral fracture non-unions are considered to be rare, and are usually treated successfully with exchange nailing. However, recalcitrant aseptic cases often require additional bone grafting. The efficacy of BMP-7 in the treatment of recalcitrant aseptic femoral non-unions was studied. Since 2003 a multicenter registry (bmpusergroup.co.uk) was created collecting details of BMP7 application in general, between different university hospitals across Europe. Demographic data, intraoperative details, complications, clinical outcome parameters, radiological healing, VAS pain score, EuroQol-5D, and return-to-work were prospectively recorded. Radiological healing was defined as the presence of callous in two planes over 3 cortices. The minimum follow up was 12 months. Seventeen patients, who had undergone a median of 1(1 to 4) prior revision operations, over a median period from the injury of 17 months(9 to 42), were included in this observational study. In 76.4%(13/17) the BMP7 was combined with revision of the fixation. Non-union healing was verified in 14/17 cases(82.3%) in a median period of 6.5 months(3–15). Over 80% of these patients returned to their pre-injury level of activities, the median overall health state score was 82.5(35 to 100). No adverse events or complications were associated with the BMP7 application over the median follow-up of 24 months(12–68)

We present a series of 11 patients with infected tibial intramedullary nails which were treated at our tertiary referral centre from January 2000 to November 2009. All of them were males and the mean age was 36 years (26 to 47 years). All the patients had sustained post traumatic fractures which were treated with intramedullary nail. Four patients (36%) had sustained open fractures in whom adequate soft tissue cover was provided by plastic surgeons. Five of them (45%) were smokers. All of them underwent surgical debridement. Nine out of 11 patients had removal of metal work followed by one or more of the following procedures such as reaming, exchange nailing, excision of sequestrum, application of antibiotic beads and stabilisation with a frame with or without several bone grafts at a later date. Out of 11 patients six (55%) had no further episodes of infection, three (27%) still need short courses of antibiotics when the disease flares up and two (18%) underwent amputation. Causative organisms were isolated in all the patients. Commonest organism was MRSA. Overall, most of the organisms were sensitive to Vancomycin and resistant to Penicillin. Despite exploring most of the surgical procedures described for infected tibial intramedullary nails we have potentially eradicated infection only in about half of our patients. Hence we would like to emphasise that this condition still remains a serious problem and demands further insight in its management

This study addresses the evolution of the orthopaedic management of patients with hypophosphatemic rickets, with the aim of providing skeletal mature aligned lower limbs, with minimal surgical insult. Methods. We describe a case series of 8 patients with hypophosphatemic rickets that highlight an evolution in practice over the last 8 years. Our initial treatment involved external fixation with circular frames, addressing both axial deformity and length. Two contralateral long bones were addressed simultaneously and surgery was conducted in early adolescence. Problems encountered were poor quality regenerate, requiring prolonged periods in external fixation, and often recurrence of deformity following frame removal. Minor deformity recurrence made planning for the often inevitable knee replacement difficulty. Our current management is that patients only start surgical correction once skeletal maturity has been reached, two contralateral axial long bone corrections are performed using CHAOS (computer hexapod-assisted orthopaedic surgery) procedures with IM nails and multiple osteotomies (occasionally locking plates are required). Patients are able to fully weight bear immediately post operatively, after a suitable recovery period the remaining bones can be corrected. Then lengthening can be considered once the osteotomies have fully consolidated by exchange nailing of the femur, for an IM lengthening nail. At this stage the patient is able to fully consider the risks and benefits of this final and potentially unnecessary procedure. Conclusions. Hypophosphotaemic rickets is a rare condition, both the disease and its management can have severe effects on patients both physically and psychologically, at Bristol we have developed an treatment pathway that we feel helps to minimize the physical and psychological effects of treatment, with the end result of aligned lower limbs, that should provide a good basis for arthroplasty surgery if required in adulthood

Purpose: Femoral fracture non-unions are considered to be rare, and are usually treated successfully with exchange nailing. However, recalcitrant aseptic cases often require additional bone grafting procedures. The purpose of this study was to investigate the efficacy of BMP-7 (biological enhancement) in the treatment of recalcitrant aseptic femoral non-unions. Material & Methods: Since 2003 a multicenter registry (bmpusergroup.co.uk) was created to collect details of BMP7 application in general, between different university hospitals across Europe. Demographic data, intraoperative details, complications, clinical outcome parameters, radiological healing, VAS pain score, EuroQol-5D, and return-to-work were prospectively recorded. Radiological healing was defined as the presence of callous in two planes over 3 cortices. The minimum follow up was 12 months. Results: Thirty patients, who had undergone a median of 1 (1 to 5) prior revision operations, over a median period from the injury of 24 months (9 to 65), were included in this observational study. In 76.7% (23/30) the application of BMP7 was combined with a revision of the fixation. Non-union was verified in 26/30 cases (86.7%) in a median period of 6 months (range 4–10). Over 70% of these patients returned to their preinjury level of activities, the median overall health state score was 82.5 (45 to 95). No adverse events or complications were associated with the BMP7 application over the median follow-up of 30 months (12–68). Discussion/Conclusion: This case series has verified the safety and efficacy of the use of BMP7 in a manner comparable to the scarce existing evidence on femoral non-unions. The establishment of multicenter networks and the systematic and long-term follow-up of these patients are expected to provide further information and significantly improve our understanding on this promising osteoinductive bone substitute

To determine the outcome of subtrochanteric fractures treated by intramedullary (IM) nailing and identify causes for implant failure. We performed a retrospective analysis of all subtrochanteric fractures treated by intramedullary nailing in Belfast trauma units between February 2006 and 2009. This subgroup of patients was identified using the Fractures Outcome Research Database (FORD). Demographic data, implant type, operative details, duration of surgery and level of operator were collected and presented. Post-operative X-rays were assessed for accuracy of reduction. One hundred and twenty two (122) patients were identified as having a subtrochanteric fracture treated by IM nailing. There were 79 females and 43 males. Age range was 16 to 93 (mean 78). 95 (78%) cases were performed by training grades and 27 (22%) by consultants. Duration of surgery ranged from 73–129mins (mean 87mins). 47 patients (38.5%) were found to have a suboptimal reduction and 75 patients (61.5%) had an anatomical reduction on immediate post-operative x-ray. One year from surgery 73/122 patients were available for follow up. Of those patients with suboptimal reduction, 13/47 (27.7%) required further surgery. 8 required complete revision with bone grafting, and 5 underwent dynamisation. A further 6 patients had incomplete union. In the anatomical group, 4 patients underwent further surgery (5%). 3 required dynamisation and one had exchange nailing for an infected non-union. 3 patients had incomplete union at last follow up. 5/47 (10.6%) had open reduction in the suboptimal group compared to 25/75 (33.3%) in the anatomical group. Of the 27 cases performed by consultants, 13 (48%) were open reduction, compared to 17/93 (18%) by training grades. This study has shown that inadequate reduction of subtrochanteric fractures, leads to increased rates of non union and ultimately implant failure. We recommend a low threshold for performing open reduction to ensure anatomical reduction is achieved in all cases