Objectives. The purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method. Methods. In this matched case study, 16 adult patients underwent 19 tibial lengthening over nails (LON) procedures. For the matched case group, 17 patients who underwent 19 Ilizarov tibial lengthenings were retrospectively matched to the LON group. Results. The mean external fixation time for the LON group was 2.6 months and for the matched case group was 7.6 months. The mean lengthening amounts for the LON and the matched case groups were 5.2 cm and 4.9 cm, respectively. The radiographic consolidation time in the LON group was 6.6 months and in the matched case group 7.6 months. Using a clinical and radiographic outcome score that was designed for this study, the outcome was determined to be excellent in 17 and good in two patients for the LON group. The outcome was excellent in 14 and good in five patients in the matched case group. The LON group had increased blood loss and increased cost. The LON group had four deep infections; the matched case group did not have any deep infections. Conclusions. The outcomes in the LON group were comparable with the outcomes in the matched case group. The LON group had a shorter external fixation time but experienced increased blood loss, increased cost, and four cases of deep infection. The advantage of reducing external fixation treatment time may outweigh these disadvantages in patients who have a healthy soft-tissue envelope. Cite this article: J. E. Herzenberg. Tibial lengthening over intramedullary nails: A matched case comparison with Ilizarov tibial lengthening. Bone Joint Res 2016;5:1–10. doi: 10.1302/2046-3758.51.2000577

Aims. Due to their radiolucency and favourable mechanical properties, carbon fibre nails may be a preferable alternative to titanium nails for oncology patients. We aim to compare the surgical characteristics and short-term results of patients who underwent intramedullary fixation with either a titanium or carbon fibre nail for pathological long-bone fracture. Methods. This single tertiary-institutional, retrospectively matched case-control study included 72 patients who underwent prophylactic or therapeutic fixation for pathological fracture of the humerus, femur, or tibia with either a titanium (control group, n = 36) or carbon fibre (case group, n = 36) intramedullary nail between 2016 to 2020. Patients were excluded if intramedullary fixation was combined with any other surgical procedure/fixation method. Outcomes included operating time, blood loss, fluoroscopic time, and complications. Fisher’s exact test and Mann-Whitney U test were used for categorical and continuous outcomes, respectively. Results. Patients receiving carbon nails as compared to those receiving titanium nails had higher blood loss (median 150 ml (interquartile range (IQR) 100 to 250) vs 100 ml (IQR 50 to 150); p = 0.042) and longer fluoroscopic time (median 150 seconds (IQR 114 to 182) vs 94 seconds (IQR 58 to 124); p = 0.001). Implant complications occurred in seven patients (19%) in the titanium group versus one patient (3%) in the carbon fibre group (p = 0.055). There were no notable differences between groups with regard to operating time, surgical wound infection, or survival. Conclusion. This pilot study demonstrates a non-inferior surgical and short-term clinical profile supporting further consideration of carbon fibre nails for pathological fracture fixation in orthopaedic oncology patients. Given enhanced accommodation of imaging methods important for oncological surveillance and radiation therapy planning, as well as high tolerances to fatigue stress, carbon fibre implants possess important oncological advantages over titanium implants that merit further prospective investigation. Level of evidence: III, Retrospective study. Cite this article: Bone Jt Open 2022;3(8):648–655

Introduction. IM (Intra Medullary) nail fixation is the standard treatment for diaphyseal femur fractures and also for certain types of proximal and distal femur fractures. Despite the advances in the tribology for the same, cases of failed IM nail fixation continue to be encountered routinely in clinical practice. Common causes are poor alignment or reduction, insufficient fixation and eventual implant fatigue and failure. This study was devised to study such patients presenting to our practice and develop a predictive model for eventual failure. Materials and Methods. 57 patients who presented with failure of IM nail fixation (± infection) between Jan 2011 – Jun 2020 were included in the study and hospital records and imaging reviewed. Those fixed with any other kinds of metalwork were excluded. Classification for failure of IM nails – Type 1: Failure with loss of contact of lag screw threads in the head due to backing out and then rotational instability, Type 2A: Failure of the nail at the nail and lag screw junction, Type 2B: Failure of the screws at the nail lag screw junction, Type 3: Loosening at the distal locking sites with or without infection. X-rays reviewed and causes/site of failure noted. Results. Total patients - 57. Demography - Average age - 58.9 years, 22 Males and 35 females. Eleven patients were noted to have an infection at the fracture site that needed oral or IV antibiotics.16 patients - at least 1 cerclage wire for fracture reduction and fixation + IM Nail. Subtrochanteric fractures (42/57) were the most common to fail. In those fractures with postero-medial comminution, locking of the lag screw in position thus preventing backout can prevent failure. In type 2 failures, preventing varus fixation by early open reduction and temporary fixation with plates and screws can achieve improved results. Those with type 3 failures with periosteal reaction should be considered to be infected until proven otherwise. Conclusions. This classification for failure of IM nails in the femur can be used as a predictive model for failures and allow early recognition and intervention to tackle them

Freehand distal interlocking of intramedullary nails is technical demanding and prone to handling issues. It requires the surgeon to precisely place a screw through the nail under x-ray. If not performed accurately it can be a time consuming and radiation expensive procedure. The aims of this study were to assess construct and face validity of a new training device for distal interlocking of intramedullary nails. 53 participants (29 novices and 24 experts) were included. Construct validity was evaluated by comparing simulator metrics (number of x-rays, nail hole roundness, drill tip position and accuracy of the drilled hole) between experts and novices. Face validity was evaluated by means of a questionnaire concerning training potential and quality of simulated reality using a 7-point Likert scale (range 1-7). Mean realism of the training device was rated 6.3 (range 4-7) and mean training potential as well as need for distal interlocking training was rated 6.5 (range 5-7) with no significant differences between experts and novices, p≥0.236. All participants stated that the simulator is useful for procedural training of distal nail interlocking, 96% would like to have it at their institution and 98% would recommend it to their colleagues. Total number of x-rays were significantly higher for novices (20.9±6.4 vs. 15.5±5.3), p=0.003. Successful task completion (hit the virtual nail hole with the drill) was significantly higher in experts (p=0.04; novices hit: n=12; 44,4%; experts hit: n=19; 83%). The evaluated training device for distal interlocking of intramedullary nails yielded high scores in terms of training capability and realism. Furthermore, construct validity was established as it reliably discriminates between experts and novices. Participants see a high further training potential as the system may be easily adapted to other surgical task requiring screw or pin position with the help of x-rays

Aims. To report the outcomes of patients with a fracture of the distal tibia who were treated with intramedullary nail versus locking plate in the five years after participating in the Fixation of Distal Tibia fracture (FixDT) trial. Methods. The FixDT trial reported the results for 321 patients randomized to nail or locking plate fixation in the first 12 months after their injury. In this follow-up study, we report the results of 170 of the original participants who agreed to be followed up until five years. Participants reported their Disability Rating Index (DRI) and health-related quality of life (EuroQol five-dimension three-level questionnaire) annually by self-reported questionnaire. Further surgical interventions related to the fracture were also recorded. Results. There was no evidence of a difference in patient-reported disability, health-related quality of life, or the need for further surgery between participants treated with either type of fixation at five years. Considering the combined results for all participants, there was no significant change in DRI scores after the first 12 months of follow-up (difference between 12 and 24 months, 3.3 (95% confidence interval -1.8 to 8.5); p = 0.203), with patients reporting around 20% disability at five years. Conclusion. This study shows that the moderate levels of disability and reduced quality of life reported by participants 12 months after a fracture of the distal tibia persist in the medium term, with little evidence of improvement after the first year. Cite this article: Bone Joint J 2023;105-B(7):795–800

Aims. The primary aim of this study was to identify independent predictors associated with nonunion and delayed union of tibial diaphyseal fractures treated with intramedullary nailing. The secondary aim was to assess the Radiological Union Scale for Tibial fractures (RUST) score as an early predictor of tibial fracture nonunion. Methods. A consecutive series of 647 patients who underwent intramedullary nailing for tibial diaphyseal fractures were identified from a trauma database. Demographic data, comorbidities, smoking status, alcohol consumption, use of non-steroidal anti-inflammatory drugs (NSAIDs), and steroid use were documented. Details regarding mechanism of injury, fracture classification, complications, and further surgery were recorded. Nonunion was defined as the requirement for revision surgery to achieve union. Delayed union was defined as a RUST score < 10 at six months postoperatively. Results. There were 41 nonunions (6.3%), of which 13 were infected (31.7%), and 77 delayed unions (11.9%). There were 127 open fractures (19.6%). Adjusting for confounding variables, NSAID use (odds ratio (OR) 3.50; p = 0.042), superficial infection (OR 3.00; p = 0.026), open fractures (OR 5.44; p < 0.001), and high-energy mechanism (OR 2.51; p = 0.040) were independently associated with nonunion. Smoking (OR 1.76; p = 0.034), open fracture (OR 2.82; p = 0.001), and high-energy mechanism (OR 1.81; p = 0.030) were independent predictors associated with delayed union. The RUST score at six-week follow-up was highly predictive of nonunion (sensitivity and specificity of 75%). Conclusion. NSAID use, high-energy mechanisms, open fractures, and superficial infection were independently associated with nonunion in patients with tibial diaphyseal fractures treated with intramedullary nailing. The six-week RUST score may be useful in identifying patients at risk of nonunion. Cite this article: Bone Jt Open 2021;2(4):227–235

Aim. The treatment of fracture-related infections (FRI) focuses on obtaining fracture healing and eradicating infection to prevent osteomyelitis. Treatment guidelines include removal, exchange, or retention of the implants used according to the stability of the fracture and the time from the infection. Infection of a fracture in the process of healing with a stable fixation may be treated with implant retention, debridement, and antibiotics. Nonetheless, the retention of an intramedullary nail is a potential risk factor for failure, and it is recommended to exchange or remove the nail. This surgical approach implies additional life-threatening risks in elderly fragile hip fracture patients. Our study aimed to analyze the results of implant retention for the treatment of infected nails in elderly hip fracture patients. Methods. Our retrospective analysis included patients 65 years of age or older with an acute fracture-related infection treated with implant retention from 2012 to 2020 in 6 Spanish hospitals with a minimum 1-year follow-up. Patients that required open reduction during the initial fracture surgery were excluded. Variables included in our analysis were patient demographics, type of fracture, date of FRI diagnosis, causative microorganism, and outcome. Treatment success was defined as fracture healing with infection eradication without the need for further hospitalization. Results. A total of 48 patients were identified. Eight patients with open reduction were excluded and 11 did not complete a 1-year follow-up. Out of the 29 remaining patients, the mean age was 81.5 years, with a 21:9, female to male ratio. FRI was diagnosed between 10 and 48 days after initial surgery (mean 26 days). Treatment success was achieved in 24 patients (82.7%). Failure was objectivated in polymicrobial infections or infections caused by microorganisms resistant to antibiofilm antibiotics. Seven patients required more than one debridement with a success rate of 57%. Twelve patients had an infection diagnosed after 21 days from the initial surgery and implant retention was successful in all of them. Conclusion. Our results suggest implant retention is a valid therapeutic approach for fracture-related infection in elderly hip fracture patients treated by closed reduction and intramedullary nailing

Many pre-clinical models of atrophic non-union do not reflect the clinical scenario, some create a critical size defect, or involve cauterization of the tissue which is uncommonly seen in patients. Atrophic non-union is usually developed following high energy trauma leading to periosteal stripping. The most recent reliable model with these aspects involves creating a non-critical gap of 1mm with periosteal and endosteal stripping. However, this method uses an external fixator for fracture fixation, whereas intramedullary nailing is the standard fixation device for long bone fractures. OBJECTIVES. To establish a clinically relevant model of atrophic non-union using intramedullary nail and (1) ex vivo and in vivo validation and characterization of this model, (2) establishing a standardized method for leg positioning for a reliable x-ray imaging. Ex vivo evaluation: 40 rat's cadavers (adult male 5–6 months old), were divided into five groups (n=8 in each): the first group was fixed with 20G intramedullary nail, the second group with 18G nail, the third group with 4-hole plate, the fourth group with 6-hole plate, and the fifth group with an external fixator. Tibiae were harvested by leg disarticulation from the knee and ankle joints. Each group was then subdivided into two subgroups for mechanical testing: one for axial loading (n=4) and one for 4-point bending (n=4) using Zwick/Roell® machine. Statistical analysis was carried out by ANOVA with a fisher post-hoc comparison between groups. A p-value less than 0.05 was considered statistically significant. To maintain the non-critical gap, a spacer was inserted in the gap, the design was refined to minimize the effect on the healing surface area. In vivo evaluation was done to validate and characterize the model. Here, a 1 mm gap was created with periosteal and endosteal stripping to induce non-union. The fracture was then fixed by a hypodermic needle. A proper x-ray technique must show fibula in both views. Therefore, a leg holder was used to hold the knee and ankle joints in 90º flexion and the foot was placed in a perpendicular direction with the x-ray film. Lateral view was taken with the foot parallel to the x-ray film. Ex vivo: axial load stiffness data revealed that intramedullary nails are significantly stronger and stiffer than other devices. Bending load to failure showed that 18G nails are significantly stronger than 20G, thus it is used for the in vivo experiments. In vivo: final iteration revealed 3/3 non-union, and in controls with the periosteum and endosteum intact but with the 1mm non-critical gap, it progressed to 3/3 union. X-ray positioning: A-P view in supine position, there was an unavoidable degree of external rotation in the lower limb, thus the lower part of the fibula appeared behind the tibia. To overcome this, a P-A view of the leg was performed with the body in prone rather, this arrangement allowed both upper and lower parts of the fibula to appear clearly in both views. We report a novel model of atrophic non-union, the surgical procedure is relatively simple and the model is reproducible

Aims. Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail. Methods. A retrospective study was conducted on 112 patients treated for intertrochanteric femur fracture with a double proximal screw nail (Endovis BA2; EBA2) from January to September 2021. The analyzed variables were age, sex, BMI, comorbidities, fracture type, side, time of surgery, quality of reduction, pre-existing therapy with bisphosphonate for osteoporosis, screw placement in two different views, and TAD. The last follow-up was at 12 months. Logistic regression was used to study the potential factors of screw cut-out, and receiver operating characteristic curve to identify the threshold value. Results. A total of 98 of the 112 patients met the inclusion criteria. Overall, 65 patients were female (66.3%), the mean age was 83.23 years (SD 7.07), and the mean follow-up was 378 days (SD 36). Cut-out was observed in five patients (5.10%). The variables identified by univariate analysis with p < 0.05 were included in the multivariate logistic regression model were screw placement and TAD. The TAD was significant with an odds ratio (OR) 5.03 (p = 0.012) as the screw placement with an OR 4.35 (p = 0.043) in the anteroposterior view, and OR 10.61 (p = 0.037) in the lateral view. The TAD threshold value identified was 29.50 mm. Conclusion. Our study confirmed the risk factors for cut-out in the double-screw nail are comparable to those in the single screw. We found a TAD value of 29.50 mm to be associated with a risk of cut-out in double-screw nails, when good fracture reduction is granted. This value is higher than the one reported with single-screw nails. Therefore, we suggest the role of TAD should be reconsidered in well-reduced fractures treated with double-screw intramedullary nail. Cite this article: Bone Jt Open 2024;5(6):457–463

Unstable distal tibia fractures are challenging injuries requiring surgical treatment. Intramedullary nails are frequently used; however, distal fragment fixation problems may arise, leading to delayed healing, malunion or nonunion. Recently, a novel angle-stable locking nail design has been developed that maintains the principle of relative construct stability, but introduces improvements expected to reduce nail toggling, screw migration and secondary loss of reduction, without the requirement for additional intraoperative procedures. The aim of this study was to investigate the biomechanical competence of a novel angle-stable intramedullary nail concept for treatment of unstable distal tibia fractures, compared to a conventional nail in a human cadaveric model under dynamic loading. Ten pairs of fresh-frozen human cadaveric tibiae with a simulated AO/OTA 42-A3.1 fracture were assigned to 2 groups for reamed intramedullary nailing using either a conventional (non-angle-stable) Expert Tibia Nail with 3 distal screws (Group 1) or the novel Tibia Nail Advanced system with 2 distal angle-stable locking low-profile screws (Group 2). The specimens were biomechanically tested under conditions including quasi-static and progressively increasing combined cyclic axial and torsional loading in internal rotation until failure of the bone-implant construct, with monitoring by means of motion tracking. Initial axial construct stiffness, although being higher in Group 2, did not significantly differ between the 2 nail systems, p=0.29. In contrast, initial torsional construct stiffness was significantly higher in Group 2 compared to Group 1, p=0.04. Initial nail toggling of the distal tibia fragment in varus and flexion was lower in Group 2 compared to Group 1, being significant in flexion, p=0.91 and p=0.03, respectively. After 5000 cycles, interfragmentary movements in terms of varus, flexion, internal rotation, axial displacement and shear displacement at the fracture site were all lower in Group 2 compared to Group 1, with flexion and shear displacement being significant, p=0.14, p=0.04, p=0.25, p=0.11 and p=0.04, respectively. Cycles to failure until both interfragmentary 5° varus and 5° flexion were significantly higher in Group 2 compared to Group 1, p=0.04. From a biomechanical perspective, the novel angle-stable intramedullary nail concept has the potential of achieving a higher initial axial and torsional relative stability and maintaining it with a better resistance towards loss of reduction under dynamic loading, while reducing the number of distal locking screws, compared to conventional locking in intramedullary nailed unstable distal tibia fractures

Freehand distal interlocking of intramedullary nails remains a challenging task. If not performed correctly it can be a time consuming and radiation expensive procedure. Recently, the AO Research Institute developed a new training device for Digitally Enhanced Hands-on Surgical Training (DEHST) that features practical skills training augmented with digital technologies, potentially improving surgical skills needed for distal interlocking. Aim of the study: To evaluate weather training with DEHST enhances the performance of novices without surgical experience in free-hand distal nail interlocking compared to a non-trained group of novices. 20 novices were assigned in two groups and performed distal interlocking of a tibia nail in an artificial bone model. Group 1: DEHST trained novices (virtual locking of five nail holes during one hour of training). Group 2: untrained novices without DEHST training. Time, number of x-rays, nail hole roundness, critical events and success rates were compared between the groups. Time to complete the task (sec.) and x-ray exposure (µGcm2) were significantly lower in Group1 414.7 (290–615) and 17.8 (9.8–26.4) compared to Group2 623.4 (339–1215) and 32.6 (16.1–55.3); p=0.041 and 0.003. Perfect circle roundness (%) was 95.0 (91.1–98.0) in Group 1 and 80.8 (70.1–88.9) in Group 2; p<0.001. In Group 1 90% of the participants achieved successful completion of the task (hit the nail with the drill), whereas only 60% of the participants in group 2 achieved this; p=0.121. Training with DEHST significantly enhances the performance of novices without surgical experience in distal interlocking of intramedullary nails. Besides radiation exposure and operation time the com-plication rate during the operation can be significantly reduced

Aims. Using tibial shaft fracture participants from a large, multicentre randomized controlled trial, we investigated if patient and surgical factors were associated with health-related quality of life (HRQoL) at one year post-surgery. Methods. The Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) trial examined adults with an open or closed tibial shaft fracture who were treated with either reamed or unreamed intramedullary nails. HRQoL was assessed at hospital discharge (for pre-injury level) and at 12 months post-fracture using the Short Musculoskeletal Functional Assessment (SMFA) Dysfunction, SMFA Bother, 36-Item Short Form 36 (SF-36) Physical, and SF-36 Mental Component scores. We used multiple linear regression analysis to determine if baseline and surgical factors, as well as post-intervention procedures within one year of fracture, were associated with these HRQoL outcomes. Significance was set at p < 0.01. We hypothesize that, irrespective of the four measures used, prognosis is guided by both modifiable and non-modifiable factors and that patients do not return to their pre-injury level of function, nor HRQoL. Results. For patient and surgical factors, only pre-injury quality of life and isolated fracture showed a statistical effect on all four HRQoL outcomes, while high-energy injury mechanism, smoking, and race or ethnicity, demonstrated statistical significance for three of the four HRQoL outcomes. Patients who did not require reoperation in response to infection, the need for bone grafts, and/or the need for implant exchanges had statistically superior HRQoL outcomes than those who did require intervention within one year after initial tibial fracture nailing. Conclusion. We identified several baseline patient factors, surgical factors, and post-intervention procedures within one year after intramedullary nailing of a tibial shaft fracture that may influence a patient’s HRQoL. Cite this article: Bone Jt Open 2021;2(1):22–32

Introduction. Femoral-shortening osteotomy for the treatment of leg length discrepancy is demanding technique. Many surgical technique and orthopaedic devises have been suggested to perform this procedure. Herein, we describe modified femoral shortening osteotomy over a nail, using a percutaneous multiple drill-hole osteotomy technique. Materials and Methods. We operated on six patients with LLD. Mean femoral shortening was 4.2 cm. Osteotomy was performed using a multiple drill-hole technique, and bone was stabilized using an intramedullary nail. Post-operative clinical and radiological data were reported. Results. Shortening was achieved, with a final LLD of < 1 cm in all patients. All patients considered the lengths of the lower limbs to be equal. No special surgical skills or instrumentation were needed. Intraoperative and post-operative complications were not recorded. Conclusions. Percutaneous femoral-shortening osteotomy over a nail using multiple drill-hole osteotomy technique was effective and safe in treating LLD

The fixation of comminuted femoral fractures with intramedullary nails is commonplace but there remains little work on the mechanical ability of the different diameters of nail available to resist bending. What previous work there is has produced conflicting conclusions. The bending stiffness against the intramedullary nail diameter and the extent of the comminuted fracture is clinically important due to the impact on fracture healing and implant failure. Intramedullary nails of differing diameters (10 mm, 11 mm and 13 mm) were loaded axially in fourth generation composite femurs with increasing mid shaft bone defects, namely 3cm, 5cm, 8cm and 10cm bones. The loading versus the displacement was recorded for each nail. A one-way ANOVA analysis demonstrated a significant difference between intramedullary nail diameters and the bending stiffness, with p values of less than 0.012; 3cm mean 12.26 (CI 9.06-15.46) mm, p=0.012; 5 cm mean 10.63 (CI 8.35-12.92) mm, p=<0.001; 8 cm mean 11.04 (CI 8.35-13.74) mm, p=<0.001; 10 cm mean 11.68 (CI 7.86-15.50) mm, p=<0.001. For the 11 mm diameter intramedullary nail, failure occurred at around two times the body weight of an average individual or 1400 to 1800 N. A repeated measure ANOVA analysis of the effect of the increasing bone defect showed a mixed picture, with a significant difference between the 5 cm and 8 cm gap and only a trend towards significance between 5 cm and 10 cm. Caution should be advised when considering using a cannulated femoral intramedullary nail in a patient with a fracture gap of greater than 5 cm. Further, the mechanical effect of comminuted fractures treated with nails suggests reduced stiffness with increasing length of fracture gap although the picture is complex and explains the divergence of research conclusions

There is a growing trend towards using pre-clinical models of atrophic non-union. This study investigated different fixation devices, by comparing the mechanical stability at the fracture site of tibia bone fixed by either intramedullary nail, compression plate or external fixator. 40 tibias from adult male Wistar rats' cadavers were osteotomised at the mid-shaft and a gap of 1 mm was created and maintained at the fracture site to simulate criteria of atrophic non-union model. These were divided into five groups (n=8 in each): the first group was fixed with 20G intramedullary nail, the second group with 18G nail, the third group with 4-hole plate, the fourth group with 6-hole plate, and the fifth group with external fixator. Tibia was harvested by leg disarticulation from the knee and ankle joints, the soft tissues were carefully removed from the leg, and tibias were kept hydrated throughout the experiment. Each group was then subdivided into two subgroups for mechanical testing: one for axial loading (n=4) and one for 4-point bending (n=4). Statistical analysis was carried out by ANOVA with a fisher post-hoc comparison between groups. A p-value less than 0.05 was considered statistically significant. Axial load to failure data and stiffness data revealed that intramedullary nails are significantly stronger and stiffer than other devices, however there was no statistically significant difference axially between the nail thicknesses. In bending, load to failure revealed that 18G nails are significantly stronger than 20G. We concluded that 18G nail is superior to the other fixation devices, therefore it has been used for in-vivo experiments to create a novel model of atrophic non-union with stable fixation

Background. Currently about 4–6% of all femur fractures consist of distal femoral fractures. Different methods and implants have been used for the surgical treatment of distal femoral fractures, including intramedullary nails. Retrograde nail. By contrast with antegrade nails, surgical approach or retrograde nailing exposes the knee joint which may lead to tendency of infection and increased knee pain. Present study aims to compare the biomechanical behaviour of distal angular condyler femoral intramedullary nail (DACFIN), retrograde nail and plate fixation. Methods. Fifteen 4th generation Saw bones were used to evaluate the biomechanical differences between the groups (Group 1: Plate fixation, Group 2: Retrograde nailing, Group 3: DACFIN; (n=5)). Biomechanical test was performed by using an electromechanical test device Shimadzu (AG-IS 5kN, Japan). Displacement values were recorded by using a Non-contact Video Extensometer (DVE-101/201, Shimadzu, Japan) during the loading each femur with 5 cycles of 500 N at a rate of 10 N/s to determine axial stiffness. The faliure stiffness was measured by axial load to each constructat a displacement rate of 5 mm/min. Torsional loading applied to all groups in amount of 6 Nm of torque with a velocity of 18 degrees/min. Results. The mean torsion stiffness value of Group 3 (6.33 Nm/degree) was signifacantly higher than Group 1 (1.18 Nm/degree) and Group 2 (2.11Nm/degree), p<0.05). The failure stiffness, Group 3 (1725 N/mm) was significantly higher than Group 1 (1275 N/ mm) and Group 2 (1290 N/mm). However, In axial stiffness, the mean value of Group 2 (2554 N/mm) was higher than Group 3 (1822 N/mm), and signifantly higher than Group 1(468 N/mm), p<0.05). Conclusions. DACFIN is more stiffer than retrograde nail and plate fixation during torsional and failure load conditions. But in axial stiffness retrograde nail was stiffer. DACFIN provide intramedullary femur condyle fracture fixations without open knee joint. Level of evidence. Level 5. Disclosure. Authors declare that there is no conflict of interest related to the present study

Recent concerns regarding the prospective growth disruption of the olecranon apophysis in skeletally immature patients with intramedullary nail fixation for ulnar fractures has been documented. This retrospective review investigated the long-term functional and radiological outcomes of intramedullary nail fixation through the olecranon apophysis in skeletally immature patients. Intramedullary nail fixation through the olecranon apophysis in skeletally immature patients is an effective, efficient procedure with excellent functional outcomes and without radiographic evidence of growth disruption at maturity. To investigate the long-term radiological and functional outcomes on the olecranon apophysis after intra-medullary nail fixation in skeletally immature ulnar fractures. Retrospective review of patients who where skeletally immature at the time of intramedullary nail fixation through the olecranon apophysis. Patients were excluded if they had previous forearms fractures or fracture of the contralateral forearm. Functional measures included the “Activities Scale for Kids (ASK)”, “Disabilities of the Arm, Shoulder and Hand (DASH)” and “Elbow Assessment Form (EAF)” questionnaires. Radiological outcomes where independently evaluated for ulnar, olecranon, coronoid and trochlear notch proportions at follow-up and initial post-op radiographic data. All patients had a clinical exam and the injured forearm outcomes were compared to the contralateral forearm. Nineteen patients were assessed. The average age at surgical intervention was 10.8 years (range, 1.6–15.9) with a mean follow up time of 3.4 years (range, 1.2–7.2). We outlined the demographics, clinical outcomes and functional questionnaire outcomes for the study cohort. Detailed radiographic measurements for ulnar, olecranon, coronoid and trochlear notch proportions are outlined also. Intramedullary nail fixation through the olecranon apophysis in skeletally immature patients is an effective, efficient procedure with excellent functional outcomes and without radiographic evidence of growth disruption at maturity. When skeletally immature ulnar fractures require an intramedullary nail fixation, disrupting the olecranon apophysis has not been shown to affect the long-term functional and radiological outcomes. Please contact author for tables and/or diagrams

Humeral diaphysis fractures consist a rather frequent injury. The aim of our study is to evaluate the results of the treatment of humeral diaphysis fractures with the use of an interlocking intramedullary nail. During the period March 1999 – December 2001, 25 intramedullary nailings were performed in 24 patients with a humeral fracture (16 women and 8 men), aged 26–81 years (Average: 57.1 years) using a Russell-Taylor humeral nail. There were 16 cases of acute humeral fractures, 3 cases of pathologic fractures, and 6 cases of delayed union or non-union. Follow-up ranged from 6 to 36 months (Average: 20 months). Fracture union was recorded, and the results were evaluated according to the scoring system of Neer. No immediate postoperative complications were recorded. The final result was excellent in 9 cases (36%), good in 12 (48%), unsatisfactory in 3 (12%), while there was one failure (4%), where a reoperation was required. Fracture union was achieved within 4 months in 21 cases (84%), while 2 cases of delayed union and 2 non-unions were recorded. Interlocking intramedullary nailing offers a dependable solution in the treatment of humeral diaphysis fractures, providing a very satisfactory functional outcome and a high union rate. It offers an excellent option in the treatment of pathologic fractures of the humerus, as well as in severely comminuted fractures and humeral fractures in polytrauma patients

Introduction: The majority of midshaft humeral fractures will achieve a satisfactory outcome with non-operative management. However, internal fixation is occasionally required to assist with rehabilitation, particularly in multiply-injured patients. Although the clinical risks and benefits of the locking plate and humeral nail are well known, there is a paucity of data comparing their mechanical properties. The aim of this study was to determine the torsional and 4-point bending properties of a midshaft humeral osteotomy reconstructed with either an intramedullary nail or locking plate. Methods: 19 fresh cadaveric humeri were DEXA scanned to ensure similar BMD. Non-destructive 4-point bending was performed on the intact bone to determine stiffness in the sagittal and coronal planes. Load was applied using an MTS MiniBionix 858 (Mechanical Testing Systems, MN) at a rate of 1 mm/min to a maximum of 450 N. A transverse midshaft osteotomy was created and a spacer ensured a constant 3-mm gap between the bone ends. Reconstruction was performed with either. Trigen humeral nail (Smith & Nephew, TN) – 10 specimens. Humeral locking plate (Synthes, PA) – 9 specimens. Non-destructive 4-point bending was repeated, and then each humerus was embedded in a low-melting point alloy proximally and distally for torsional testing. Torque was applied at 5 deg/min until failure. Maximum torque, maximum angle and stiffness were calculated. All data were analysed with SPSS for Windows (SPSS Inc., Il) using ANOVA. Results: One specimen in the locking plate group fractured during plate application and was excluded from the study. Non-destructive bending tests showed no significant difference in stiffness of the intact bones between the two groups. 4-point bending: the bones reconstructed with the intramedullary nail were ~50% as stiff as the intact state in both planes. There was no statistically significant difference in stiffness between the intact bones and those reconstructed with the locking plate. Torsional testing: the locking plate specimens were 3 times as stiff as the intramedullary nail specimens (P< 0.05) and failed at twice the torque (P< 0.05). Discussion: Humeral intramedullary nails are reported to have an advantage over plates under axial loading (Chen et al, 2002). However, this study demonstrates that locking plates are superior to intramedullary nails in torsion and four-point bending. Although the clinical situation often dictates the most appropriate management, locking plates should be considered in patients when torsional or four-point bending loads are expected to predominate in the post-operative period