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.

Aims: Present our experience with a protocol for acute Ç gradual È femoral distraction for post- traumatic femoral shotening. Methods: Six females and four men with an average age of 35 y/o with al least one year follow-up and an average shortening of 4.5 cm (range 3–6). A butterßy osteotomy was performed at the diaphysary-subtrochanteric level. A femoral distractor was applied to the lateral side of the femur. An antegrade femoral intramedullary nail was then inserted and locked proximally. The patients were admitted to the orthopaedic ßoor and distraction started the same day under clinical monitoring of the neurovascular status. When the desired length was achieved, intrelocking was completed and the femoral distractor removed. Limb length was evaluated with scanograms. Radiographic healing was deþned as bridging callus at both sides of the osteotomy on AP, lateral and oblique views. Range of motion was evaluated at the one year follow-up visit. Results: Lenghening averaged 4.2 cm (range 2.7–6). Distraction period averaged 6 days (range 3–12). Distraction rate averaged 7 mm a day (range 3–11). Average healing time was 5 months (range 2–11). Shanz pins bent in 6 cases. Pin tract superþcial infections were identiþed in 3 cases. All infections subsided with oral antibiotics and no deep infection was detected. No nails or interlocking screws breakage were detected. Conclusion: Lengthening of the femur over a intramedullary nail is better to other tecniques. The butterßy osteotomy splits the distraction gap in halves, decreasing the risk of non-union and comlications reported for acute lengthenings. Lengthening of the femur up to 6 cm was possible in this series of patients following this protocol for acute Ç gradual Èdistraction over an intramedullary nail.