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. 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. To assess macroscopic and microscopic changes to the implants and assess differences following design modification, with identification of potential surgical, implant and patient risk factors. Method. 15 nails were retrieved from 13 patients following lower limb lengthening. Macroscopic and microscopic surface damage to the nails were identified. Further analysis included radiology and micro-CT prior to sectioning. The internal mechanism was then analysed with Scanning Electron Microscopy and Energy Dispersive X-ray Spectroscopy to identify corrosion. Results. 7 male and 3 females underwent 12 femoral lengthenings, 9 antegrade and 3 retrograde. 3 females underwent tibial lengthening. All patients obtained the desired length with no implant failure and full regenerate consolidation. Surface degradation was noted on the telescopic part of every nail design, less on the latest implants. Microscopic 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 had evidence of corrosive debris. The latest designs had evidence of biological deposits suggestive of fluid ingress within the nail. Conclusion. This study suggests fluid ingress occurs with every generation of Precice nail despite modifications. The presence of biological fluid could be an early warning sign of potential corrosion. This in theory could lead to actuator pin fracture and implant failure. The clinical relevance is the potential re-use of a “dormant” nail in patients requiring secondary limb segment lengthening. Retraction of the nail in-situ and re-use for further lengthening requires careful consent for potential implant failure

The results of the treatment of 31 open femoral fractures (29 patients) with significant bone loss in a single trauma unit were reviewed. A protocol of early soft-tissue and bony debridement was followed by skeletal stabilisation using a locked intramedullary nail or a dynamic condylar plate for diaphyseal and metaphyseal fractures respectively. Soft-tissue closure was obtained within 48 hours then followed, if required, by elective bone grafting with or without exchange nailing.

The mean time to union was 51 weeks (20 to 156). The time to union and functional outcome were largely dependent upon the location and extent of the bone loss. It was achieved more rapidly in fractures with wedge defects than in those with segmental bone loss. Fractures with metaphyseal defects healed more rapidly than those of comparable size in the diaphysis. Complications were more common in fractures with greater bone loss, and included stiffness of the knee, malunion and limb-length discrepancy.

Based on our findings, we have produced an algorithm for the treatment of these injuries. We conclude that satisfactory results can be achieved in most femoral fractures with bone loss using initial debridement and skeletal stabilisation to maintain length, with further procedures as required.