Aims. Limb-lengthening nails have largely replaced external fixation in limb-lengthening and reconstructive surgery. However, the adverse events and high prevalence of radiological changes recently noted with the STRYDE lengthening nail have raised concerns about the use of internal lengthening nails. The aim of this study was to compare the prevalence of radiological bone abnormalities between STRYDE, PRECICE, and FITBONE nails prior to nail removal. Methods. This was a retrospective case series from three centres. Patients were included if they had either of the three limb-lengthening nails (STYDE, PRECICE, or FITBONE) removed. Standard orthogonal radiographs immediately prior to nail removal were examined for bone abnormalities at the junction of the telescoping nail parts. Results. In total, 306 patients (168 male, 138 female) had 366 limb-lengthening nails removed. The mean time from nail insertion to radiological evaluation was 434 days (36 to 3,015). Overall, 77% of STRYDE nails (20/26) had bone abnormalities at the interface compared with only 2% of FITBONE (4/242) and 1% of PRECICE nails (1/98; p < 0.001). Focal osteolysis in conjunction with periosteal reaction at the telescoping interface was only observed in STRYDE nails. Conclusion. Bone abnormalities at the interface of telescoping nail parts were seen in the majority of STRYDE nails, but only very rarely with FITBONE or PRECICE nails. We conclude that the low prevalence of radiological changes at the junctional interface of 242 FITBONE and 98 PRECICE nails at the time of nail removal does not warrant clinical concerns. Cite this article: Bone Joint J 2021;103-B(11):1731–1735

Aims. The aim of this study was to present the first retrieval analysis findings of PRECICE STRYDE intermedullary nails removed from patients, providing useful information in the post-market surveillance of these recently introduced devices. Methods. We collected ten nails removed from six patients, together with patient clinical data and plain radiograph imaging. We performed macro- and microscopic analysis of all surfaces and graded the presence of corrosion using validated semiquantitative scoring methods. We determined the elemental composition of surface debris using energy dispersive x-ray spectroscopy (EDS) and used metrology analysis to characterize the surface adjacent to the extendable junctions. Results. All nails were removed at the end of treatment, having achieved their intended lengthening (20 mm to 65 mm) and after regenerate consolidation. All nails had evidence of corrosion localized to the screw holes and the extendable junctions; corrosion was graded as moderate at the junction of one nail and severe at the junctions of five nails. EDS analysis showed surface deposits to be chromium rich. Plain radiographs showed cortical thickening and osteolysis around the junction of six nails, corresponding to the same nails with moderate – severe junction corrosion. Conclusion. We found, in fully united bones, evidence of cortical thickening and osteolysis that appeared to be associated with corrosion at the extendable junction; when corrosion was present, cortical thickening was adjacent to this junction. Further work, with greater numbers of retrievals, is required to fully understand this association between corrosion and bony changes, and the influencing surgeon, implant, and patient factors involved. Cite this article: Bone Jt Open 2021;2(8):599–610

Aims. Distraction osteogenesis with intramedullary lengthening devices has undergone rapid development in the past decade with implant enhancement. In this first single-centre matched-pair analysis we focus on the comparison of treatment with the PRECICE and STRYDE intramedullary lengthening devices and aim to clarify any clinical and radiological differences. Methods. A single-centre 2:1 matched-pair retrospective analysis of 42 patients treated with the STRYDE and 82 patients treated with the PRECICE nail between May 2013 and November 2020 was conducted. Clinical and lengthening parameters were compared while focusing radiological assessment on osseous alterations related to the nail’s telescopic junction and locking bolts at four different stages. Results. Osteolysis next to the telescopic junction was observed in 31/48 segments (65%) lengthened with the STRYDE nail before implant removal compared to 1/91 segment (1%) in the PRECICE cohort. In the STRYDE cohort, osteolysis initially increased, but decreased or resolved in almost all lengthened segments (86%) after implant removal. Implant failure was observed in 9/48 STRYDE (19%) and in 8/92 PRECICE nails (9%). Breakage of the distal locking bolts was found in 5/48 STRYDE nails (10%) compared to none in the PRECICE cohort. Treatment-associated pain was generally recorded as mild and found in 30/48 patients (63%) and 39/92 (42%) in the STRYDE and PRECICE cohorts, respectively. Temporary range of motion (ROM) limitations under distraction were registered in 17/48 (35%) segments treated with the STRYDE and 35/92 segments (38%) treated with the PRECICE nail. Conclusion. Osteolysis and periosteal reaction, implant breakage, and pain during lengthening and consolidation is more likely in patients treated with the STRYDE nail compared to the PRECICE nail. Temporary ROM limitations during lengthening occurred independent of the applied device. Implant-related osseous alterations seem to remodel after implant removal. Cite this article: Bone Joint J 2023;105-B(1):88–96

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

Introduction. The free hand technique remains the most popular method for distal locking; however, radiation exposure and increased operative time is a major concern. In an endeavor to overcome this concern, a new technique of distal locking with nail over nail technique is evaluated. Method. Seventy patients with femoral diaphyseal fractures treated by intramedullary nailing were divided in two groups: distal locking either with free hand technique (group 1) or with nail over nail technique (group II). Group I contained 35 patients (21 males and 14 females) with average age of 44.14 years. Group II contained 35 patients (19 males and 16 females) with average age of 45.7 years. In group II 1.5 mm of over-reaming was performed to avoid the nail deformation while insertion. Results. Average diameter of the nails used in free hand technique was 11.3 mm and 10.7 mm in nail over nail technique. Precision problems in insertion of distal interlocking screws occurred in 9 screws in group I and 11 screws in group II. The average number of images/exposures taken by image intensifier for nail insertion, for distal locking, and for the complete procedure in group I, were respectively 25.8, 24.2, and 50.08 compared with 24.8, 4.1 and 28.9, respectively in group II. All second distal (more proximal) holes were inserted successfully in group II. The statistically extremely significant decrease in radiation by 44% in the average total number of images required during the complete procedure was observed in nail over nail technique versus free hand technique. Conclusion. This prospective study on distal locking of femoral intramedullary nails shows that radiation exposures to achieve equivalent precision are reduced with the nail over nail technique as compared with the free hand technique. It can also be used when an image intensifier is unavailable or goes out of order peroperatively. However, over reaming of 1.5mm is the key to the success of technique as it avoids nail deformation during insertion. Level of evidence: therapeutic level IV

Introduction. Intramedullary lengthening devices have been in use in older children with closed /open growth plates with good success. This study aims to present the early experience of the FITBONE nail since withdrawal of the PRECICE nail. Materials & Methods. Retrospective analysis of both antegrade and retrograde techniques were utilized. Only patients where union was achieved and full weight bearing commenced were included. The complication rate, length gained, distraction index, weight bearing index (WBI) as well as mechanical axes were analysed. Results. 14 (7 males, 7 females) of a total of 16 (7 males, 7 females) patients with a mean age of 16.9 years with varied diagnosis of LLD were analysed. The mean length gained was 38 mm with an average distraction index of 0,74 mm/day. WBI in these patients on average was 59,6 days/cm lengthened. 6 complications were observed, including two nonunions (successfully treated) and a knee subluxation. Mechanical axis deviation improved from 13,3 mm to 6 mm on average. Overall there has been a nonsignificant tendency for WBI to decrease (Spearman's rank correlation coefficient −0.47, p=0.08) with increasing number of cases done, while no correlation between length gained and WBI (−0.01, p=0.96, respectively) was observed. Some nuances will be discussed. Conclusions. Limb lengthening with the FITBONE nail is relatively safe and efficient, however no significant change was seen in the outcome with previous motorized nails

Introduction. Fully implantable distraction nails are frequently used for lengthening of the lower leg. What are the indications for humerus lengthening and which results can be expected?. Materials and Methods. The humerus as the best healing bone in the human body is suitable for lengthening with a nail as well but the indications are rare in comparison with the lower legs. Especially when driving a car or when working on a tablet length discrepancy of the arms of more than 4–5cm may cause severe hardening of the cervical muscles and induce chronical pain in the upper spine. Results. A distraction nail (FITBONE) was used in 5 cases for humerus lengthening. The nail was inserted in all cases from proximal. The mean age of the patients was 34 years. The mean lengthening amount was 58mm (55–100). In one case the system was exchanged to reach the desired length. There was no infection, no radial nerve irritation and no chronical shoulder pain. The system was removed in 4 cases in an average of 15 months the other nail will be removed soon as well. Conclusions. The preliminary results of our 5 cases demonstrate, that the FITBONE device is advantageous for lengthening the humerus, if the initial length is sufficient for implantation. In comparison with the use of external fixators the functional outcome, the comfort of treatment and the cosmetic result is amazing

Aims. The STRYDE nail is an evolution of the PRECICE Intramedullary Limb Lengthening System, with unique features regarding its composition. It is designed for load bearing throughout treatment in order to improve patient experience and outcomes and allow for simultaneous bilateral lower limb lengthening. The literature published to date is limited regarding outcomes and potential problems. We report on our early experience and raise awareness for the potential of adverse effects from this device. Methods. This is a retrospective review of prospective data collected on all patients treated in our institution using this implant. We report the demographics, nail accuracy, reliability, consolidation index, and cases where concerning clinical and radiological findings were encountered. There were 14 STRYDE nails implanted in nine patients (three male and six female) between June 2019 and September 2020. Mean age at surgery was 33 years (14 to 65). Five patients underwent bilateral lengthening (two femoral and three tibial) and four patients unilateral femoral lengthening for multiple aetiologies. Results. At the time of reporting, eight patients (13 implants) had completed lengthening. Osteolysis and periosteal reaction at the junction of the telescopic nail was evident in nine implants. Five patients experienced localized pain and swelling. Macroscopic appearances following retrieval were consistent with corrosion at the telescopic junction. Tissue histology was consistent with effects of focal metallic wear debris. Conclusion. From our early experience with this implant we have found the process of lengthening to be accurate and reliable with good regenerate formation and consolidation. Proposed advantages of early load bearing and the ability for bilateral lengthening are promising. We have, however, encountered concerning clinical and radiological findings in several patients. We have elected to discontinue its use to allow further investigation into the retrieved implants and patient outcomes from users internationally. Cite this article: Bone Joint J 2021;103-B(6):1168–1172

Introduction. Stryde® lengthening nail has been recently withdrawn because of concerns about osteolysis and other bone lesions that have been observed early after implantation. The present study analyses the incidence and features of these bone lesions in our patients. Materials and Methods. This is a retrospective review of a series of patients from two centres specializing in limb reconstruction. Inclusion criteria was a history of surgery with Stryde® lengthening nail with more than one year follow-up available. All postoperative x-rays were and clinical notes were reviewed. Results. 36 patients with 75 bone segments were included. 11 (30.5%) patients and 32 (42.6%) bone segments were without any lesion. In 3 (8.3%) patients and 3 (4%) segments, osteolytic lesions only were noticed. 11(30.5%) patients and 14 (18.6%) segments had combined lytic lesions and periosteal reaction or cortical thickening. 12 (33.3%) patients and 26 (34.6%) segments developed only periosteal reaction or cortical thickening. 54.8% of patients with bilateral nailing had bilateral lesions. 52% of the patients with bone lesions reported late onset of pain after the completion of the lengthening. The average earliest interval that any of the lesions was noticed was 10.2 months post-surgery. Conclusions. Patients with Stryde® nails should be monitored clinically and radiologically at regular intervals until removal. The early failure and withdrawal of Precise Stryde® nail, is a significant event in the field of limb reconstruction; this study adds useful data to the growing pool of published data related to the this event

Aims. As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach. Methods. A total of 58 patients (median age 17 years (interquartile range (IQR) 15 to 21)) treated by unilateral tibial distraction osteogenesis for a median leg length discrepancy of 41 mm (IQR 34 to 53), and nine patients with disproportionate short stature treated by bilateral simultaneous tibial distraction osteogenesis, with magnetically controlled motorized ILNs inserted via an antegrade approach, were retrospectively analyzed. The median follow-up was 37 months (IQR 30 to 51). Outcome measurements were accuracy, precision, reliability, bone healing, complications, and patient-reported outcome assessed by the Limb Deformity-Scoliosis Research Society Score (LD-SRS-30). Results. A median tibial distraction of 44 mm (IQR 31 to 49) was achieved with a mean distraction index of 0.5 mm/day (standard deviation 0.13) and median consolidation index of 41.2 days/cm (IQR 34 to 51). Accuracy, precision, and reliability were 91%, 92%, and 97%, respectively. New temporary range of motion limitations occurred in 51% of segments (34/67). Distraction-related equinus deformity treated by Achilles tendon lengthening was the most common major complication recorded in 16% of segments (11/67). In 95% of patients (55/58) the distraction goal was achieved with 42% unplanned additional interventions per segment (28/67). The median postoperative LD-SRS-30 score was 4.0 (IQR 3.6 to 4.3). Conclusion. Tibial distraction osteogenesis using motorized ILNs inserted via an antegrade approach appears to be a reliable and precise procedure. Temporary joint stiffness of the knee or ankle should be expected in up to every second patient. A high rate and wide range of complications of variable severity should be anticipated. Cite this article: Bone Joint J 2024;106-B(3):293–302

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. Fully implantable systems are used commonly only after maturity. What are indications to use fully implantable systems at the femur even in children?. Materials and Methods. Implantable lengthening nails (FITBONE) were used retrograde at the femur in minimal invasive technique to correct a limb length discrepancy of >6 cm. In 5 cases a relevant deformity was corrected in the same surgery. In all cases a final step of lengthening was planned at the femur and at the tibia with fully implantable devices at maturity. Results. 18 patients with the medium age of 10,3 years (8–14) were treated. In 17 cases the goal of lengthening was achieved without any complication. In one case of proximal femoral deficiency lengthening had to be stopped because of increasing tendency of knee joint luxation. Bone formation occurred circular around the nail in all cases. Full load bearing was possible in the average after 2,2 days/mm. No technical problems occur. In one case induced deformity in the lateral plane was observed which was corrected at the final step. At the end of treatment functional and cosmetical result was perfect in all cases. Conclusions. Fully implantable motorized distraction nails are a favorable option for lengthening and deformity correction of the femur even for children older than 10 years to correct limb length discrepancy of more than 6 cm. The treatment has a low pain level, is comfortable and nearly no scars are visible

Aims. Double-level lengthening, bone transport, and bifocal compression-distraction are commonly undertaken using Ilizarov or other fixators. We performed double-level fixator-assisted nailing, mainly for the correction of deformity and lengthening in the same segment, using a straight intramedullary nail to reduce the time in a fixator. Patients and Methods. A total of 23 patients underwent this surgery, involving 27 segments (23 femora and four tibiae), over a period of ten years. The most common indication was polio in ten segments and rickets in eight; 20 nails were inserted retrograde and seven antegrade. A total of 15 lengthenings were performed in 11 femora and four tibiae, and 12 double-level corrections of deformity without lengthening were performed in the femur. The mean follow-up was 4.9 years (1.1 to 11.4). Four patients with polio had tibial lengthening with arthrodesis of the ankle. We compared the length of time in a fixator and the external fixation index (EFI) with a control group of 27 patients (27 segments) who had double-level procedures with external fixation. The groups were matched for the gain in length, age, and level of difficulty score. Results. The mean gain in length was statistically similar in the two groups: 3.9 cm (1.5 to 9.0) in the study group and 4.2 cm (3.4 to 5.0) in the control group (p = 0.350). The mean time in a fixator was significantly less in the study group compared with the control group: 8.6 weeks (2.0 to 22.8) versus 30.2 weeks (25.0 to 35.4; p < 0.001). The mean EFI was significantly lower in the study group compared with the control group: 17.7 days/cm (10.6 to 35.6) versus 73.4 days/cm (44.5 to 102.3; p < 0.001). The ASAMI (Association for the Study and Application of the Method of Ilizarov) bone score was excellent in 22, good in four, and fair in one. The ASAMI functional score was excellent in 20 and good in seven. There were no infections, superficial or deep. Conclusion. Double-level osteotomies or two procedures using a custom-made straight nail and external fixation can be used to correct deformities or to treat nonunion or malunion and may be combined with arthrodesis of the ankle with lengthening. It is a reasonably safe procedure that allows accurate and cost-effective treatment with a relatively short time in a fixator

Aim & introduction. Infected knee with bone defect resulting from failed total knee arthroplasty (TKA) or destruction of native joint can necessitate restoration of segmental defect and arthrodesis for therapy of infection and maintenance of walking ability. In segmental knee defect external fixators or KAFO are not suitable, not comfortable and poor tolerated by elderly patients. Both custom-made Femoro-Tibial Nail (FTN) combined with acrylic cement spacer and Knee Arthrodesis Nail System (KANS) offer maintenance of supportive function of extremity and avoidance of leg length discrepance after removal of TKA. Method. The group consists of 13 patients. In 12 cases knee arthrodesis have been performed due to infection with bone defect after removal of infected TKA, and in 1case due to inflammatory destruction of native knee joint. In 7 cases FTN with ALAC spacer and in 6 cases KANS (5 cases Orthopedic Salvage System-OSS; 1 case Link KANS) was used. In cases treated with FTN the gap between distal femur and proximal tibia was filled with hand-made acrylic cement spacer loaded with selected antibiotic (2g per 40 g cement) so that the spacer finally gained cylindrical shape. Results. Stable knee was noted after 7 years in 4 of 7 knees treated with FTN with ALAC spacer and after 2 years in 6 of 6 after KANS. Infection free knee was gained after 7 years in 4 of 7 cases treated with FTN with ALAC spacer and after 2 years in 5 of 6 cases treated with KANS. Amputation was necessary after 6 years in 3 of 7 cases treated with FTN with ALAC spacer and after 2 years in none case treated with KANS. Complications occurred in 2 cases after FTN with ALAC spacer (1x: FTN breackage, 1x: stress fracture of femoral neck) and in 1 case after KANS (OSS implant failure). Replacement of FTN nail and cement spacer in 1 case and respectively revision of OSS KANS in 1 cases was performed. Conclusions. Compared with the KANS, custom-made FTN combined with ALAC spacer proved to be effective up to 6 years, but shoved higher rate of complications and amputations after 6 years. It can be considered as a temporary low-cost salvage procedure for infected TKA with segmental bone defect as 1. st. stage in two-stage arthrodesis for infected knee prosthesis

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

Introduction. The STRYDE nail is an evolution of the PRECICE Intramedullary Limb Lengthening System, with unique features regarding its composition. It is designed for load bearing throughout treatment in order to improve patient experience and outcomes and allow for simultaneous bilateral lower limb lengthening. The literature published to date is limited with regards to both outcomes and potential issues. In this paper we report on our early experience and raise awareness for the potential of adverse effects from this device. Materials and Methods. This is a review of all patients treated in our institution using this implant. Data were prospectively recorded. We report on demographics, nail accuracy, reliability, consolidation index and cases where concerning clinical and radiological findings were encountered. Results. 14 Stryde nails were implanted in nine patients (three males and six females) between June 2019 and September 2020. Mean age at surgery was 33 years old (14–65 years old). Five patients underwent bilateral lengthening (two femoral and three tibial) and four patients unilateral femoral lengthening for multiple aetiologies. By the time of this report eight patients (13 implants) had completed lengthening. Osteolysis and periosteal reaction at the junction of the telescopic nail was evident in nine implants. Five patients experienced localised pain and swelling. Macroscopic appearances following retrieval were consistent with corrosion at the telescopic junction. Tissue histology was consistent with effects of focal metallic wear debris. Conclusions. From our early experience with this implant we have found the process of lengthening to be accurate and reliable with good regenerate formation and consolidation. Proposed advantages of early load bearing and the ability for bilateral lengthening are promising. We have, however, encountered cases with concerning clinical and radiological findings. We have elected to discontinue its use to allow further investigation into the retrieved implants and patient outcomes from users internationally

Abstract. Background. Fractures Proximal humerus account for nearly 10 % of geriatric fractures. The treatment options varies. There is no consensus regarding the optimal treatment, with almost all modalities giving functionally poor outcomes. Hence literature recommends conservative management over surgical options. MULTILOC nail with its design seems to be a promising tool in treating these fractures. We hereby report our early experience in the treatment of 37 elderly patients. Objectives. To evaluate the radiological outcome with regards to union, collapse, screw back out/cut through, implant failures, Greater tuberosity migration. To evaluate the functional outcome at the end of 6 months using Constant score. Study Design & Methods. All patients aged >65 years who underwent surgery for 3,4-part fracture proximal humerus using the MULTILOC nail were included in the study after consent. Pre – existing rotator cuff disease were excluded. Within the time frame, a total of 39 patients underwent the said surgery. 2 patients were lost to follow up. All the measurements were taken at the end of 6 months and results tabulated and analysed. Results. Union was achieved in all the 37 patients. There were no varus collapse or screw backout/cut through seen in any of the patients. There was Greater tuberosity migration in 1 patient who underwent revision surgery at 6 weeks. All the patients got a minimum of 70 degrees of abduction and forward flexion. We had 29 excellent, 6 good, 2 fair and none poor results as per Constant scoring system. Study done in Tejasvini Hospital & SSIOT Mangaluru India

Introduction. We have previously published limb lengthening using external fixation in pathological bone diseases. We would like to report a case series of femoral lengthening using the PRECICE system in a similar pathological group especially looking at it's feasibility and complications. Materials and Methods. This is a case series of four patients, two patients with osteogenesis imperfecta and two with Ollier's disease, who underwent femoral lengthening via distraction osteogenesis using the PRECICE intramedullary nail system. It was a retrospective study from a prospective database from clinical records and radiographs. Results. The mean age at the time of surgery was 15.5 years, the mean preoperative leg length discrepancy was 30mm, and the mean distraction distance achieved was 28.75mm. Since these patients were of shorter heigh, limb lengthening was considered. All 4 patients had successful insertion of the nail. The outcomes noted from the 4 patients are collated, with several complications occurring including delayed femoral union, fixed flexion deformity of the hip, persisting pain and quadriceps weakness. Those with Ollier's disease underwent an increased rate of distraction to prevent premature healing. The implications of long-term bisphosphonate therapy in OI are discussed with regards to the risk of delayed femoral union and intra-operative fracture. Conclusions. Intramedullary femoral lengthening in pathological bone disease is possible, but the surgeon needs to give attention to certain details. The regenerate formation is based on the background pathology irrespective of the hardware used. There is much more compliance with the nail technique

Introduction. With an aging population, the prevalence of fragility ankle fractures is rising. The surgical management of these injuries is challenging and associated with high rates of complications. The incidence of fragility ankle fractures is currently estimated to be around 150 per 100,000 people annually and is anticipated to rise to around 269 per 100,000 by 2030. The aim of surgery is to restore mobility, preserve function and to prevent complications related to non-weight-bearing and the application of hind foot nail (HFN) seems to provide these advantages. This systematic review aims to investigate the role of HFN in the treatment of fragility ankle fractures. We aim to review the available evidence published on the functional recovery observed in patients following treatment with HFN and the observed complications in the literature. Materials and Methods. A review of the current literature was conducted to identify recent systematic reviews on the use of HFN in the treatment of fragility ankle fractures. Our electronic search included the following databases; Web of Sciences, Cochrane Database of Systematic Review, MEDLINE, CINHAL, and Academic Search Premier. We also conducted a web search using Google Scholar for sake of completeness. Studies published from the inception of data until September 2019 that assess the effectiveness of HFN in patients with osteoporotic ankle fractures were included. Articles meeting the inclusion criteria were read in full and assessed against the eligibility criteria. Results. Six case series and one randomized controlled trial included in our review. The total number of patients included was 194, of them, 145 were females and 49 males. The age range of all cases was 37–98 years (mean 76.39 years). Patients' demographic data, follow-up duration, Postoperative weight-bearing status, postoperative complications, mortality and Olerud and Molander score (OMAS) scores have been obtained in details. Conclusions. The use of HFN have found that it has favorable outcomes regarding early rehabilitation, restoration of function and length of hospital stay. Prospective trials comparing the outcome of patients with fragility ankle fractures treated with HFN vs conventional treatments are warranted, particularly with long periods of follow ups

Intramedullary nailing is the standard fixation method for displaced diaphyseal fractures of the tibia in adults. Anecdotal clinical evidence indicates that current nail designs do not fit optimally for Asian patients. This study aimed to develop a method to quantitatively assess the fitting of two nail designs for Asian tibiae. We used 3D models of two different tibial nail designs (ETN (Expert Tibia Nail) and ETN-Proximal-Bend, Synthes), and 20 CT-based 3D cortex models of Japanese cadaver tibiae. The nail models were positioned inside the medullary cavity of the intact bone models. The anatomical fitting between nail and bone was assessed by the extent of the nail protrusion from the medullary cavity into the cortical bone, which in a real bone would lead to axial malalignments of the main fragments. The fitting was quantified in terms of the total surface area, and the maximal distance of nail protrusion. In all 20 bone models, the total area of the nail protruding from the medullary cavity was smaller for the ETN-Proximal-Bend (average 540 mm2) compared to the ETN (average 1044 mm2). Also, the maximal distance of the nail protruding from the medullary cavity was smaller for the ETN-Proximal-Bend (average 1.2 mm) compared to the ETN (average 2.7 mm). The differences were statistically significant (p < 0.05) for both the total surface area and the maximal distance measurements. For all bone models, the nail protrusion occurred on the posterior side in the middle third of the tibia. For 12 bones the protrusion was slightly lateral to the centre of the shaft, for seven bones it was centred, and for one bone it was medial to the shaft. The ETN-Proximal-Bend shows a statistical significantly better intramedullary fit with less cortical protrusion than the original ETN. The expected clinical implications of an improved anatomical nail fit are fewer complications with malreduction and malalignments, a lower likelihood for fracture extension and/or new fracture creation during the nail insertion as well as an easier handling for the nail insertion. By utilising computer graphical methods we were able to conduct a quantitative fit assessment between implanted nail and bone geometry in 3D. In addition to the application in implant design, the developed method could potentially be suitable for pre-operative planning enabling the surgeon to choose the most appropriate nail design