Aims. There are concerns regarding nail/medullary canal mismatch and initial stability after cephalomedullary nailing in unstable pertrochanteric fractures. This study aimed to investigate the effect of an additional anteroposterior blocking screw on fixation stability in unstable pertrochanteric fracture models with a nail/medullary canal mismatch after short cephalomedullary nail (CMN) fixation. Methods. Eight finite element models (FEMs), comprising four different femoral diameters, with and without blocking screws, were constructed, and unstable intertrochanteric fractures fixed with short CMNs were reproduced in all FEMs. Micromotions of distal shaft fragment related to proximal fragment, and stress concentrations at the nail construct were measured. Results. Micromotions in FEMs without a blocking screw significantly increased as nail/medullary canal mismatch increased, but were similar between FEMs with a blocking screw regardless of mismatch. Stress concentration at the nail construct was observed at the junction of the nail body and lag screw in all FEMs, and increased as nail/medullary canal mismatch increased, regardless of blocking screws. Mean stresses over regions of interest in FEMs with a blocking screw were much lower than regions of interest in those without. Mean stresses in FEMs with a blocking screw were lower than the yield strength, yet mean stresses in FEMs without blocking screws having 8 mm and 10 mm mismatch exceeded the yield strength. All mean stresses at distal locking screws were less than the yield strength. Conclusion. Using an additional anteroposterior blocking screw may be a simple and effective method to enhance fixation stability in unstable pertrochanteric fractures with a large nail/medullary canal mismatch due to osteoporosis. Cite this article: Bone Joint Res 2022;11(3):152–161

Aims. The aim of this study was to determine the immediate post-fixation stability of a distal tibial fracture fixed with an intramedullary nail using a biomechanical model. This was used as a surrogate for immediate weight-bearing postoperatively. The goal was to help inform postoperative protocols. Methods. A biomechanical model of distal metaphyseal tibial fractures was created using a fourth-generation composite bone model. Three fracture patterns were tested: spiral, oblique, and multifragmented. Each fracture extended to within 4 cm to 5 cm of the plafond. The models were nearly-anatomically reduced and stabilized with an intramedullary nail and three distal locking screws. Cyclic loading was performed to simulate normal gait. Loading was completed in compression at 3,000 N at 1 Hz for a total of 70,000 cycles. Displacement (shortening, coronal and sagittal angulation) was measured at regular intervals. Results. The spiral and oblique fracture patterns withstood simulated weight-bearing with minimal displacement. The multifragmented model had early implant failure with breaking of the distal locking screws. The spiral fracture model shortened by a mean of 0.3 mm (SD 0.2), and developed a mean coronal angulation of 2.0° (SD 1.9°) and a mean sagittal angulation of 1.2° (SD 1.1°). On average, 88% of the shortening, 74% of the change in coronal alignment, and 75% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. The oblique fracture model shortened by a mean of 0.2 mm (SD 0.1) and developed a mean coronal angulation of 2.4° (SD 1.6°) and a mean sagittal angulation of 2.6° (SD 1.4°). On average, 44% of the shortening, 39% of the change in coronal alignment, and 79% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. Conclusion. For spiral and oblique fracture patterns, simulated weight-bearing resulted in a clinically acceptable degree of displacement. Most displacement occurred early in the test period, and the rate of displacement decreased over time. Based on this model, we offer evidence that early weight-bearing appears safe for well reduced oblique and spiral fractures, but not in multifragmented patterns that have poor bone contact. Cite this article: Bone Joint J 2021;103-B(2):294–298

It is common belief that consolidated intramedullary nailed trochanteric femur fractures can result in secondary midshaft or supracondylar fractures, involving the distal screws, when short or long nails are used, respectively. In addition, limited data exists in the literature to indicate when short or long nails should be selected for treatment. The aim of this biomechanical cadaveric study was to investigate short versus long Trochanteric Femoral Nail Advanced (TFNA) fixation in terms of construct stability and generation of secondary fracture pattern following trochanteric fracture consolidation. Eight intact human cadaveric femur pairs were assigned to 2 groups of 8 specimens each for nailing using either short or long TFNA with blade as head element. Each specimen was first biomechanically preloaded at 1 Hz over 2000 cycles in superimposed synchronous axial compression to 1800 N and internal rotation to 11.5 Nm. Following, internal rotation to failure was applied over an arc of 90° within 1 second under 700 N axial load. Torsional stiffness, torque at failure, angle at failure and energy at failure were evaluated. Fracture patterns were analyzed. Outcomes in the groups with short and long nails were 9.7±2.4 Nm/° and 10.2±2.9 Nm/° for torsional stiffness, 119.8±37.2 Nm and 128.5±46.7 Nm for torque at failure, 13.5±3.5° and 13.4±2.6° for angle at failure, and 887.5±416.9 Nm° and 928.3±461.0 Nm° for energy at failure, respectively, with no significant differences between them, P≥0.167. Fractures through the distal locking screw occurred in 5 and 6 femora instrumented with short and long nails, respectively. Fractures through the lateral entry site of the head element were detected in 3 specimens within each group. For short nails, fractures through the distal shaft region, not interfacing with the implant, were detected in 3 specimens. From biomechanical perspective, the risk of secondary peri-implant fracture after intramedullary nailed trochanteric fracture consolidation is similar when using short or long TFNA. Moreover, for both nail versions the fracture pattern does not unexceptionally involve the distal locking screw

Distal locking screw fixation, in intramedullary nail (IMN) fixation, remains the most technically demanding and problematic portion of the procedure being responsible for as much as one-half of the exposure of the surgeon‘s hands to radiation. This biomechanical study was undertaken to compare the effectiveness of using one distal locking cross screw instead of two cross screws in femoral fractures fixed with IMN system. A composite model made from a stainless steel IMN (12mm×1mm), was axially loaded to 2kN (3 times body weight) to reproduce the forces experienced during weight bearing, or until a maximum displacement of 1 mm was reached. The distal locking end of the intramedullary nail was attached to the centre of the cylinder, representing different parts of the distal femur, with a dedicated single or two rods (5mm diameter), made from stainless steel and titanium, to represent the distal locking cross screw. In the 50mm×5mm cylinder (diaphyseal femur), the mean stability of fracture model using either single or two screws were similar. But in the 75mm×5mm and 100mm×3mm cylinders (metaphyseal and distal femur), the mean stability of the fracture model significantly decreased (50%) with single distal locking cross screw fixation when compared to two distal locking cross screws fixation. Similarly, stainless steel alloy provided more stability compared to titanium alloy cross screws in 75mm×5mm and 100mm×3mm cylinders. However there was no difference between the cross screws performance for 50mm×5mm when comparing both the alloys. As shown in this experiment, femoral shaft (diaphyseal) fractures fixed with shorter IMN had the same stability for one or two distal locking cross screws. However fractures fixed with longer IMNs, to fix diaphyseo-metaphyseal junction fractures and extreme distal femoral fractures, single distal locking cross screw fixation provide poorer fracture stability compared to two distal locking cross screws fixation

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 AO/OTA 31 A-3 fractures are very unstable and biomechanically differ from the 31 A-1 and A-2 fractures. Recent papers state that the extra-medullary implants used to treat these fractures have a failure rate as high as 56%. Few papers report the results with intramedullary implants, and, sometimes to heal the fracture, the nails had to be dynamised by to removing the distal screw or the fracture is “self-dyna-mised” by breaking the distal screw. Material and Methods: A prospective clinical study was designed to treat 57 consecutive patients with a 31 A-3 fracture. Mean age (84.2 years). The GT Short Nail (17-cm long, 16-mm upper diameter, and a distal locking oval hole allowing 12 mm of proximal sliding), was inserted through the apex of the greater trochanter to stabilize these fractures with a single 9-mm rotationally unlocked hip-screw, and a distal dynamically locked screw. 43 patients followed for six months were included in the study. Radiological studies: screw-tip migration (Doppelt’s method), hip-screw sliding, tip-apex distance (Baumgaertner), and proximal sliding of the distal locking screw (intra-op, one week, one month, three and six months). Full weight bearing with the needed help was encouraged as soon as possible. Results: All fractures but one, healed uneventfully. No cutouts, no thigh pain, 1 implant failure in the only delayed healing case, and no deep infections. Three patients had further surgery to heal a bleeding skin incision. The failed implant was removed and replaced by a 90° Synthes hip plate. The average tip-screw migration was 2.4 mm, the tip-apex-distance was < than 25 mm in 94% of the cases, the average hip-screw sliding was 6.4 mm, and the average proximal sliding of the distal locking screw was 4.9 mm. In 24.5 % of the cases (14) the proximal sliding of the distal dynamically locked screw was over 10 mm. Conclusions: A single 9-mm diameter rotationally unlocked hip screw works very well through the healing process of these very unstable fractures. A dynamically distal locked screw controls the femoral shaft rotation. Our study shows that the distal locking hole of the trochanteric nails should allow at least 10 mm of proximal sliding to provide the unknown needed proximal sliding of the distal fragment to minimize delayed or non-healing of these fractures

Fragility ankles fractures in the geriatric population are challenging to manage, due to fracture instability, soft tissue compromise, patient co-morbidities. Traditional management options include open reduction internal fixation, or conservative treatment, both of which are fraught with high complication rates. We aimed to present functional outcomes of elderly patients with fragility ankle fractures treated with tibiotalocalcaneal nails. 171 patients received a tibiotalocalcaneal nail over a six-year period, but only twenty met the inclusion criteria of being over sixty and having poor bone stock, verified by radiological evidence of osteopenia or history of fragility fractures. Primary outcome was mortality risk from co-morbidities, according to the Charlson co-morbidity index (CCI), and patients’ post-operative mobility status compared to pre-operative mobility. Secondary outcomes include intra-operative and post-operative complications, six-month mortality rate, time to mobilisation and union. The mean age was 77.82 years old, five of whom are type 2 diabetics. The average CCI was 5.05. Thirteen patients returned to their pre-operative mobility state. Patients with low CCI are more likely to return to pre-operative mobility status (p=0.16; OR=4.00). Average time to bone union and mobilisation were 92.5 days and 7.63 days, respectively. Mean post-operative AOFAS ankle-hindfoot and Olerud-Molander scores were 53.0 (range 17-88) and 50.9 (range 20-85), respectively. There were four cases of broken distal locking screws, and four cases of superficial infection. Patients with high CCI were more likely to acquire superficial infections (p=0.264, OR=3.857). There were no deep infections, periprosthetic fractures, nail breakages, non-unions. TTC nailing is an effective treatment methodology for low-demand geriatric patients with fragility ankle fractures. This technique leads to low complication rates and early mobilisation. It is not a life-changing procedure, with many able to return to their pre-operative mobility status, which is important for preventing the loss of socioeconomic independence

Introduction: The current techniques used for locking the distal end of intramedullary nails with cross screws remain a technical operative challenge for many clinicians. The surgeon uses his/her experience and judgement to locate the distal holes in the intramedullary nail, relying heavily on the use of two dimensional intra operative X-ray images (fluoroscopy) to undertake a three dimensional task. As a result, a large number of X-ray images are frequently required, significantly increasing the radiation exposure to both the patient and the operative team. Also there is an overall proportional increase in the operating time. Aim: We aimed to develop a simple new radiological alignment jig that would allow the accurate placement of distal locking cross screws during intramedullary nailing, with minimal radiation exposure and without having to visualise the distal screw holes. Materials and method: Laboratory tests were conducted using plastic femora (Sawbones Limited) fixed with intramedullary nails. Tests were performed three times using each of the different femoral intramedullary nails (Russell-Taylor, Smith & Nephew) investigating whether the length or diameter of the nail had any influence upon the accuracy of distal screw insertion. After successfully concluding the laboratory tests, a limited clinical study was conducted using the new alignment jig to insert distal locking screws in patients. Results: Both the bench tests and limited clinical study were 100% successful and permitted the clinician to identify the distal holes correctly without needing to visualise the distal screw holes radiologically. Conclusion: Our initial bench tests and clinical study show that the new alignment jig allows simple and accurate insertion of the distal locking screws with minimal radiological guidance. It also has considerable potential to reduce the overall operating time

The PFNA is used routinely at the RUH for unstable peri-trochanteric and femoral fractures. Failure of operative treatment is associated with increased morbidity and financial burden. We analysed surgical and fracture factors, aiming to identify those associated with fixation failure. Retrospective analysis of 76 consecutive patients treated with a PFNA between 2009–2012 was performed. Patient demographics were assessed, along with fracture classification, adequacy of reduction, tip apex distance (TAD) and grade of surgeon. Failure was defined as metal work failure, non-union or need for repeat procedure. The mean age was 78.9 years (25.9–97.4). 21 were male and 49 female. There were 17 failures (24.3%) (7 required further surgery). 10 failures were per-trochanteric, 2 sub-trochanteric and 5 mid-shaft fractures. Complications included 4 broken and 6 backed-out distal locking screws, 2 blade cut-outs, 1 nail fracture and 4 non-unions. All per-trochanteric were adequately reduced with a TAD <25 mm. 11/17 had consultant supervision. A high rate of backed-out distal locking screws was identified. We found no concerns with adequacy of reduction, TAD or consultant supervision

A 52 year old male presented with a pathological subtrochanteric femoral fracture secondary to multiple myeloma. While stabilising the fracture with a Long Proximal Femoral Nail (PFN) distal femur fracture occurred, while introducing the distal locking screw, which was fixed with two cables. Partial weight bearing was allowed for the first six weeks. Three months after surgery the distal static locking screw broke. Eighteen months post surgery patient developed sudden spontaneous right hip pain and was treated with further chemotherapy and radiotherapy. Radiographs showed the fracture had not healed but there was no evidence of implant failure. Two years later patient presented with sudden increase in right hip pain with inability to walk. Radiographs showed that the nail had broken at the proximal hip screw hole. At revision surgery, with difficulty the broken distal locking screws were removed and the broken nail was removed by pushing it from below through the knee. The non union was stabilised with another long PFN. At four months post revision surgery there were radiological signs of bone healing and patient had no symptoms. Discussion: Reconstruction nails such as long PFN are bio mechanically suited for proximal femoral fractures and metastases. Bone cement augmentation has been reported to provide additional support in metastases. Dynamisation of the fracture leads to fracture impaction and promotes fracture healing. In this case implant failure was probably due to non union and fatigue failure of the implant. In spite of ‘spontaneous’ dynamisation (broken static distal screw), union did not occur initially. This is the first reported incidence of failure of long PFN in a pathological femoral fracture stabilisation

In femoral locked nailing, the distal locking screws is vulnerable to mechanical failure. The stress on these screws is substantially affected by fitness of the nail in the medullary canal. In this study a closed form mathematical model based on elastic column-beam theory is developed to investigate how the nail-cortical contact which is simulated by a linear elastic foundation affects the stress of the distal locking screws. The model is comprised of a construct of a fractured femur with an intramedullay locked nail loaded by an eccentric vertical load. The stress of the locking screw is analysed as a function of the depth of the locking screw in the distal fragment under two situations: with or without nail-cortical contact in the distal fragment. In situation with nail-cortical contact, the screw stress is decreased as the length of nail-cortical contact and the depth of the screw in the distal fragment increases, but this stress contrarily increased when the nail is inserted beyond a certa

Techniques for fixation of fractures of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce the incidence of complications. We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities. Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion. Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

Aim: Distal extra articular fractures of femur and tibia are difþcult to treat by conventional nails because of inability to use distal locking screws. The aim of this study is to analyse the effectiveness of this new I.M. Nail that does not require the use of distal locking screws for rotational stability. Methods & Material: Since 1994 we have treated a total of 68 such cases. Of these 40 were fractures of distal tibia and 28 were that of femur. Age range was from 11– 92. After insertion of the nail in the usual way, a ÒTrio WireÒ was introduced through the nail. This wire fans out in the distal segment which maintains rotational stability. Patients were mobilised with partial weight bearing within 3 weeks. Results: Most of the fractures were united without any signiþcant problem. Delayed union occurred in 2 cases. Breakage of the trio wire occurred in one case and 1 patient with supra-condylar fracture of femur needed revision for persistent varus deformity. Conclusion: We conclude that this I.M. Nail can be used effectively for þxation of these difþcult fractures. This is does not require X-ray exposure for distal locking. Operative time is thus minimised. This also saves surgeonñs hands from direct exposure to radiation. The þxation also allows for dynamisation of the fracture to promote early union

Introduction: The present study was performed to compare the mechanical properties and fixation stability of tibial nails of the newest generation used in the management of distal metaphyseal fractures. Furthermore, we tried to evaluate whether distal locking with 4 locking screws might increase load-sharing after stabilization of distal metaphyseal tibial fractures. Methods: We used 16 Sawbones third generation large left tibiae (Sawbones Inc., Sweden) to create an unstable distal metaphyseal fracture model (AO type 43-A3). In 8 specimens the fracture was stabilized with 2 nails with 3 distal locking options (4x VersaNail™, DePuy Orthopaedics, Johnson& Johnson, Warsaw, IN; 4x T2 Tibial Nailing System™, Stryker, Kiel, Germany) and in 8 specimens with 2 nails with 4 locking options (4x Connex™, ITS Spectromed, Lassnitzhöhe, Austria; 4x Expert Tibial Nail™, Synthes, Switzerland). Each specimen was loaded cyclically with three loading sequences over a period of 40,000 cycles in each series (700N, 1,500N, 1,800N). Implant stiffnes during axial cyclic loading series in 7° valgus alignement was recorded as well as cycles until failure of the bone-implant-construct. Results: In the second loading series, implant failure was observed in all tibial nails with 3 distal locking screws after a mean period of 57,196.7 cycles. If distal locking was performed with 4 screws, implant failure was recorded in the third and last loading series after a mean period of 87,518.3 cycles (p< 0.001). If distal locking was performed with 3 distal locking screws, implant stiffness was 1776 (±99) N/mm. If distal locking was performed with 4 locking screws, implant stiffness was 2674 (±208) N/mm (p< 0.001). Conclusion: Distal locking with 4 screws improves implant-bone stability. Stability is influenced by the number of locking screws and not by screw diameter. In these fracture type, nails with 4 distal locking options should be used

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

We report the outcomes of 20 patients (12 men, 8 women, 21 feet) with Charcot neuro-arthropathy who underwent correction of deformities of the ankle and hindfoot using retrograde intramedullary nail arthrodesis. The mean age of the patients was 62.6 years (46 to 83); their mean BMI was 32.7 (15 to 47) and their median American Society of Anaesthetists score was 3 (2 to 4). All presented with severe deformities and 15 had chronic ulceration. All were treated with reconstructive surgery and seven underwent simultaneous midfoot fusion using a bolt, locking plate or a combination of both. At a mean follow-up of 26 months (8 to 54), limb salvage was achieved in all patients and 12 patients (80%) with ulceration achieved healing and all but one patient regained independent mobilisation. There was failure of fixation with a broken nail requiring revision surgery in one patient. Migration of distal locking screws occurred only when standard screws had been used but not with hydroxyapatite-coated screws. The mean American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS-FAO) score improved from 50.7 (17 to 88) to 65.2 (22 to 88), (p = 0.015). The mean Short Form (SF)-36 Health Survey Physical Component Score improved from 25.2 (16.4 to 42.8) to 29.8 (17.7 to 44.2), (p = 0.003) and the mean Euroqol EQ‑5D‑5L score improved from 0.63 (0.51 to 0.78) to 0.67 (0.57 to 0.84), (p = 0.012). Single-stage correction of deformity using an intramedullary hindfoot arthrodesis nail is a good form of treatment for patients with severe Charcot hindfoot deformity, ulceration and instability provided a multidisciplinary care plan is delivered. Cite this article: Bone Joint J 2015;97-B:76–82

Introduction: Intramedullary nailing is an acceptable method of treatment for femoral shaft fractures today. We present our experience from the use-of four different nails. Patients and Methods: Thirty fractures of the femoral shaft were treated by intramedullary nailing from Jan98–DecOl in our department. The patients’ age ranged from 19 to 87 (avg 36 ys). Twelve fractures were in poly-trauma patients. In 6 patients, due to an intense comminution, an external fixation was initially applied and a delayed intramedullary nailing was performed. Four different types of nails were used 8 Grosse & .Kempf, 1 Orthofix ,2 ZMS (Zimmer), and 19 Marchetti Vicenzi. Results: All patients were followed up until complete union of the fracture. A 1.5 cm shortening was found in one patient and two patients presented a valgus 7° at the fracture site. One pseudarthosis with broken implant (Marchetti) was seen and treated with a new nail of the same type. The Orthofix nail was used only once due to its lack of anatomic curvature. The mean surgical time of the GK and ZMS nails was 30 minutes more than that of Marchetti nails, due to the distal locking screws required. Conclusions: In our own experience, GK and ZMS nails provide a larger contact area in the endosteum as well as the best conditions for biomechanically sound distribution of loading. The placement of distal locking screws constitutes a major problem, as it requires extended surgical time and increased exposure to irradiation. The important advantage of the Marchetti nail is that no distal screws are required, so the operation and fluoroscopy time are much shorter. The main disadvantages of the Marchetti nail are the absence of quidewire during nail insertion, the minimal 13mm femoral canal diameter required proximally, the contraindication for very distal fractures and the inability to fully weightbear early

We review the results of the Gamma nail fixation to elucidate its effectiveness in the treatment of peritro-chanteric and subtrochanteric fractures of the neck of femur. We report the result of 718 cases of Gamma nail fixation in all such cases presenting at our institution since 1988. 573 cases of peritrochanteric and 145 cases of sub-trochanteric fractures were treated by means of standard and long Gamma nail. Age groups of the patients are from 33 to 99 years. No distal locking screw was used in cases of standard nails. All grades of surgeons were involved. Full weight bearing was allowed on the first post operative day. Cases were followed up for one year. No intraoperative iatrogenic fracture was encountered. Minimal post operative pain was experienced and mobility was regained early. All fractures healed satisfactorily except the following: 51 cases developed coxa vera deformity; 37 cases of undisplaced fractures of base of greater trochanter were noticed at 6 weeks follow up - all healed spontaneously; 1 case of external rotational deformity occurred in a long nail where no distal locking screw was used. 2 cases of deep infection were treated successfully by removal of nail and antibiotic treatment; 4 cases of fracture at the level of the distal end of the prosthesis, presented at 6 weeks to 2 year period following a subsequent trauma, were treated with exchange of device with long nail. Upward penetration of hip screw 22. No case of metal failure observed. Gamma nail provides a stable fixation in both simple and complex fractures of proximal femur with a much less invasive tehcnique which allows minimal disturbance of fracture haematoma, less incidence of wound infection and less amount of postoperative pain. Early mobility is regained with immediate and unrestricted weight bearing. Biomechanically also Gamma nail produces a better means of osteosynthesis

Conventional methods of treating ankle fractures in the elderly are associated with high rates of complication. We describe the results of treating these injuries in 48 frail elderly patients with a long calcaneotalotibial nail. The mean age of the group was 82 years (61 to 96) and 41 (85%) were women. All were frail, with multiple medical comorbidities and their mean American Society of Anaesthesiologists score was 3 (3 to 4). None could walk independently before their operation. All the fractures were displaced and unstable; the majority (94%, 45 of 48) were low-energy injuries and 40% (19 of 48) were open. . The overall mortality at six months was 35%. Of the surviving patients, 90% returned to their pre-injury level of function. The mean pre- and post-operative Olerud and Molander questionnaire scores were 62 and 57 respectively. Complications included superficial infection (4%, two of 48); deep infection (2%, one of 48); a broken or loose distal locking screw (6%, three of 48); valgus malunion (4%, two of 48); and one below-knee amputation following an unsuccessful vascular operation. There were no cases of nonunion, nail breakage or peri-prosthetic fracture. . A calcaneotalotibial nail is an excellent device for treating an unstable fracture of the ankle in the frail elderly patient. It allows the patient to mobilise immediately and minimises the risk of bone or wound problems. A long nail which crosses the isthmus of the tibia avoids the risk of peri-prosthetic fracture associated with shorter devices. Cite this article: Bone Joint J 2014; 96-B:817–22