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

Little is known about the increase in length of tendons in postnatal life or of their response to limb lengthening procedures. A study was carried out in ten young and nine adult rabbits in which the tibia was lengthened by 20% at two rates 0.8 mm/day and 1.6 mm/day. The tendon of the flexor digitorum longus (FDL) muscle showed a significant increase in length in response to lengthening of the tibia. The young rabbits exhibited a significantly higher increase in length in the FDL tendon compared with the adults. There was no difference in the amount of lengthening of the FDL tendon at the different rates. Of the increase in length which occurred, 77% was in the proximal half of the tendon. This investigation demonstrated that tendons have the ability to lengthen during limb distraction. This occurred to a greater extent in the young who showed a higher proliferative response, suggesting that there may be less need for formal tendon lengthening in young children

The response of the muscle is critical in determining the functional outcome of limb lengthening. We hypothesised that muscle response would vary with age and therefore studied the response of the muscles during tibial lengthening in ten young and ten mature rabbits. A bromodeoxyuridine technique was used to identify the dividing cells. The young rabbits demonstrated a significantly greater proliferative response to the distraction stimulus than the mature ones. This was particularly pronounced at the myotendinous junction, but was also evident within the muscle belly. Younger muscle adapted better to lengthening, suggesting that in patients in whom a large degree of muscle lengthening is required it may be beneficial to carry out this procedure when they are young, in order to achieve the optimal functional result

We investigated the effect of progesterone on the nerve during lengthening of the limb in rats. The sciatic nerves of rats were elongated by leg lengthening for ten days at 3 mm per day. On alternate days between the day after the operation and nerve dissection, the progesterone-treated group received subcutaneous injections of 1 mg progesterone in sesame oil and the control group received oil only. On the fifth, tenth and 17th day, the sciatic nerves were excised at the midpoint of the femur and the mRNA expression level of myelin protein P0 was analysed by quantitative real time polymerase chain reaction. On day 52 nodal length was examined by electron microscopy, followed by an examination of the compound muscle action potential (C-MAP) amplitude and the motor conduction velocity (MCV) of the tibial nerve on days 17 and 52. The P0 (a major myelin glycoprotein) mRNA expression level in the progesterone-treated group increased by 46.6% and 38.7% on days five and ten, respectively. On day 52, the nodal length in the progesterone-treated group was smaller than that in the control group, and the MCV of the progesterone-treated group had been restored to normal. Progesterone might accelerate the restoration of demyelination caused by nerve elongation by activating myelin synthesis

Objectives. Lengthening osteotomies of the calcaneus in children are in general grafted with bone from the iliac crest. Artificial bone grafts have been introduced, however, their structural and clinical durability has not been documented. Radiostereometric analysis (RSA) is a very accurate and precise method for measurements of rigid body movements including the evaluation of joint implant and fracture stability, however, RSA has not previously been used in clinical studies of calcaneal osteotomies. We assessed the precision of RSA as a measurement tool in a lateral calcaneal lengthening osteotomy (LCLO). Methods. LCLO was performed in six fixed adult cadaver feet. Tantalum markers were inserted on each side of the osteotomy and in the cuboideum. Lengthening was done with a plexiglas wedge. A total of 24 radiological double examinations were obtained. Two feet were excluded due to loose and poorly dispersed markers. Precision was assessed as systematic bias and 95% repeatability limits. Results. Systematic bias was generally below 0.10 mm for translations. Precision of migration measurements was below 0.2 mm for translations in the osteotomy. Conclusion. RSA is a precise tool for the evaluation of stability in LCLO. Cite this article: Bone Joint Res 2015;4:78–83

Osteomyelitis is an inflammatory condition accompanied by the destruction of bone and caused by an infecting microorganism. Open contaminated fractures can lead to the development of osteomyelitis of the fractured bone in 3-25% of cases, depending on fracture type, degree of soft-tissue injury, degree of microbial contamination, and whether systemic and/or local antimicrobial therapies have been administered. Untreated, infection will ultimately lead to non-union, chronic osteomyelitis, or amputation. We report a case series of 10 patients that presented with post-operative infected non-union of the distal femur with or without prior surgery. The cases were performed at Padmashree Dr. D. Y. Patil Hospital, Nerul, Navi Mumbai, India. All the patients’ consents were taken for the study which was carried out in accordance with the Helsinki Declaration. The methodology involved patients undergoing a two-stage procedure in case of no prior implant or a three-stage procedure in case of a previous implant. Firstly, debridement and implant removal were done. The second was a definitive procedure in form of knee arthrodesis with ring fixator and finally followed by limb lengthening surgery. Arthrodesis was planned in view of infection, non-union, severe arthritic, subluxated knee, stiff knee, non-salvage knee joint, and financial constraints. After all the patients demonstrated wound healing in 3 months along with good radiographic osteogenesis at the knee arthrodesis site, limb lengthening surgeries by tibial osteotomy were done to overcome the limb length discrepancy. Distraction was started and followed up for 5 months. All 10 patients showed results with sound knee arthrodesis and good osteogenesis at the osteotomy site followed by achieving the limb length just 1-inch short from the normal side to achieve ground clearance while walking. Our case series is unique and distinctive as it shows that when patients with infected nonunion of distal femur come with the stiff and non-salvage knee with severe arthritic changes and financial constraints, we should consider knee arthrodesis with Ilizarov ring fixator followed by limb lengthening surgery

Introduction. The recent introduction of Chatbots has provided an interactive medium to answer patient questions. The accuracy of responses with these programs in limb lengthening and reconstruction surgery has not previously been determined. Therefore, the purpose of this study was to assess the accuracy of answers from 3 free AI chatbot platforms to 23 common questions regarding treatment for limb lengthening and reconstruction. Method. We generated a list of 23 common questions asked by parents before their child's limb lengthening and reconstruction surgery. Each question was posed to three different AI chatbots (ChatGPT 3.5 [OpenAI], Google Bard, and Microsoft Copilot [Bing!]) by three different answer retrievers on separate computers between November 17 and November 18, 2023. Responses were only asked one time to each chatbot by each answer retriever. Nine answers (3 answer retrievers × 3 chatbots) were randomized and platform-blinded prior to rating by three orthopedic surgeons. The 4-point rating system reported by Mika et al. was used to grade all responses. Result. ChatGPT had the best response accuracy score (RAS) with a mean score of 1.73 ± 0.88 across all three raters (range of means for all three raters – 1.62 – 1.81) and a median score of 2. The mean response accuracy scores for Google Bard and Microsoft Copilot were 2.32 ± 0.97 and 3.14 ± 0.82, respectively. This ranged from 2.10 – 2.48 and 2.86 – 3.54 for Google Bard and Microsoft Copilot, respectively. The differences between the mean RAS scores were statistically significant (p < 0.0001). The median scores for Google Bard and Microsoft Copilot were 2 and 3, respectively. Conclusion. Using the Response Accuracy Score, the responses from ChatGPT were determined to be satisfactory, requiring minimal clarification, while the responses from Microsoft Copilot were either satisfactory, requiring moderate clarification, or unsatisfactory, requiring substantial clarification

Introduction. The heterogeneity of outcomes used in the field of lower limb lengthening surgery (LLLS) affects our ability to synthesize evidence. This hampers robust systematic reviews and treatment recommendations for clinical practice. Ultimately this reduces the impact of research for both patients and healthcare professionals. This scoping review aimed to describe the outcomes and outcome measurement instruments (OMIs) used within the field of LLLS. Method. A systematic literature search of WOS, Scopus, Embase, MEDLINE, and the Cochrane Library identified all studies reporting outcomes in children and adults after LLLS. All outcomes and OMIs were extracted verbatim. An iterative process was used to group outcome terms under standardized outcome headings categorized using the COMET Taxonomy of Outcomes. Result. Data saturation was achieved in 2020. A total of 142 studies were included between 2024-2020, reporting 2964 verbatim outcomes with 663 standardized outcome terms collapsed into 119 outcome headings (subdomains). A total of 29 patient-reported and 26 clinician-reported outcome instruments were identified. The most commonly reported outcome was “Lengthening amount”, reported in over 72% of the included studies, while “health-related quality of life” was measured in 16% and all life impact outcomes were reported in 19% of the included studies. Conclusion. A large number of peer-reviewed publications are available, demonstrating that significant resources are being devoted to research on LLLS. However, reported outcomes for people with LLLS are heterogeneous, subject to reporting bias, and vary widely in the definitions and measurement tools used to collect them. Outcomes likely to be important to patients, such as quality of life and measures of physical function, have been neglected. This scoping review identifies a need to standardize outcomes and outcome measures reported on patients recovering from lower limb lengthening surgery; this can be addressed by creating a core set of outcomes

The regenerative potential of bone is enormous, and it is possible to lengthen limbs by bone distraction. However, there remains a major risk of fracture after lengthening the bone. Previous studies have described how the pixel value ratio may be used for determining the time for frame removal. The aim of this study was to investigate the intrarater and the interrater reliability of pixel value scores from radiographs in tibial lengthening prior to frame removal. Moreover, the study aimed to determine the overall number of X- rays obtained during circular frame treatment. Retrospective study. Patients treated with tibial lengthening by a circular frame at Aalborg University Hospital from January 1st 2000 to December 31st 2017 and a minimum of 12 months after frame removal were included. The bone was divided in proximal-, regenerate- and distal bone zone. These 3 zones were in AP x-ray divided in an anterior and posterior zone and in sagittal X-ray medial and lateral zone producing 6 zones in which the pixel value was measured. Pixel value ratio was calculated as: (Proximal pixel value+Distal pixel value)/2/Regenerate pixel value. Interrater correlations were calculated from measurements obtained by an orthopaedic registrar and an orthopaedic specialist. Intrarater correlation was calculated from repeated measurements obtained by an orthopaedic specialist. Mean duration of circular frame treatment was: 6 (+-3) months. Median number of x-ray controls during frame treatment were: 9 (+-4). Out of 90 tibial lengthening it was only possible to measure pixel value in all six areas of interest on 20 lengthening prior to frame removal. Major reasons for inability to obtain measurements were metal hardware crossing the areas of bone interest on x-rays. The mean (95 % confidence intervals) pixel ratios values were: 1) lateral: 0.96 (0.93–1.00); 2) medial: 0.95 (0.92–0.99); 3) anterior: 0.94 (0.90–0.97); 4) posterior: 0.96 (0.93–0.99). The mean (95 % confidence intervals) inter ratter ICC estimates were: 1) lateral: 0.8 (0.5–0.9); 2) medial: 0.8 (0.4–0.9); 3) anterior: 0.4 (−0.5–0.8); 4) posterior: 0.6 (0.1–0.9). The mean (95 % confidence intervals) intra ratter ICC estimates were: 1) lateral: 1.0 (0.9–1.0); 2) medial: 1.0 (1.0–1.0); 3) anterior: 0.9 (0.9–1.0); 4) posterior: 1.0 (1.0–1.0). Out of the 20 lengthening examined one fracture occurred in the bone regenerate after frame removal. Prospective studies are warranted to determine whether the pixel value ratio can be used as an indicator for frame removal

Introduction and Objective. Several studies have described double and triple femoral neck lengthening osteotomies to correct coxa brevis deformity, however, no overview exists in literature. Our aim was to perform the first systematic review of the outcomes of double and triple femoral neck lengthening. Materials and Methods. After an extensive search in Pubmed, CINAHL and Embase libraries for published articles using the following search strategy: ‘(((proximal femoral deformity) OR hip dysplasia) OR coxa brevis) AND (((femoral neck lengthening) OR double proximal femoral osteotomy) OR triple proximal femoral osteotomy)’, we included studies reporting the results of double and triple femoral neck osteotomies. Clinical and radiological outcomes, and reported complications were extracted. The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results. After evaluating 456 articles, we included 11 articles reporting 149 osteotomies in 143 patients (31% male, 64% female, 5% unspecified). Mean age of the patients was 20 years (range 7 years to 52 years). Indications were developmental hip dysplasia (51%), Perthes disease (27%), infection (6%), post-trauma (4%), congenital disorders (2%), slipped capital femoral epiphysis (1%), idiopathic (3%) and unknown (6%). The mean limb length discrepancy reduced by 12 mm (0 mm to 40 mm). In total, 65% of 101 positive Trendelenburg sign hips experienced improvement of abductor muscle strength. An 18% (9% to 36%) increase could be found in functional hip scores. Mean increase in articulo-trochanteric distance was 24 mm (10 mm to 34 mm). Five patients older than 30 years at the time of osteotomy and two younger patients with prior hip incongruency had disappointing results and required arthroplasty. In all, 12 complications occurred in 128 osteotomies, in which complications were reported. Conclusions. This first systematic review of double and triple femoral neck lengthening osteotomies shows that favorable outcomes and few complications can be expected in coxa brevis, however, excessive caution is required in older patients with incongruent hips

Introduction. Previous studies have shown the potential for virtual reality (VR) immersion as a promising technique for pain and anxiety management. The aim of our study was to evaluate the feasibility of VR in the management of pain and anxiety during post-op external fixator care procedures. Method. This study involved patients aged 5-21 years following limb lengthening/reconstruction surgery with an external fixator. Aqua VR application from the KindVR® was utilized for this study. Subjects were seen during the first four postoperative visits and assigned to a ‘VR-first’ or ‘no-VR-first’ group. Visits alternated between VR immersion and no VR immersion during care procedures. The study endpoints (pain and anxiety levels) were assessed before, during, and after procedures using the Wong-Baker Faces (FACES) and Children's Fear Scale, respectively. Proxy scores for pain and anxiety were also obtained from parents or legal guardians and providers. Result. A total of 29 patients (16 male and 13 female) were evaluated. The mean age at enrollment was 14.4 ± 2.2 years for group 1 and 14.7 ± 4.0 years for group 2. The median number of pin sites was 7. Anxiety scores were consistently higher during the non-VR immersion experience compared to the VR immersion visits. The pain and anxiety scores were significantly lower in the ‘VR-first’ group during the non-VR immersion study visits compared to patients in the ‘no-VR-first’ group. This observation was also consistent with survey findings among the parent proxies and providers. Conclusion. VR immersion is associated with lower anxiety scores for pin-site care procedures. VR immersion at the first post-operative visit following limb reconstruction surgery was also associated with lower pain and anxiety scores during subsequent non-VR immersion visits

Introduction. The non-union of long bones poses a substantial challenge to clinicians and patients alike. The Ilizarov fixation system and Limb Reconstruction System (LRS), renowned for their versatility in managing complex non-unions. The purpose of this retrospective study was to assess the outcomes of acute docking with the bone peg-in-bone technique for the management of non-unions of long bones. The study seeks to evaluate its effectiveness in achieving complete bony union, preserving limb length and alignment, correcting existing deformities, and preventing the onset of new ones. Method. A retrospective analysis of 42 patients was done with infected and non-infected non-unions of long bones who received treatment at a tertiary care hospital between April 2016 to April 2022. We utilized the Association for the Study and Application of Methods of the Ilizarov (ASAMI) scoring system to assess both bone and functional outcomes and measured mechanical lateral distal femoral angle (mLDFA) for the femur and the medial proximal tibial angle (MPTA) for the tibia. Result. In our retrospective study involving 42 patients, a total of 30 patients had post debridement gap of >2 cm and average gap of 4.54 cm (range 1 – 13 cm) and therefore underwent corticotomy and lengthening. The average external fixation time was 6.52 (range 4 – 11 months) and average external fixation index of 2.08 (range 0.4 – 4.5 months/cm). The ASAMI scoring system showed bone result of 38 excellent, 3 good and 1 fair. Functional result of 40 excellent and 2 good outcomes. The post op mLDFA and MPTA were in normal range except in 3 patients which not statistically significant. Conclusion. In conclusion, the use of acute docking provides several advantages such as promoting early fracture healing, increasing stability, shortening treatment time, reducing the number of surgical procedures and reduced number of complications

To analyse bone stresses in humerus-megaprosthesis construct in response to axial loading under varying implant lengths in proximal humeral replacement following tumour excision. CT scans of 10 cadaveric humeri were processed in 3D Slicer to obtain three-dimensional (3D) models of the cortical and cancellous bone. Megaprostheses of varying body lengths (L) were modelled in FreeCAD to obtain the 3D geometry. Four FE models: group A consisting of intact bone; groups B (L=40mm), C (L=100mm) and D (L=120mm) comprising of humerus-megaprosthesis constructs were created. Isotropic linear elastic behaviour was assigned for all materials. A tensile load of 200N was applied to the elbow joint surface with the glenohumeral joint fixed with fully bonded contact interfaces. Static analysis was performed in Abaqus. The bone was divided at every 5% bone length beginning distally. Statistical analysis was performed on maximum von Mises stresses in cortical and cancellous bone across each slice using one-way ANOVA (0-45% bone length) and paired t-tests (45-70% bone length). To quantify extent of stress shielding, average percentage change in stress from intact bone was also computed. Maximum stress was seen to occur distally and anteriorly above the coronoid fossa. Results indicated statistically significant differences between intact state and shorter megaprostheses relative to longer megaprostheses and proximally between intact and implanted bones. Varying levels of stress shielding were recorded across multiple slices for all megaprosthesis lengths. The degree of stress shielding increased with implant lengthening being 2-4 times in C and D compared to B. Axial loading of the humerus can occur with direct loading on outstretched upper limbs or indirectly through the elbow. Resultant stress shielding effect predicted in longer megaprosthesis models may become clinically relevant in repetitive axial loading during activities of daily living. It is recommended to use shorter megaprosthesis to prevent failure

A medializing calcaneal osteotomy (MCO) is one of the key inframalleolar osteotomies to correct progressive collapsing foot deformity (PCFD). While many studies were able to determine the hind- and midfoot alignment after PCFD correction, the subtalar joint remained obscured by superposition on plain radiography. Therefore, we aimed to perform a 3D measurement assessment of the hind- and subtalar joint alignment pre- compared to post-operatively using weightbearing CT (WBCT) imaging. Fifteen patients with a mean age of 44,3 years (range 17-65yrs) were retrospectively analyzed in a pre-post study design. Inclusion criteria consisted of PCFD deformity correct by MCO and imaged by WBCT. Exclusion criteria were patients who had concomitant midfoot fusions or hindfoot coalitions. Image data were used to generate 3D models and compute the hindfoot - and talocalcaneal angle as well as distance maps. Pre-operative radiographic parameters of the hindfoot and subtalar joint alignment improved significantly relative to the post-operative position (HA, MA. Sa. , and MA. Co. ). The post-operative talus showed significant inversion, abduction, and dorsiflexion of the talus (2.79° ±1.72, 1.32° ±1.98, 2.11°±1.47) compared to the pre-operative position. The talus shifted significantly different from 0 in the posterior and superior direction (0.62mm ±0.52 and 0.35mm ±0.32). The distance between the talus and calcaneum at the sinus tarsi increased significantly (0.64mm ±0.44). This study found pre-dominantly changes in the sagittal, axial and coronal plane alignment of the subtalar joint, which corresponded to a decompression of the sinus tarsi. These findings demonstrate the amount of alternation in the subtalar joint alignment that can be expected after MCO. However, further studies are needed to determine at what stage a calcaneal lengthening osteotomy or corrective arthrodesis is indicated to obtain a higher degree of subtalar joint alignment correction

Paediatric musculoskeletal (MSK) disorders often produce severe limb deformities, that may require surgical correction. This may be challenging, especially in case of multiplanar, multifocal and/or multilevel deformities. The increasing implementation of novel technologies, such as virtual surgical planning (VSP), computer aided surgical simulation (CASS) and 3D-printing is rapidly gaining traction for a range of surgical applications in paediatric orthopaedics, allowing for extreme personalization and accuracy of the correction, by also reducing operative times and complications. However, prompt availability and accessible costs of this technology remain a concern. Here, we report our experience using an in-hospital low-cost desk workstation for VSP and rapid prototyping in the field of paediatric orthopaedic surgery. From April 2018 to September 2022 20 children presenting with congenital or post-traumatic deformities of the limbs requiring corrective osteotomies were included in the study. A conversion procedure was applied to transform the CT scan into a 3D model. The surgery was planned using the 3D generated model. The simulation consisted of a virtual process of correction of the alignment, rotation, lengthening of the bones and choosing the level, shape and direction of the osteotomies. We also simulated and calculated the size and position of hardware and customized massive allografts that were shaped in clean room at the hospital bone bank. Sterilizable 3D models and PSI were printed in high-temperature poly-lactic acid (HTPLA), using a low-cost 3D-printer. Twenty-three operations in twenty patients were performed by using VSP and CASS. The sites of correction were: leg (9 cases) hip (5 cases) elbow/forearm (5 cases) foot (5 cases) The 3D printed sterilizable models were used in 21 cases while HTPLA-PSI were used in five cases. customized massive bone allografts were implanted in 4 cases. No complications related to the use of 3D printed models or cutting guides within the surgical field were observed. Post-operative good or excellent radiographic correction was achieved in 21 cases. In conclusion, the application of VSP, CASS and 3D-printing technology can improve the surgical correction of complex limb deformities in children, helping the surgeon to identify the correct landmarks for the osteotomy, to achieve the desired degree of correction, accurately modelling and positioning hardware and bone grafts when required. The implementation of in-hospital low-cost desk workstations for VSP, CASS and 3D-Printing is an effective and cost-advantageous solution for facilitating the use of these technologies in daily clinical and surgical practice

Introduction and Objective. Digital infra-red thermography may have the capability of identifying local inflammations. Nevertheless, the role of thermography in diagnosing pin site infection has not been explored yet and the reliability and validity of this method for pin site surveillance is in question. The purpose of this study was to explore the capability and intra-rater reliability of thermography in detecting pin site infection. Materials and Methods. This explorative proof of concept study follows GRRAS -guidelines for reporting reliability and agreement studies. After clinical assessment of pin sites by one examiner using Modified Gordon Pin Infection Classification (Grade 0 – 6), thermographic images of the pin sites were captured with a FLIR C3 camera and analyzed by the FLIR tools software package. The maximum skin temperature around the pin site and the maximum temperature for the whole thermographic picture was measured. Intra-rater agreement was established and test-retests were performed with different camera angles. Results. Thirteen (4 females) patients (age 9–72 years) were included. Indications for frames: 4 fracture, 2 deformity correction, 1 lengthening, 6 bone transport. Days from surgery to thermography ranged from 27 to 385 days. Overall, 231 pin sites were included. Eleven pin sites were diagnosed with early signs of infection: five grade 1, five grade 2, one grade 3. Mean pin site temperature was 33.9 °C (29.0–35.4). With 34 °C as cut-off value for infection, sensitivity was 73%, specificity 67%, positive predictive value 10% and negative predictive value 98%. Intra-rater reliability for thermography was ICC 0.85 (0.77–0.92). The temperature measured was influenced by the camera postioning in relation to pin site with a variance of 0.2. Conclusions. Measurements of pin sites using the handheld FLIR C3 infrared camera was a reliable method and the temperature was related to infection grading. This study demonstrates that digital thermography with a handheld camera might be used for monitoring the pin sites after operations to detect early infection, however, future larger prospective studies are necessary

Shortness of an extremity due to different causes is an issue that may adversely affect human life functional and psychologically. In this study, in the light of previous studies, it is aimed to develop a new expandable intramedullary system, providing lengthening in order to remove previous problems and complications and to annihilate leg length discrepancies at present and future without second surgical intervention as far as possibble by lenghtening the intramedullary nail. To this end, a new electromechanically activated intramedullary nail has been designed and generated. The intramedullary nail was designed to perform extremity lengthening electro-mechanically. The 3D design of the system is performed with computer software and the rapid and metal prototype of the system has been produced. The intramedullary nail system is comprised of three main units; Mechanical transmission unit, Electronic unit, Lengthening unit. The nail system is designed to function both mechanically and electronically complying with the requirement. This also provides an advantage that if any one (mechanic or electronic) fails, the lengthening process can continue with the other. Compression tests are applied in order to evaluate the strength of the system. The deformation values of the parts are recorded and stress values of each parts were calculated. The new system needs only 300N loading for mechanical lengthening. When 800N is considered as average human weight, the implant must withstand minumum 2400N load. Considering the safety conditions, we applied 4000N load on the new system. At 4000N, the whole system shows only 1.465 mm deformation which is less than the gap between the two bone parts. Also, when the system is implanted inside the bone, the loads are distributed proportionally between the bone and the implant. So, except for extraordinary conditions, the newly developed system is highly rigid and safe. In each applied method, lots of complications whether general or method-specific are seen. When the methods like Albizzia, ISKD and FITBONE avaliable and widely used today are examined separately, complications specific to these methods can be clearly observed [1–12]. Bliskunov Nail, Albizzia Nail and ISKD [13–18] have mechanical working principles and in these systems, lengthening process is obtained by rotational movement of the extremity. This rotational movement causes complications like pain, dislocation and uncontrolled lengthening [11,13,16,19–21]. In our newly developed system, only axial stimulation is needed for the activation of the mechanism. This is one of the advantages of our system. Both the mechanical unit and the electronical units are designed to be extended 0.1 mm at each activation. This means that the optimal amount of distraction (1mm/day) can be achieved in a controlled way. In other systems, the distraction amount can not be fully controlled and complications seen on other systems [1, 6, 8–10], like distruption of callus due to the excessive distraction and nonunion of the bone can be encountered. The success of the system at practice will be examined with in-vivo animal experiments and according to the results, it will be ready for use on human by performing necessary restorations

Introduction. Pediatric femoral fracture including supracondylar and subtrochantric fracture constitutes 1.6% of all pediatrics fractures. 1. Elastic nails remain the standard treatment of choice in mid shaft transverse femoral fracture in children weighting less than 45kg. 2. But in subtrochantric and spiral femoral fracture, failure rate of TENS nails are quite high. 3. . Material and methods. We retrospectively reviewed 30 subtrochantric fracture in children (average age 9 years) treated with bridge plate by mini invasive approach. Result. All fracture united well in average 14 weeks. Single complication was 5mm limb lengthening due to fixation in traction on fracture table in one case. We strongly recommend bridge plate in complex femoral fracture in children

Abstract. Objectives. Clavicle fractures are common, yet debate exists regarding which patients would benefit from conservative versus operative management. Traditionally shortening greater than 2cm has been accepted as an indicator for surgery. However, clavicle length varies between individuals. In a cadaveric study clavicle shortening greater than 15% was suggested to affect outcomes. There is no clinical correlation of this in the literature. In this study we investigate outcomes following middle third clavicle fractures and the effect of percentage shortening on union rates. Methods. We identified a consecutive series of adults with primary midshaft clavicle fractures presenting to our institution from April 2015-March 2017. Clinical records and radiographs were reviewed to elicit outcomes. Time to union was measured against factors including; percentage shortening, displacement, comminution and smoking. Statistical significance was calculated. Results. 127 patients were identified, of whom 90 were managed conservatively and 37 operatively. Fractures were displaced in 86 patients (68%). Mean age was 41.7 years (range 18–89). Mean time to union for displaced fractures was longer than for undisplaced at 13.4 and 8.9 weeks respectively (p=0.0948). Displaced fractures treated operatively had mean time to union of 12.8 weeks, three weeks shorter than those managed conservatively (p=0.0470). Mean time to union for fractures with >15% shortening was 16.0 weeks, nearly double the 8.7 weeks with <15% shortening (p= 0.0241). Smokers had 8 weeks longer time to union (p=0.0082). Nonunion rate was 10% in fractures managed conservatively and 0% in those treated operatively. Complications following operative management were plate removal (13.5%), frozen shoulder (8.1%) and infection (2.9%). Conclusions. Nonunion rate is higher in fractures managed conservatively. Shortening >15% leads to significantly longer union time and should therefore be used as an indicator for surgery. Displacement and smoking also lengthen time to union and should be considered in the operative decision process. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Background. Lengthening over nail (LON) and the use of internal lengthening nails have been developed to minimize patients' time in a frame during femur lengthening. This study compares the outcomes of two techniques of femur lengthening, LON and Intramedullary Skeletal Kinetic Distraction (ISKD). Methods. In this retrospective study, 12 consecutive ISKD procedures were performed for femoral lengthening and followed for an average of 76 months. After the ISKD group, 20 consecutive femoral lengthening procedures were performed as an LON technique and followed for an average of 27 months. Results. There was no significant difference in achieving the lengthening goals between the two procedures. The healing index for the LON group averaged 1.4 months/cm, while the ISKD group was 3.2 months/cm (p=0.242). The distraction rates for the ISKD had a fast group (>1mm/day) with an average distraction rate of 1.7 mm/day and a slow group (<1mm/day) with a distraction rate of 0.84 mm/day. The LON group had an average distraction rate of 0.88 mm/day (p<0.001). The incidence of complications that required further unanticipated surgeries for the LON group was 1/20 (5%), while the ISKD group had complications in 6/12 femurs (50%, p=0.004). Conclusions. We concluded that the LON technique is a more predictable and reliable method for femoral lengthening than the ISKD