End caps are intended to prevent nail migration (push-out) in elastic stable intramedullary nailing. The aim of this study was to investigate the force at failure with and without end caps, and whether different insertion angles of nails and end caps would alter that force at failure.

Simulated oblique fractures of the diaphysis were created in 15 artificial paediatric femurs. Titanium Elastic Nails with end caps were inserted at angles of 45°, 55° and 65° in five specimens for each angle to create three study groups. Biomechanical testing was performed with axial compression until failure. An identical fracture was created in four small adult cadaveric femurs harvested from two donors (both female, aged 81 and 85 years, height 149 cm and 156 cm, respectively). All femurs were tested without and subsequently with end caps inserted at 45°.

In the artificial femurs, maximum force was not significantly different between the three groups (p = 0.613). Push-out force was significantly higher in the cadaveric specimens with the use of end caps by an up to sixfold load increase (830 N, standard deviation (SD) 280 vs 150 N, SD 120, respectively; p = 0.007).

These results indicate that the nail and end cap insertion angle can be varied within 20° without altering construct stability and that the risk of elastic stable intramedullary nailing push–out can be effectively reduced by the use of end caps.

Cite this article: Bone Joint J 2015;97-B:558–63.

Background. Intramedullary nailing is a widely accepted treatment method for femoral fractures. Failure of locking screws is often a threatening complication, particularly on comminuted fractures. For comminuted fractures, the locking nails are load-bearing devices. The load transfer between fractured fragments is made through especially the locking screws for these load bearing situations. Nonunion, malunion, delayed union, shortening, and nail migration are the expected results if early failure of locking screws is present with comminuted fractures. In this study our aim was to compare the bending resistance of titanium and stainless steel locking screws. Methods. We tested 60 locking screws in six groups (titanium, stainless steel, unthreaded, low threaded and high threaded) in a steel tube that has 30 mm inner diameter, which imitates the lesser trochanter level. We determined the yield points at three-point bending tests that permanent deformation started in the locking screws using an axial compression testing machine. Results. The three-point bending resistance of 5 mm low threaded titanium locking screws (bending at 1413 N loading) was 46.5 % less than the three-point bending resistance of 5 mm low threaded stainless steel locking screws (bending at 2171 N loading) (p < 0.001). Five mm stainless steel locking screws are 29–57 % more resistant to three-point bending deformation than titanium ones. Conclusions. Therefore, stainless steel locking screws instead of titanium ones must be preferred in comminuted femur shaft fractures. In intramedullary nailing of comminuted or long oblique femur fractures, a locking screw should be 5 mm low threaded or unthreaded stainless steel or 5 mm unthreadedtitanium. Five mm high threaded titanium or stainless steel screws must not ever be used as a locking screw. Level of Evidence. 5. Disclosure. Authors declare that there is no conflict of interest related to the present study

The influence of rigid fixation and permanent compression on the results, the timing of fusion and rehabilitation after fractures of the femoral neck was investigated. A hip fracture is 60–80% of all fractures of the proximal femur. Despite recent advances in the treatment of this disease, the percentage of unsatisfactory outcomes as high as 25–35%. The choice of surgical treatment in femoral neck fractures in the elderly remains as controversial as it was almost 50 years ago when Speed called him as “the unsolved fracture. Hip replacement is currently the gold standard in the treatment of femoral neck fractures. But compared with the osteosynthesis operation takes more time, is accompanied by massive blood loss, sometimes the need for transfusion and a higher risk of deep wound infection. Given these facts the best is an indoor low-traumatic method of osteosynthesis locking. Compare of the results of femoral neck fractures using of osteosynthesis 3 blade nail, spongious screws and nail for permanent compression. A retrospective analysis of treatment of 252 patients from 1982 to 2015 with subcapitale and transcervical fractures of the femoral neck on the basis “RCTO named by H.J. Makazhanova”. In the research locales patients older than 40 years. All patients were divided according to the applied method of treatment: 1 group of 95 patients operated using a 3-blade-nail, in the 2nd group of 105 patients operated on spongious screws, in the 3 group of 52 patients operated nail for the permanent compression, authoring. All patients underwent x-ray examination before and after surgery. The average period from time of injury before performing the osteosynthesis amounted to 4–7 days. The follow-up period was 6–12 months. The results obtained clinically and radiographically divided into good, satisfactory, poor. Good and satisfactory results were regarded as positive, and poor results as negative. The average age of patients was 67.5 years. Among these female patients − 174 (69%), the male − 78 (31%). Traumatization more prone to elderly accounting for 206 (81.7%) cases, and only 46 (18.3%) in the middle age group. Analysis of the results of treatment showed positive results in 1 group − 69.5 %, in group 2 − 83.8 %, in group 3 − 96.2 %. In the first group of 29 (31.5 %) and in the second group of 17 (16.2 %) patients have postoperative complications: secondary displacement, nail migration, pseudarthrosis, necrosis of head. The patients of third group have postoperative complications in 2 cases (3.8 %): displacement of bone fragments according of retraumatization. Employability was restored in 1 group − 7–9 months, in group 2 - in 6–8 months, 3 group - through 6–6.5 months. 1). The method of choice for fresh fractures of the femoral neck, especially subcapital fractures in the elderly, is a minimally invasive method of closed compression osteosynthesis. 2). Comparative analysis of treatment results showed that for the consolidation and subcapital transcervical femoral neck fractures can provide rigid fixation of bone fragments. 3). The use of permanent compression is the best method, which shortens the period of consolidation

We treated 39 patients with fractures of the humeral shaft by closed retrograde locked intramedullary nailing, using Russell-Taylor humeral nails. The mean healing time of all fractures was 13.7 weeks. After consolidation, shoulder function was excellent in 92.3% and elbow function excellent in 87.2%. Functional end-results were excellent in 84.6% of patients, moderate in 10.3% and bad in 5.1%. One patient had a postoperative radial nerve palsy, which recovered within three months. There was additional comminution at the fracture site in three patients (7.7%) which did not affect healing, and slight nail migration in two older patients (5.1%). Two patients (5.1%) needed a second procedure because of disturbed fracture healing. One screw breakage was seen in a patient with delayed union. Retrograde locked humeral nailing appears to be a better solution for the stabilisation of fractures of the humeral shaft than anterograde nailing or plate and screw fixation. We found the complication rate to be acceptable and shoulder and elbow function to recover rapidly in most cases

Objectives: To assess the stabilizing effect of Ender nails on humeral shaft fracture and to assess proper nail length. Materials and Method: Ender nailing was performed in 67 patients. Age ranged from 22 to 79 years. 9 were open fractures, and the 58 were closed ones; 13 comminuted, 28 spiral, 23 transverse, and 3 segmental fractures. 19 had associated injuries in other parts. One nail was used in 18 cases, two nails in 46 cases, and three nails in 3 cases. In 16 cases long nails were used. In the 12 elderly patients nail was inserted under local anesthesia, In all cases the sling and swathe was applied postoperatively to avoid rotatory shear. Results: Radiologically visible bridging callus was observed at 6.8 weeks on average: the earlist one was at postop 5 weeks, and the latest was at postop 15 weeks. The average clinical union time was 9.3 weeks. In the 6 cases the long nail distracted the fracture gap, and resulted in delayed union. In the 10 remainders the distracted gap was spontaneously reduced when the nails migrated proximally through an entry hole. In cases of proximal nail migration, shoulder pain and partial stiffness were complicated, which disappeared after nail removal. Conclusion: It is found that intramedullary Ender nailing is a simple and less invasive surgical procedure in humerus which brings the successful fracture union with least complications

The retrograde Marchetti-Vicenzi humeral nail consists of four or five flexible branches. At one end these branches are fixed into a solid L-shaped cylinder and at the other, they are held together with a locking wire. The nail is inserted in a retrograde way through a cortical window proximal to the olecranon fossa. Once passed the fracture, removing the locking wire allows the branches to spread in the metaphysis providing proximal stability. Distal locking is achieved through screw fixation. The Marchetti-Vicenzi nail presents several theoretical advantages. Its flexible branches facilitate nail insertion and might favour fracture healing. Distal locking is performed under direct vision from posterior to anterior and additional proximal locking is not required, preventing iatrogenic neurovascular damage. Distal locking avoids nail migration and retrograde nail insertion spares the rotator cuff. Early mobilisation is often possible. This leads to an equally good elbow function, but with a better shoulder function compared to antegrade nailing. On the other hand, limited rotational stability, especially in transverse fractures, can cause non-union and hardware failure. In the initial design, the bulky L-shaped end made a large supracondylar insertion and removal window mandatory, increasing the risk of fracture in this area. In the later version, the angle of the L-shaped cylinder has therefore been modified. In our opinion, the use of the Marchetti-Vicenzi nail is not advisable in comminuted or transverse humeral fractures, in fractures extending in the distal third or in patients (young ladies) with a narrow medullary canal. Nail removal should only be considered if absolutely necessary

Aim: To evaluate time of union and functional recovery of the shoulder joint in humeral shaft fractures treated with antegrade intramedullary nailing. Methods: During 1998–2002, 29 patients (16 male and 13 female, mean age 43.7 years) with humeral shaft fractures underwent antegrade, proximal locked, intramedullary nailing. A modified extra-articular entry point, 1 cm below the greater tuberosity, was used to avoid rotator cuff damage. The nail, after accurate measurement of its length and proximal metaphysis enlargement up to 10 mm, was impacted into the narrow, cone-shaped, distal part of the humerus, without the necessity of distal screw interlocking. Passive motion of the shoulder joint was initiated from the 2nd postoperative day and active assisted exercises after the 2nd postoperative week. Results: Mean follow up period was 27 months. Solid callus formation was noted in all fractures, between the 14th and 18th postoperative week. No cases of intra-operative fractures, nerve irritation, rotational instability, nail migration and loss of distal impaction were noted. Mean Constant-Murley score was 93 points at the 16th postoperative week. Conclusion: Antegrade intramedullary nailing is a reliable and beneficial procedure for the treatment of humeral shaft fractures, regarding union and functional recovery of the arm. The extra-articular entry point should be preferred to avoid rotator cuff and articular surfaces damage whereas the accurate measurement of the nail length and the firm impaction of it at the olecranon fossa makes distally interlocking unnecessary, decreasing significantly the overall operative time and the associated complications

Intramedullary Nailing is now accepted as the standard treatment for most femoral diaphyseal fractures. Most intramedullary nails are designed for proximal and distal locking with screws. We describe our experience with the Brooker Wills femoral nail. This nail is unique as distal fixation is achieved with as transverse fixator deployed through slots in the nail, a concept first enunciated by deCamargo in 1952. The fins of the fixator pierce the distal cortex when deployed thereby conferring rotational stability. The entire nail (including the proximal and distal fixation devices) can be inserted through a single proximal incision in the skin. We treated 17 patients with femoral shaft fractures using this system. 93% of the patients were males. Motor vehicle accidents accounted for 80 % of the fractures. Most fractures involved the middle third of the femur (54%), followed by distal third (33%) and proximal third (13%). 67 % of the fractures showed Winquist and Hansen Grade 3 or 4 comminution. All the nailings were performed in the supine position. Static locking was done in 16 cases. Post operative weight bearing was individualized with 86% of the patients bearing full weight before the end of 16 weeks. The average time to full weight bearing was 14 weeks. The mean time to union was 17.1 weeks, with proximal, middle and distal third fractures showing average healing times of 19, 15.6 and 18.8 weeks respectively. All the fractures united. There was one case of delayed union. Intra-operative complications included–inability to deploy the distal fixator in one case and unwinding of the reamer in another case. There was one case of superficial infection where a patient developed a sinus over the metallic fin of the distal fixation device, which had penetrated the cortex. This healed after the distal fixation device was removed. There was one case of proximal nail migration, but the fracture went onto union with some limb shortening. Results were evaluated using the scoring system devised by Sanders etal (1991). The functional criteria in their scoring system include- knee flexion, presence of pain, femur deformity, walking distance, stair climbing and pre injury functional status. We achieved excellent results in 53% of patients, good- 27%, fair–13 % and poor-7%. We feel that the main advantage of the Brooker Wills Nail is the ease of distal locking. This saves time and also leads to lower level of radiation exposure, as the image intensifier is sparingly used for distal locking. In fact, this nail is an attractive option in centres which lack an image intensifier. We achieved good results with this nailing system and feel that it is an acceptable alternative to other nailing systems with conventional locking systems with screws

Objectives

Experimental studies indicate that non-steroidal anti-inflammatory drugs (NSAIDs) may have negative effects on fracture healing. This study aimed to assess the effect of immediate and delayed short-term administration of clinically relevant parecoxib doses and timing on fracture healing using an established animal fracture model.

Aims

The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening. This study compares outcomes following antegrade and retrograde femoral lengthening in both adolescent and adult patients.

This review is aimed at clinicians appraising preclinical trauma studies and researchers investigating compromised bone healing or novel treatments for fractures. It categorises the clinical scenarios of poor healing of fractures and attempts to match them with the appropriate animal models in the literature.

We performed an extensive literature search of animal models of long bone fracture repair/nonunion and grouped the resulting studies according to the clinical scenario they were attempting to reflect; we then scrutinised them for their reliability and accuracy in reproducing that clinical scenario.

Models for normal fracture repair (primary and secondary), delayed union, nonunion (atrophic and hypertrophic), segmental defects and fractures at risk of impaired healing were identified. Their accuracy in reflecting the clinical scenario ranged greatly and the reliability of reproducing the scenario ranged from 100% to 40%.

It is vital to know the limitations and success of each model when considering its application.