Consequent upon a retrospective audit of all acute tibial nail patients within GRI in 2010, it was agreed, due to variable follow-up, imaging and requirement for secondary intervention, a standardised protocol for management of acutely nailed tibial fractures within GRI was to be established. Subsequently, a Nurse Led Tibial Nail Clinic commenced in July 201. The majority of consultants (11 of 13) devolving follow up of these patients to a protocol based algorithm designed on evidence based principles and consensus expert opinion. Aims were to standardise/improve management of tibial nail patients in terms of patient education, weight bearing, imaging, follow-up intervals and also coordinate secondary intervention via a single consultant with an interest in limb reconstruction/non union. A secondary goal was to achieve measureable outcome data for this subgroup of patients. All patients underwent post operative radiographs prior to discharge, review in clinic at 10 days for wound assessment, 6 weeks for physiotherapy and 12 weeks where standard AP and lateral tibial radiographs were repeated. Patients are discharged at 12 weeks if the radiographs confirm bony healing on three cortices or more and fractures are clinically united. If not, repeat x rays are undertaken at 20 weeks. A parallel consultant led limb reconstruction clinic is available to review patients failing to demonstrate satisfactory progression to union with secondary intervention instigated thereafter as appropriate. Since commencement of the Nurse Led Tibial Nail Clinic, 60 patients have been treated with a tibial nail, 44 managed in the Tibial Nail Clinic. The mean number of radiographs has reduced from 6.4 to 3.1 per patient to discharge. Clinic visits are reduced from 6.4 to 3.9 per patient to discharge. Non compliance is low with 4.6% of patients failing to attend. Secondary interventions have been low (13%), confirming a relatively benign course of healing for most patients treated with an IM nail for acute tibial fractures. There has been one non union, no deep infections, two nail removals and one DVT. A protocol based specialist nurse led clinic is safe for patients, cost effective for the NHS and gives increased opportunity for measuring outcome and improving care in a previously heterogenously managed group of patients

The aim is to report a rare technique for correction of intramedullary nail acute angular deformity. Intramedullary tibial nail fixation of diaphyseal tibial fractures is the gold standard treatment allowing early mobilisation whilst preserving the soft tissues around the fracture site. Most commonly, intramedullary nails fail by metal fatigue secondary to non union, without significant deformity of the metalwork. Plastic deformity of the nail can result following new acute trauma, particularly before bone union has occurred. This is a clinical challenge as a reamed intramedullary nail is designed to achieve three point fixation with close anatomical fit, such that removal of a bent nail is technically difficult and also risks further damage to bone and soft tissues. We report a case of a 20 year old patient treated with intramedullary nail fixation of a diaphyseal right tibial fracture who was subsequently assaulted 4 weeks post operatively. This produced an unacceptable deformation of the nail into 25 degrees valgus and procurvatum. To remove the nail, the authors used a previously reported but rare technique of partial (up to 50%) nail division on the convex surface of the apex using Midas Rex High Speed Drill to weaken the nail then manipulation to correct deformity with minimal stress. The technique produced minimal metal debris and allowed simple exchange nail replacement without further complication. The authors believe this is the first reported use of the technique from the United Kingdom

INTRODUCTION. Intramedullary nail fixation has been used for successful treatment of long bone fracture such as humerus, tibia and femur. We look at the experience of our trauma unit in treating long bone fracture using the AO approved Expert femoral/tibial nail and proximal femoral nail antirotation (PFNA). We look at the union and complication rates in patients treated with AO approved nailing system for pertrochanteric, femoral and tibial shaft fracture. METHODS. We carried out retrospective case notes review of patients that underwent femoral and tibial nailing during the period of study- October 2007 to August 2009. All patients were treated using the AO approved nailing system. We identified all trauma patients that underwent femoral and tibial nailing through the trauma register. Further information was then obtained by going through medical notes and reviewing all followed-up X-rays stored within the online radiology system. RESULTS. 149 patients, 85 male and 64 female were included into the study. 150 procedures were carried out during period of study as 1 patient underwent conversion of lateral entry femoral nail to PFNA due to refracture. Patients' age ranged from 14-96 with mean of 55. 140 patients had isolated long bone fracture (either femur or tibia) compared to 9 patients with multiple bone fractures. Our unit performed 64 Expert tibial nail, 36 PFNA, 31 Expert lateral entry femoral nail and 19 Expert retrograde femoral nail during period of study. 13 patients treated with intramedullary nail sustained open fracture, 9 of them were compound tibial fracture compared to 4 compound femoral fractures. All patients were followed-up between 2 to 24 months or until death. 9 out of 17 patients that died in this study had diagnosis of tumour. Complication rates were 17% for Expert tibial nail (1 patient with valgus deformity, peroneal nerve palsy and delayed union, 3 with delayed union, 4 with broken locking screw, 2 with wound infection and 1 with abscess over wound site), 4% for lateral/retrograde femoral nail (1 each for pulmonary embolism and broken locking screw) and 4% for PFNA (1 each for delayed union and deep vein thrombosis). The overall complication rates were 10% from this study. DISCUSSION & CONCLUSIONS. We conclude that the AO approved nailing system used for treating pertrochanteric, femoral and tibial fractures were effective with high union rate. The overall complication rates were 10% from this study. Complication rates for tibial nail were as high as 17% compared to 4% for femoral nail or PFNA. The complication rates for PFNA in our study were lower compared to 29% in PFN that was reported in one literature

Surgical training in the UK is under increasing pressure with a high demand for service provision. This raises concerns about the resultant negative impact this is having on training opportunities for surgical trainees in theatre due to a high demand for surgical procedures to be performed expediently by consultants. This is due to the assumption that trainee take significantly longer time to operate in theatre and thus result in a slow progress of theatre lists. Our study evaluated the differences in operative time between orthopaedic trainees and orthopaedic consultants, as well as provide realistic timings for each stage encompassed within the entire duration a patient is in theatre. From our trauma unit electronic theatre database, we retrospectively collected data for six Joint Committee of Surgical Training (JCST) mandatory procedures. Information collected included patients' ASA grading, total surgical time and grade of surgeons. A total of 956 procedures were reviewed: 71.8% hip procedures, 14.2% intramedullary nail fixations and 14.2% ankle fixations. 46.2% and 53.8% of the procedures were performed by consultants and trainees as first surgeon, respectively. On average, consultants were found to be 13 minutes quicker in performing the hip procedures and this difference was found to be statically significant (p < 0.05). However, trainees were found to be quicker in performing intramedullary femoral nailings and simple ankle fixations, but consultant were faster at performing intramedullary tibial nailings and complex ankle fixations. However, the differences were not found to be statistically significant (p > 0.05)

Early diagnosis of delayed- and non-union tibial fractures is difficult, but treatment options are available if timely data are available. Direct correlation between implant forces and healing status is difficult during stance phase loading due to soft tissue forces. This ongoing study seeks to find a minimal set of strain gauge sites needed to determine healing at any of several fracture sites, using isometric loading suitable for routine clinical usage. A series of instrumented tibial nails are being used to help determine whether an alternative technology can replace or augment existing routine methods for assessment of fracture healing. In a prior study, a single strain gauge positioned close to the fracture site had produced mixed results. In the current study, a TRIGEN META NAIL, 10mm OD x 380mm long, was instrumented with 8 gauged sites spiraled down the nail at 34mm axial and 120deg angular separation (Gen1), and loaded in a Sawbone model in offset axial compression, 3 point bending and torque. In order to gain early clinical results, and in a design informed by the Gen1 data, a set of instrumented nails have been made for an ovine wireless telemetry study (Gen3a), shortly to commence, in which the tibial nail has been over-gauged enabling multiple d.o.f. measurements to be made during gait, torque, axial compression and 3 point bending; the latter protocols offering more controlled patient postures. This study is to be followed by a similar human study (Gen3) involving five subjects (12 gauges per nail). Meanwhile, a parallel biomechanical study involving six nails with 20 gauges each is also planned. In the Gen1 study, the strains diminished with distance from the fracture site and with out-of-plane sites during bending. During torque, however, the response was much more uniform for all strain sites. Significant increases in strains due to both loading regimes were seen in the fractured case vs. an intact bone. Preliminary conclusions are that strains measured due to applied torque may offer a more sensitive and fracture site-independent means of assessing healing than induced bending. We now aim to confirm these observations in animal and human studies

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.

The treatment of fractures of the proximal tibia is complex and makes great demands on the implants used. Our study aimed to identify what levels of primary stability could be achieved with various forms of osteosynthesis in the treatment of diaphyseal fractures of the proximal tibia. Pairs of human tibiae were investigated. An unstable fracture was simulated by creating a defect at the metaphyseal-diaphyseal junction. Six implants were tested in a uniaxial testing device (Instron) using the quasi-static and displacement-controlled modes and the force-displacement curve was recorded. The movements of each fragment and of the implant were recorded video-optically (MacReflex, Qualysis). Axial deviations were evaluated at 300 N.

The results show that the nailing systems tolerated the highest forces. The lowest axial deviations in varus and valgus were also found for the nailing systems; the highest axial deviations were recorded for the buttress plate and the less invasive stabilising system (LISS). In terms of rotational displacement the LISS was better than the buttress plate.

In summary, it was found that higher loads were better tolerated by centrally placed load carriers than by eccentrically placed ones. In the case of the latter, it appears advantageous to use additive procedures for medial buttressing in the early phase.

The aim of this study was to validate the use of three models of fracture fixation in the assessment of technical skills. We recruited 21 subjects (six experts, seven intermediates, and eight novices) to perform three procedures: application of a dynamic compression plate on a cadaver porcine model, insertion of an unreamed tibial intramedullary nail, and application of a forearm external fixator, both on synthetic bone models. The primary outcome measures were the Objective Structural Assessment of technical skills global rating scale on video recordings of the procedures which were scored by two independent expert observers, and the hand movements of the surgeons which were analysed using the Imperial College Surgical Assessment Device.

The video scores were significantly different for the three groups in all three procedures (p < 0.05), with excellent inter-rater reliability (α = 0.88). The novice and intermediate groups specifically were significantly different in their performance with dynamic compression plate and intramedullary nails (p < 0.05). Movement analysis distinguished between the three groups in the dynamic compression plate model, but a ceiling effect was demonstrated in the intramedullary nail and external fixator procedures, where intermediates and experts performed to comparable standards (p > 0.6). A total of 85% (18 of 21) of the subjects found the dynamic compression model and 57% (12 of 21) found all the models acceptable tools of assessment.

This study has validated a low-cost, high-fidelity porcine dynamic compression plate model using video rating scores for skills assessment and movement analysis. It has also demonstrated that Synbone models for the application of and intramedullary nail and an external fixator are less sensitive and should be improved for further assessment of surgical skills in trauma. The availability of valid objective tools of assessment of surgical skills allows further studies into improving methods of training.

The stress response to trauma is the summation of the physiological response to the injury (the ‘first hit’) and by the response to any on-going physiological disturbance or subsequent trauma surgery (the ‘second hit’).

Our animal model was developed in order to allow the study of each of these components of the stress response to major trauma. High-energy, comminuted fracture of the long bones and severe soft-tissue injuries in this model resulted in a significant tropotropic (depressor) cardiovascular response, transcardiac embolism of medullary contents and activation of the coagulation system. Subsequent stabilisation of the fractures using intramedullary nails did not significantly exacerbate any of these responses.