INTRODUCTION: Cases of aseptic non-unions in patients with a femoral shaft fracture, who have initially been subjected to internal fixation by plating, are not rare. The aim of this retrospective, polycentric study was to evaluate intramedullary nailing as method of treatment of these patients.

MATERIALS AND METHODS: Thirty patients with aseptic femoral shaft non-union, after plating, were treated by reamed intramedullary nailing (IMN). The type of nailing was chosen according to the type of non-union. The mean follow-up time was 30 months and for statistical analysis, the student’s t-test was used.

RESULTS: All non-unions were healed in a mean time of 7.8 months (5–18) after nailing. The mean healing time after fracture was about 18.6 months (9–54). The healing times were irrelevant to whether the fracture was open or closed, the type non-union (atrophic or hypertrophic) and the type of fracture, according the AO classification. On the contrary, the delay from the initial plating to definitive treatment (IMN) affected the healing time and the final outcome, in a statistically significant way. Healing time was increased by 34.45% when the definitive operation was performed after between 8 and 16 months compared to the ones before the 8th month and by 72.28% if the IMN was delayed to between 16 and 24 months.

DISCUSSION: In conclusion IMN can be an ideal and cost effective method in treating patients with aseptic femoral non-union, after plating failure. This definitive operation should be performed as soon as the non-union is diagnosed in order to avoid unnecessary delay in fracture healing.

Purpose: Little has been written about the size of bone defect that could be restored with one-stage lengthening over a reamed intramedullary nail. The aim of this study was to investigate the mechanical properties of the callus created at gaps of various sizes in sheep tibiae treated with reamed intramedullary nailing.

Material-Methods: Sixteen adult female sheep were divided into four main groups: a simple osteotomy group (group I) and three segmental defect groups (1, 2, and 3 cm gap; groups I to III). One intact left tibia from each group was also used as the non-osteotomized intact-control group (group V). In all cases the osteotomy was fixed with an interlocked Universal Humeral Nail after 7 mm reaming. The osteotomized site was closed in layers including the periosteum without additional bone grafting and the limb was protected with long soft cast for 5 weeks postoperatively. Healing of the osteotomies was evaluated after 16 weeks by biomechanical testing. The examined parameters were torsional stiffness, shear stress and angle of torsion at the time of fracture.

Results: Samples with a simple osteotomy or 1 cm gap were fractured distally to the callus zone, whereas samples with 2 and 3 cm gaps were fractured at the callus zone or at distal metaphysis. The regenerate bone obvious in the x-rays in the group of 1 cm and 2 cm gap had considerable mechanical properties. Torsional stiffness in these two groups was nearly similar and its value was about 60% of the stiffness of the simple osteotomy group. A gradually decreased stiffness was observed as the osteotomy gap increased. There was a decrease in maximum shear stress from simple osteotomy to osteotomy with a fracture gap of 3 cm. No significant differences were found among the angles of torsion at fracture for the various osteotomies or the intact bone. Our results showed that the group of 1 cm gap had the 65% of the shear stress at failure of the simple osteotomy group.

Conclusion: We believe that there is evidence indicating that intramedullary nailing would be a reasonable option when one-stage lengthening of a long bone of 1 or 2 cm is contemplated.

Purpose: The purpose of this prospective investigation is to determine if soft tissue and intra-articular local anaesthetic injection with bupivacaine and adrenaline have beneficial post-operative effects in patients who had total knee replacement (TKR) for osteoarthritis.

Material and Methods: 97 patients were divided randomly into 2 groups. The mean age was 74.7 years. In control group I there were 17 men and 33 women with a mean age of 73.5 years, in group II 16 men and 31 women of mean age of 74.9 years. The patients who were allocated to control group I (n =50) had no intraarticular treatment. We used general anaesthesia in all these patients. The study group II of 47 patients had received intraoperative injection of 0.25% bupivacaine(8ml) with epinephrine (1ml – 1mg) with 2/3 injected into the soft tissues and 1/3 injected into the joint. Clinical parameters evaluated included pain, blood use and bleeding index (calculated by preoperative haemoglobin minus postoperative hemoglobin plus the number of units of packed red blood cells transfused) and range of motion (ROM) at discharge.

Results: Flexion at discharge was improved from 70 (60–90)° in the control group to 90 (80–120)° in study group II (p = 0.005), the difference between the two groups receiving different amounts of analgesics were statistically significant. Number of days until 90 degrees of flexion and until discharge was reduced in group II compared with the control group I (p = 0.003 and 0.002). Also and the blood loss decreased.

Conclusion: This simple method is effective in improving all the postoperative course of primary TKR and should be considered as a part of a perioperative patient treatment program.

Aims: To evaluate the effectiveness of external fixation exchange by intramedullary nailing during consolidation phase following callus distraction phase. Methods: In 12 skeletally mature female sheep, equally divided in two groups (group A and group B), we performed tibial shaft osteotomy and 2cm gradual callus distraction using Ilizarov external fixator in a 0,5mm/12h rate. In group A, Ilizarov fixator was removed immediately after lengthening completion, and static unreamed intramedullary nail was inserted. In group B, Ilizarov device remained during consolidation phase. Formatted callus was studied, with radiographs, ultrasonograms, and triplex. All animals were sacrificed 70 days after osteotomy and bone specimens, were evaluated by DEXA and histopathologic examination. Results: In group A, all animals successfully tolerated intramedullary nailing and limb alignment was attained. All but one formatted mature callus and had started the remodeling phase retaining callus length, before being sacrificed. One animal had delayed callus maturation and 0,5cm loss of callus length, because of failed insertion of distal locking screw in the nail. In group B, all formatted mature callus too, but 2 had serious axis disorder, 3 persistent superficial pin-track infections and 1 deep infection in the same time. Conclusions: Replacement of Ilizarov device by static unreamed intramedullary nail during callus consolidation phase decreases the total duration of external fixation, limits joint stiffness, pin-track infections and axial deformities, and provides protection against refracture. Our results suggest that there is no considerable difference between callus maturation in the two groups.

We evaluate the effectiveness of external fixation exchange by intramedullary nailing during consolidation phase following callus distraction phase. In 12 skeletally mature female sheep, equally divided in two groups (group A and group B), we performed tibial shaft osteotomy and 2cm gradually callus distraction using Ilizarov external fixator in a 0.5mm/12h rate. In group A, immediately after lengthening completion, Ilizarov fixator was removed, and static unreamed intramedullary nail was inserted under fluoroscopic guidance. In group B (control group), Ilizarov frame remained (according to the usual technique) during consolidation phase. Callus maturity was studied in both groups, in specific time intervals, with plain x-rays, ultrasonograms, triplex and digital subscription angiograms. All animals were sacrificed 70 days after osteotomy and bone specimens including callus, were evaluated with MRI, DEXA and histopathologic examination.

In group A, all animals successfully tolerated intramedullary nailing, keeping limp alignment. All but one formatted a mature callus and kept callus length before being sacrificed. One sheep had a delayed formation of the callus and 0.5cm loss of callus length, because of failed insertion of distal locking screw in the nail. In group B, four of six formatted mature callus, two had axis disorder, three superficial pin-track infections and one deep infection in the same time.

We conclude that replacement of Ilizarov device by static unreamed intramedullary nail during callus consolidation phase decreases the total duration of external fixation, limits articular stiffness, pin-track infections and axial deformities, and provides protection against refracture. Our results suggest that there is no considerable difference between callus formations in the two groups.