Aim: To study a staged technique for the removal of the Ilizarov fixator following bony union. Method: A prospective case series of all fractures treated by the senior author between May 2005 and May 2007 were reviewed. When patients were able to weight bear pain free with radiological evidence of healing, the frames were dynamised initially by loosening the rods across the fracture site, then by removing all rods across the fracture site and finally the frame was removed under general anaesthetic. Patients were followed up for 6 months clinically and radiologically. Results: Of 39 fractures (38 patients) 37 underwent staged dynamisation. No patients required further, casting, bracing or walking aids after frame removal. There were no incidences of re-fracture, non-union or late mal-union at 6 months follow up. Conclusion: The proposed method of staged dynamisation is a safe and useful technique for confirming fracture union and guiding frame removal

Introduction: Increasing number of osteoporotic fractures of the femur, especially upper part of the femur creates everyday problem of health services. Treatment of these fractures has been improving markedly during the past 25 years. DHS, gamma nail and some other implants are very useful in everyday surgery. However some of complications still can not be resolved like cut out. Osteoporotic fractures in subtrochanteric area represent even bigger challenging. Diaphyseal fractures are also difficult to be treated. The main problem is quality of osteoporotic bone. Plate with parallel screws doesn’t provide reliable fixation. Intramedulary nails, because of wide channel in distal femur area also don’t provide desirable fixation stability. Material and Method: We analysed results of using of one new device: selfdynamisable internal fixator (SIF) in the series of 389 patients treated because of upper femur fractures. That device has possibilities of spontaneous dynamisation in two axes: along the femoral neck axis and along the diaphyseal axis. Spontaneous dynamisation in the diaphyseal axis is very important if diaphyseal or subrtochanteric fracture or comminuted fracture of the upper femur with subtrochanteric extension treated. For activation of axial dynamisation it not necessary to do any action from outside the body. This feature is activated spontaneously if there is no progress in fracture union within 6–8 weeks. This device provides three-dimensional fixation using clams and rod onto the lateral surface of the femur. The age of patients was from 59 to 87 years. This internal fixator is applied using minimally invasive method – by one or two small incisions. Results: During the treatment it has been confirmed working of self-dynamisation concept. Spontaneous dynamisation in the long axis of the femur has been proven in 21% of patients with subtrochanteric and diaphyseal fractures and it has been proven radiologically that sliding happened between 1–4 mm (average 2.5 mm). Such dynamisation together with 3D configuration of screws resulted in relatively quick fracture healing. Follow up was 19 months (6–60). Altogether 97.6% fractures healed within normal healing time. There were 1 infection, 2 cut out, 1 mechanical complication, 4 delay unions and one non-union. Conclusion: According to results obtained, it can bee concluded that new biological internal fixator is suitable for minimally invasive technique, without opening of fracture site

Introduction. Traditionally, radiological union of fractures treated with an Ilizarov frame is confirmed by a period of dynamization - destabilisation of the frame for a period prior to removal. Reduced clinic availability during the COVID-19 pandemic caused a shift to selective dynamisation in our department, whereby lower risk patients had their frames removed on the same day as destabilisation. This study investigates the effects of this change in practice on outcomes and complication rates. Materials & Methods. Adult patients treated with circular frames between April 2020 and February 2022 were identified from our Ilizarov database. Patients were divided into 2 groups: - “dynamised” if their frame was destabilised for a period to confirm union prior to removal; or “not dynamised” if the decision was taken to remove the frame without a period of dynamisation, other than a short period in the clinic. A retrospective review of clinical notes was conducted to determine outcome. Results. 175 patients were included in the final analysis, 70 in the dynamised and 103 in the not dynamised groups, median follow-up was 33 months. 3 patients in the dynamised group failed dynamisation and had their period of fixation extended, subsequently having their frames removed without complication. Two patients suffered a refracture or non-union after frame removal in the dynamised group and none in the not dynamised group, this difference was not statistically significant. Conclusions. In our practice, selective frame removal without a period of dynamisation appears safe. This has the potential to shorten frame time and reduce the number of clinic appointments and radiographic investigations for these patients. Some patients find the period of dynamisation uncomfortable and associated with pin site infection, which can be avoided. We plan to continue this practice and collect further data to confirm these findings in a larger dataset

Introduction. Frame configuration for the management of complex tibial fractures is highly variable and is dependent not only on fracture pattern and soft tissue condition but also surgeon preference. The optimal number of rings to use when designing a frame remains uncertain. Traditionally, larger, stiffer constructs with multiple rings per segment were thought to offer optimal conditions for bone healing, however, the concept of reverse dynamisation questions this approach. Materials & Methods. We compared clinical outcomes in 302 consecutive patients with tibial fractures treated in our unit with either a two-ring circular frame or a three-or-more-ring (3+) frame. The primary outcome measure was time spent in frame. Secondary outcomes were the incidence of malunion and the need for further surgical procedures to achieve bone union. The groups were evenly matched for age, co-morbidities, energy of injury mechanism, fracture classification, post-treatment alignment and presence of an open fracture. Results. The mean time in frame was 168 days for the 2-ring group and 200 days for the 3+ rings group (p=0.003). No significant difference was found in the rate of malunion (p=0.428) or the requirement for secondary surgical intervention to achieve union (p=0.363). No significant difference in time in frame was found between individual surgeons. Conclusions. This study finds that 2-ring frame constructs are a reliable option associated with significantly shorter duration of treatment and no increase in rates of adverse outcomes compared with larger, more complex frame configurations. Although this study cannot identify the underlying cause of the difference in treatment time between frame designs, it is possible that differences in mechanical stability lead to a more favourable strain environment for fracture healing in the 2-ring group

Non-union of femoral and tibial shaft fractures is a serious complication, prolonging patient morbidity and ultimately influencing functional recovery. The aim of the study was to assess the effectiveness of different surgical options in the treatment of non-union of femoral shaft fractures after initial intramedullary nailing. Between January 1995 and November 2003, 320 patients with femoral or tibial shaft fractures were treated with closed intramedullary nailing. The mechanism of injury, fracture pattern, concomitant injuries, subsequent surgical treatment and complications were prospectively recorded and retrospective analysis was performed. 16 of the 157 patients (10%) with femoral fractures and 31 of the 161 patients (19%) with tibial fractures developed non-union after initial primary intramedullary nailing. This group of patients had 2–3 further operations before union was established. 26 patients had initial dynamisation and 11 had exchange nailing alone. The remaining patients had autologous bone grafting and/or internal fixation with a plate. Subsequently a further 3 patients required dynamisation, 2 required exchange nailing and another 3 bone grafting. Finally 2 patients required a fourth procedure to reach solid union. Our experience showed that exchange nailing and dynamisation are the most effective method of treatment of non-union of femoral and tibial shaft fractures after intramedullary nailing

Aim. The purpose of the study was to evaluate the results of Expert tibial nailing for distal tibial fractures. Methods. All patients who had a distal third or distal end fracture of the tibia treated with the Expert tibial nail over a three year period at our institution were included in the study. A total of 44 distal tibial fractures in the same number of patients were treated with the nailing system. One patient died in the immediate post operative period from complications not directly related to the procedure and 3 were lost to follow up leaving a cohort of 40 patients for evaluation. 31 of the fractures were closed while the remaining 9 were open. The average age group of the cohort was 46.8 years with 26 males and 14 females. Results. All 40 patients were followed up to full radiological union of their tibia fractures. The average time to radiological union was 12.5 weeks for the closed fracture group and 15.1 weeks for the open fractures. The difference in time to union between the two groups was not statistically significant. There was infection around a distal locking screw in a closed fracture which settled with screw removal. Three patients in the closed fracture group required dynamisation to hasten union while none required dynamisation in the open fracture group. No bone grafting was performed on any of the patients. One patient had non union of a distal fibula fracture which required plating of as an additional procedure. On follow-up none of the patients reported knee pain or had limitation of ankle movements. Conclusion. The Expert tibial nail is an effective implant for the treatment of both open and closed distal tibial fractures with a low complication rate

To determine the outcome of subtrochanteric fractures treated by intramedullary (IM) nailing and identify causes for implant failure. We performed a retrospective analysis of all subtrochanteric fractures treated by intramedullary nailing in Belfast trauma units between February 2006 and 2009. This subgroup of patients was identified using the Fractures Outcome Research Database (FORD). Demographic data, implant type, operative details, duration of surgery and level of operator were collected and presented. Post-operative X-rays were assessed for accuracy of reduction. One hundred and twenty two (122) patients were identified as having a subtrochanteric fracture treated by IM nailing. There were 79 females and 43 males. Age range was 16 to 93 (mean 78). 95 (78%) cases were performed by training grades and 27 (22%) by consultants. Duration of surgery ranged from 73–129mins (mean 87mins). 47 patients (38.5%) were found to have a suboptimal reduction and 75 patients (61.5%) had an anatomical reduction on immediate post-operative x-ray. One year from surgery 73/122 patients were available for follow up. Of those patients with suboptimal reduction, 13/47 (27.7%) required further surgery. 8 required complete revision with bone grafting, and 5 underwent dynamisation. A further 6 patients had incomplete union. In the anatomical group, 4 patients underwent further surgery (5%). 3 required dynamisation and one had exchange nailing for an infected non-union. 3 patients had incomplete union at last follow up. 5/47 (10.6%) had open reduction in the suboptimal group compared to 25/75 (33.3%) in the anatomical group. Of the 27 cases performed by consultants, 13 (48%) were open reduction, compared to 17/93 (18%) by training grades. This study has shown that inadequate reduction of subtrochanteric fractures, leads to increased rates of non union and ultimately implant failure. We recommend a low threshold for performing open reduction to ensure anatomical reduction is achieved in all cases

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

We tested the hypothesis that it is possible to accelerate fracture healing by changing the mechanical environment used in current methods i.e., from initial rigidity or micromovement followed by dynamisation to initial macromovement followed by rigidity (micro-movement). It is accepted that callus formation requires movement at the fracture site and this callus response is limited to the first few weeks after fracture. Logically, early macromovement at the fracture site would be beneficial for callus formation. Additional callus is not produced by further movement. Indeed, it may be counter-productive, just as continuing movement around two ends of a wooden stick bonded with glue will retard and even prevent “union”. We postulate that continuing movement at the fracture site after the callus response has ceased will also delay union. As a result, rigidity rather than dynamisation is required in the later stage of fracture healing. After testing an animal model, we built an external fixator which allowed 5 mm of axial movement without “self-locking” and could be compressed at a later date in order to prevent further movement. A trial containing 15 patients with unilateral tibial shaft fractures (closed or grade 1 open) was undertaken after permission was obtained from the Helsinki Ethical Committee. So far, 13 patients have been entered into the trial. They have completed therapy and are at least one year post-fracture (12 months to 22 months). Age range is from 20 to 49. The group is composed of nine males and one female. Under general anaesthetic, an external fixator was applied and the fracture reduced. The patients started ankle exercises (active and passive) the following day, with as much weight-bearing on the fractured leg as possible on the day after. The patients were seen every two weeks and AP and lateral radiographs were taken. The fracture was compressed two to six weeks later. The percentage of body weight that the patient was able to tolerate through the fractured limb was measured by using the scales of Meggit’s step test. The fixators were removed when there was radiographic union and the patient could take at least 80% of body weight through the fractured limb. Mean time duration up to removal of the fixator was 10.8 weeks (range 7 to 15.4 weeks). We conclude that it is possible to increase the speed of bone healing by changing the mechanical environment to initial macromovement followed by elimination of movement

Background. Humerus fracture non-union is a challenge for which a wide range of treatments exist. We present our experience of managing these by hybrid Ilizarov frame fixation, without bone graft or debridement of the non-union site. Methods. Case notes review of a consecutive series of 20 patients treated for aseptic humeral non-union between 2004 and 2016. Eighteen patients had previous plate or intramedullary nail fixations, and 2 had no prior surgery. During Ilizarov application, any existing metalwork preventing dynamisation of the fracture site was removed through minimal incisions before compression of the fracture site was then achieved. Only 3 patients had open debridement or osteotomy of the non-union site, otherwise all other patients had no debridement of their non-union. Results. Bony union was achieved in 17 patients (85%), with a further 2 achieving a functional fibrous union. The remaining patient subsequently had successful open surgery. Union rates were 66% (2/3) and 88% (15/17) for the debridement/osteotomy and non-debridement groups respectively. Mean frame duration was 193 days. One patient was treated for pin-site infection. The Chertsey Outcome Score for Trauma was used to assess patient reported outcomes. Conclusions. Simple changes to the physical properties acting upon a humeral non-union, such as adequate control of its strain environment and restoration of the mechanical axis, are enough on their own to initiate healing. In our practice, this eliminates any morbidity associated with extensive fracture debridements or donor harvest sites

Purpose: Reaming is classically contraindicated for open leg fractures. For certain authors, reaming can favour bone healing without increasing the risk of infection (Court-Brown JBJS 90B and 91B, Wiss Coor 95). The aim of this retrospective analysis of patients treated in a single centre was to validate these notions and determine the role of locked centromedullary nailing (LN) with reaming for the treatment of open leg fractures. Material and methods: Between 1989 and June 2000, 141 open leg fractures were fixed with locked centromedullary nailing without reaming in 103 men and 38 women, mean age 34 years, who were mainly accident victims (2-wheel vehicles 43%, 4-wheel vehicles 22%). Multiple trauma was present in 18.7% of the cases and multiple fractures in 28%. Skin wounds were (Gustilo classification): type I 81 (57%), type II 38 (27%), type IIIA 14, and type IIIB 8. There was a simple fracture in 50% of the cases, a wedge fracture in 32%, and comminution in 18% with bifocal fractures in 10 cases. Osteosynthesis was performed within a mean 5.5 hours (2–18) and deferred in six cases. The Grosse and Kempf nail was used in all cases with reaming (man 11). Static locking was used in 88% of the cases. type I, II and IIA skin wounds were sutured after debridement. Three aponeurotomies were performed as preventive measures. Type IIIB wounds were treated by early plasty. A brief antibiotic prophylaxis was given in all cases. Results: There was one aggravation of the comminution, two dismantelings subsequent to unauthorised weight-bearing, three compartment syndromes and one lateral sciatic popliteal paralysis. Two patients died from their multiple injuries. Four patients developed infection: two healed without removing the nail, one was amputated (free flap failure). One patient consulted another unit. Ten patients who were not residents of our area were lost to follow-up. Dynamisation was performed in 31 patients (25.6%) at a mean 4.4 months. Four patients with delayed healing cured after a new nailing with secondary reaming. Delay to bone healing was related to the type of fracture (p < 0.01): 4.2 months for type A (AO classification), 5.2 months for type B and 5.9 months for type C. Bone healing was correlated with Gustilo type (p < 0.05): 4.5 months for types I, 4.6 months for type II, 5.8 months for types III. Six patients developed nonunion: four were revised with success after a new nailing and secondary reaming (two lost to follow-up). Delayed healing and non-union were related to type of fracture (A = 3.8%, B = 15.6%, C = 18%) and soft tissue damage (Gustilo I: 4.1%; II: 10.7%; III: 15.8%). Discussion conclusion: Locked centromedullary nailing with reaming is appropriate when the skin wound is minimal; dynamisation and/or replacement of the nail with secondary reaming should be discussed early in case of delayed healing

Background. The Schatzker classification is applied in the management of tibial plateau fractures. The unique pattern of Schatzker VI fractures requires recognition for proper fixation. Method:. We have treated 33 patients with Schatzker IV tibial plateau fractures including non-unions and mal-unions. Patients had a temporary spanning Ilizarov frame with intraoperative distraction, articular reconstruction and olive wires for indirect reduction. No open surgery was performed. Patients mobilised fully weight-bearing and underwent post-operative CT scan and regular outpatient reviews. At six weeks the femoral ring was removed, and patients underwent a staged dynamisation protocol prior to frame removal. Results:. Twenty seven patients have achieved union and completed at least 1-year follow-up. Of these, 25 were reviewed at a mean follow-up of 5.4 years. The mean IOWA score was 85 and the mean ROM was 119 degrees. Two patients were not contactable for final review. The remaining six patients are still undergoing treatment. The mean time to union was 145 days. Conclusion:. Shatzker IV fracture requires understanding of the axial/valgus pattern of injury so that appropriate fixation can be applied to produce good results

Introduction:. TTC fusion for the salvage of failed TARs with significant bone loss using a hindfoot nail and femoral head allograft has been reported in a number of small series. We present our experience of this procedure. Method:. Review of the theatre records from 2006 to July 2011 identified twenty four cases using this technique. The case notes and imaging were retrospectively reviewed. Results:. Overall eighteen of the twenty four cases had achieved union (mean time 18.8 months). Of this number two had under gone a revision hindfoot nailing and another case needed revision with a circular frame. A further three cases required dynamisation to unite. There were five non unions and one loss to follow up (at two months). Complications included one deep infection (non union) and one case with chronic regional pain syndrome. Metalwork complications included five nail fractures and five cases that required prominent screw removal. Conclusions:. This is the largest series reported using this technique for the salvage of failed TARs with significant bone loss. Other smaller series using this technique have reported union rates around fifty per cent. The time to union is long and half of these cases required further procedures during this course. This is important to reflect when consenting the patient for this type of surgery

Percutaneous grafting of non-union using bone marrow concentrates has shown promising results, we present our experience and outcomes following the use of microdrilling and marrowstim in long bone non-unions. We retrospectively reviewed all patients undergoing a marrowstim procedure for non-union in 2011–12. Casenotes and radiographs were reviewed for all. Details of injury, previous surgery and non-union interventions together with additional procedures performed after marrowstim were recorded for all patients. The time to clinical and radiological union were noted. We identified 32 patients, in sixteen the tibia was involved in 15 the femur and in one the humerus. Ten of the 32 had undergone intervention for non-union prior to marrowstim including 4 exchange nailings, 2 nail dynamisations, 3 caption graftings, 2 compression in circular frame and 1 revision of internal fixation. Three underwent adjunctive procedures at the time of marroswstim. In 18 further procedures were required following marrowstim. In 4 this involved frame adjustment, 5 underwent exchange nailing, 4 revision internal fixation, 2 additional marrowstim, 2 autologous bone grafting and 3 a course of exogen treatment. In total 27 achieved radiological and clinical union at a mean of 9.6 months, of these ten achieved union without requiring additional intervention following marrowstim, at a mean of 5.4 months. There were no complications relating to marrowstim harvest or application. Marrowstim appears to be a safe and relatively cheap addition to the armamentarium for treatment of non-union. However many patients require further procedures in addition to marrowstim to achieve union. Furthermore given the range of procedures this cohort of patients have undergone before and after marrowstim intervention it is difficult to draw conclusions regarding it efficacy

The Orthofix acute correction template has been developed for multiplanar deformity corrections, with or without lengthening, using a monolateral external fixation system such as the limb reconstruction system (LRS). Pin placement is achieved by marrying the template onto the particular deformity in the frontal, sagittal and rotational planes, so that after the osteotomy the pins can be rearranged by manipulating the fragments to permit application of the standard Orthofix fixation system. The options of compression, dynamisation or lengthening through the osteotomy sites remain available should they be required in the reconstructive procedure. We have found the template useful in correcting multiplanar deformities intra-operatively. This is followed by internal fixation and removal of the external fixator at the end of the procedure. Internal fixation of diaphyseal and metaphyseal osteotomies is achieved with intramedullary nailing and blade fixation respectively. This technique simplifies complex procedures, following careful planning by accurate pin placement. The fragments are compressed before definitive internal fixation. The correct mechanical axis is checked radiologically before stable fixation

Introduction. Arthrodesis is usually offered to patients in whom a two stage exchange arthroplasty has already failed or is likely to fail because of local factors (such as soft tissue damage, bone loss or poor perfusion), or because of systemic conditions which categorise the patient as a C-host (e.g. immune deficiency, diabetes and malnutrition). In other words arthrodesis is selected for patients with the worst prognosis. Method. I use an intramedullary nail extending from trochanter to just above the ankle which is locked distally only. The nail is curved with an arc of a 2 meter radius. This conforms to the shape of the femur and when passed through to the straight tibia it ends against the posterior cortex of the distal tibia where the bone is thickest. It creates an angle of between 9° and 11° of flexion at the knee. The nail is bent into 5° of valgus at the point where the femur and tibia meet. This allows the two bones to coapt, dynamise and unite. The procedure is performed in two stages. At the first every effort is made to eradicate the infection by debridement and appropriate local and systemic antibiotics. The nail is inserted at the second procedure and again every effort is made to deal with infection. If infection persists one can easily remove the nail when the knee has fused, and repeat the attempt to eradicate the infection in better circumstances. I have devised a scoring system in order to evaluate the eradication of infection based on clinical grounds, laboratory investigations and radiological examination. This allows for the fact that cure of an infection is not based on any one parameter. Results. I have performed such an arthrodesis in 99 patients. Fusion occurred in 74% of those who had more than six months follow-up. The affected limb was shortened on average by 4 cm. After nailing, pain was relieved in 80% of patients using a sliding scale. Using the scoring system, 31% were definitely cured of infection, 34.5% were intermediate and 34.5% definitely failed. 29 patients had their nail removed and the infection was re-addressed. Using the same evaluation system 12 (24%) were definitely cured, 12 (24%) had a probable cure and 5 (18%) remained infected. This gives an overall eradication of infection of 84%. In 4 patients apparent union of the knee broke down resulting in a jog of movement at the knee. Three of these patients were made comfortable with a gaiter to support the knee. One had his knee re-fixed with a long intramedullary nail. Three nails fractured in situ. In one of these patients the nail had locking screws proximally and distally which prevented dynamisation and union. In the other two non-union was apparent and the nail sustained a fatigue fracture. NO DISCLOSURES

Introduction Retrograde nailing of femoral shaft fractures, through the knee joint, have been increasing. The indications for retrograde nailing are presently still evolving. This paper aims to discuss the indications for retrograde nailing. Methods We had conducted a prospective trial of nailing of femoral shaft fractures, using the retrograde approach. Nails were placed and reamed, with both distal and proximal locking done. Attention was given to the appropriate entry point. A literature review is also presented. Results The set-up was easy. Operative time was a median of 70 minutes and average blood loss 200 mls. Time to union was 15 weeks with minimal complications, but dynamisation rates were high. No knee problems were found at a follow-up period of 47 months. Conclusions The indications for retrograde nailing are ipsilateral femoral and acetabular fractures, ipsilateral patellar and femoral shaft fractures, ipsilateral tibial amd femoral shaft fractures, multiple trauma, femoral fracture with previous ipsilateral hip fusion, bilateral femoral shaft fractures, the obese or pregnant patient with a unilateral/bilateral femoral shaft fractures and perhaps the elderly with a unilateral femoral shaft fracture. We feel that the retrograde nailing is a useful technique for the orthopaedic surgeon to have in his/her armamentarium. Due to the longer union time and possible knee damage, indications should be respected

In a prospective study from October 2002 to December 2003, we evaluated 102 femoral fractures treated with the new Synthes antegrade femoral nail. It is a titanium femoral nail with a recon locking option, distal dynamisation slot and trochanteric entry point. There were 99 patients (76 males and 23 females), three of whom had bilateral fractures and 42 polytrauma. The mean age was 36 years (13 to 87). The mean Injury Severity Score was 42 (23 to 65). Motor vehicle accidents were the cause of 44 fractures and gunshot injuries the cause of 37. There were 25 transverse fractures (AO 32-A), 37 wedge type fractures (AO 32-B) and 40 complex (AO 32-B) fractures. There were 38 Gustilo type-II and type-III open fractures. Surgery was performed within 24 hours in 80% of the fractures. Nine required open reduction. Unreamed nails were inserted in 38 patients. All fractures united. However, 11 showed angulations greater than 5°. Two patients had shortening of more than 1 cm, one of them requiring reoperation. One patient sustained a iatrogenic fracture, four developed fat embolism syndrome and three had DVT. Three patients had early superficial wound infection and two had late infections with a draining sinus. One locking screw broke. We found this to be a reliable femoral nail with a safe entry point

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

Aims: Nonunions of the distal tibia are difþcult to treat due to the short distal segment, the proximity to the ankle joint and the fragile soft tissue envelope. Intramedullary nailing is an attractive solution as it avoids extensive soft tissue dissection and remains intraosseus, posing little problem for the soft tissues. The purpose of this study was to determine the efþcacy of reamed intramedullary nailing in the treatment of non-unions of the distal one-quarter of the tibia. Methods: Thirty-two patients with nonunions of the distal one-quarter of the tibia were treated by reamed, locked intramedullary nailing. Prior treatments included casting as well as intramedullary or extramedullary þxation techniques. No patient had signs of an active infection at the time of surgery. Time to union, correction of deformity and complications including infection and reoperation were examined. Results: Twenty-nine out of thirty-two patients achieved union at an average of 3.5 months after surgery. Of the remaining three, two patients united rapidly after dynamisation and one after exchange nailing. Deformity was corrected to a maximum of four degrees in all planes. Four patients had positive intraoperative culture, and only two required removal of the nail after achieving union to eradicate infection. There were no cases of chronic osteomyelitis after the procedure. Conclusions: Reamed, locked intramedullary nailing is a reliable and safe procedure in the treatment of nonunions in the distal one-quarter of the tibia. It allows for excellent correction of deformity, which is an essential component of the procedure