We report four patients who sustained secondary fractures of the posterior wall of the tibial shaft during the removal of one pattern of intramedullary nail after fracture healing. The cause of this complication is discussed.

We report two cases with windswept deformities of the lower extremities. All deformities were corrected by fixator-assisted intramedullary nailing. At the latest follow-up, the patients had normal alignment, without symptoms and no loss of correction.

In a frail elderly patient a pathological fracture of the femur at the lower end of a loose femoral stem was treated by the retrograde insertion of an intramedullary nail over the tip of the prosthesis.

1. A series of 142 fractures of the trochanteric region treated by fixation with Vitallium nail-plates of the original McLaughlin pattern is described. The hospital mortality was 9 per cent. Disruption of the nail-plate junction occurred in 8 per cent of cases. This confirms McLaughlin and Garcia's (1955) view that this pattern of nail-plate should no longer be used.

2. Despite this, satisfactory functional results were achieved in 78 per cent of the survivors.

3. The new Model V McLaughlin nail-plate is described, and the stresses in nail-plates are considered. On theoretical grounds and laboratory tests the weakness at the nail-plate junction has been eliminated in the new model, and the strength of the appliance as a whole compares favourably with other types of nail-plate. Full clinical trial is therefore justified, and seventy-one patients have so far been operated on, with satisfactory early results.

4. Marked stiffness of the hip joint greatly increases angulatory and rotational stresses on the nail-plate, and a high incidence of disruption is to be expected in these cases.

We performed a prospective randomised trial on matched groups of patients with displaced tibial shaft fractures to compare conservative treatment with closed intramedullary nailing. The results showed conclusively that intramedullary nailing gave more rapid union with less malunion and shortening. Nailed patients had less time off work with a more predictable and rapid return to full function. We therefore consider that closed intramedullary nailing is the most efficient treatment for displaced fractures of the tibial shaft.

Aims. Due to their radiolucency and favourable mechanical properties, carbon fibre nails may be a preferable alternative to titanium nails for oncology patients. We aim to compare the surgical characteristics and short-term results of patients who underwent intramedullary fixation with either a titanium or carbon fibre nail for pathological long-bone fracture. Methods. This single tertiary-institutional, retrospectively matched case-control study included 72 patients who underwent prophylactic or therapeutic fixation for pathological fracture of the humerus, femur, or tibia with either a titanium (control group, n = 36) or carbon fibre (case group, n = 36) intramedullary nail between 2016 to 2020. Patients were excluded if intramedullary fixation was combined with any other surgical procedure/fixation method. Outcomes included operating time, blood loss, fluoroscopic time, and complications. Fisher’s exact test and Mann-Whitney U test were used for categorical and continuous outcomes, respectively. Results. Patients receiving carbon nails as compared to those receiving titanium nails had higher blood loss (median 150 ml (interquartile range (IQR) 100 to 250) vs 100 ml (IQR 50 to 150); p = 0.042) and longer fluoroscopic time (median 150 seconds (IQR 114 to 182) vs 94 seconds (IQR 58 to 124); p = 0.001). Implant complications occurred in seven patients (19%) in the titanium group versus one patient (3%) in the carbon fibre group (p = 0.055). There were no notable differences between groups with regard to operating time, surgical wound infection, or survival. Conclusion. This pilot study demonstrates a non-inferior surgical and short-term clinical profile supporting further consideration of carbon fibre nails for pathological fracture fixation in orthopaedic oncology patients. Given enhanced accommodation of imaging methods important for oncological surveillance and radiation therapy planning, as well as high tolerances to fatigue stress, carbon fibre implants possess important oncological advantages over titanium implants that merit further prospective investigation. Level of evidence: III, Retrospective study. Cite this article: Bone Jt Open 2022;3(8):648–655