Femoral lengthening using the Precice intramedullary limb-lengthening system: outcome comparison following antegrade and retrograde nails.

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. PATIENTS AND METHODS: A retrospective review of prospectively collected data was undertaken of a consecutive series of 107 femoral lengthening operations in 92 patients. In total, 73 antegrade nails and 34 retrograde nails were inserted. Outcome was assessed by the regenerate healing index (HI), hip and knee range of movement (ROM), and the presence of any complications. RESULTS: The mean lengthening was 4.65 cm (1.5 to 8) in the antegrade group and 4.64 cm (1.6 to 8) in the retrograde group. Of the 107 lengthenings, 100 had sufficient datapoints to calculate the mean HI. This was 31.6 days/cm (15 to 108). There was a trend toward a lower (better) HI with an antegrade nail and better outcomes in adolescent patients, but these were not statistically significant. Hip and knee ROM was maintained and/or improved following commencement of femoral lengthening in 44 patients (60%) of antegrade nails and 13 patients (38%) of retrograde nails. In female patients, loss of movement occurred both earlier and following less total length achieved. Minor implant complications included locking bolt migration and in one patient deformity of the nail, but no implant failed to lengthen and there were no deep infections. Three patients had delayed union, five patients required surgical intervention for joint contracture. CONCLUSION: This study confirms excellent results in femoral lengthening with antegrade and retrograde Precice nails. There is a trend for better healing and less restriction in hip and knee movement following antegrade nails. There are clinical scenarios, that mandate the use of a retrograde nail. However, when these are not present, we recommend the use of antegrade nailing. Cite this article: Bone Joint J 2019;101-B:1168-1176.

A retrieval analysis of the Precice intramedullary limb lengthening system.

OBJECTIVES: The Precice nail is the latest intramedullary lengthening nail with excellent early outcomes. Implant complications have led to modification of the nail design. The aim of this study was to perform a retrieval study of Precice nails following lower-limb lengthening and to assess macroscopical and microscopical changes to the implants and evaluate differences following design modification, with the aim of identifying potential surgical, implant, and patient risk factors. METHODS: A total of 15 nails were retrieved from 13 patients following lower-limb lengthening. Macroscopical and microscopical surface damage to the nails were identified. Further analysis included radiology and micro-CT prior to sectioning. The internal mechanism was then analyzed with scanning electron microscopy and energy dispersive x-ray spectroscopy to identify corrosion. RESULTS: Seven male and three female patients underwent 12 femoral lengthenings. Three female patients underwent tibial lengthening. All patients obtained the desired length with no implant failure. Surface degradation was noted on the telescopic part of every nail design, less on the latest implants. Microscopical analysis confirmed fretting and pitting corrosion. Following sectioning, black debris was noted in all implants. The early designs were found to have fractured actuator pins and the pin and bearings showed evidence of corrosive debris. The latest designs showed evidence of biological deposits suggestive of fluid ingress within the nail but no corrosion. CONCLUSION: This study confirms less internal corrosion following modification, but evidence of titanium debris remains. We recommend no change to current clinical practice. However, potential reuse of the Precice nail, for secondary limb lengthening in the same patient, should be undertaken with caution.Cite this article: V. C. Panagiotopoulou, K. Davda, H. S. Hothi, J. Henckel, A. Cerquiglini, W. D. Goodier, J. Skinner, A. Hart, P. R. Calder. A retrieval analysis of the Precice intramedullary limb lengthening system. Bone Joint Res 2018;7:476-484. DOI: 10.1302/2046-3758.77.BJR-2017-0359.R1.

Recurrent multifocal diabetic myonecrosis: a cause of severe extremity pain in a diabetic patient.

We detail the unusual occurrence of successive episodes of diabetic myonecrosis in both lower and upper limbs in a young woman with diabetic end organ dysfunction. We highlight the importance of recognising this as a differential diagnosis for acute limb pain in diabetic patients and advocate conservative measures for successful treatment and return to function.

"No one has ever asked for it back!" A survey assessing the fate of reusable external fixation equipment in mortuaries.

Technicians from one hundred and eighteen Human Tissue Authority (HTA) approved mortuaries licensed to perform post-mortems in England completed a telephone interview. All were questioned on whether they had contact with reusable external fixators, who was responsible for the removal, the number removed annually, and the destination of the fixator post-removal. Opinion was sought on how the return of the equipment could be better facilitated. Seventy-four of the technicians interviewed could remember seeing external fixation devices, but were unable to quantify how many were removed annually. Sixty-one of those questioned stated that they personally removed the fixator, three always requested an Orthopaedic surgeon to remove the device and five contacted a Nurse Specialist. Forty-eight stated that they returned the devices to their local Sterile Services Department or Orthopaedic department. Nine technicians always discarded the fixators, eight always left them with the body and two stored them in the mortuary. Many reusable external fixation devices are inappropriately disposed of each year due to a lack of knowledge and communication with Orthopaedic departments. Confusion also exists among some technicians over whether external fixation components should be treated as 'implants'. There is a need for clear guidelines to raise awareness and ensure the appropriate return of these high cost devices.

Hydroxyapatite coating of an acetabular prosthesis. Effect on stability.

We report the radiological and clinical outcome of a press-fit (SLF) acetabular component at two to three years in two groups of patients having primary total hip replacement. In 69 the implant was coated with hydroxyapatite (HA) and in 40 it was uncoated. The stability of the cup was assessed by measurement of proximal migration and change in the angle of inclination. The clinical results in the two groups did not differ significantly, and the mean proximal linear wear was similar in both. Fewer radiolucent lines (RLLs) were seen on the radiographs of cups coated with HA. The mean proximal migration was studied by calculating regression lines for each patient using migration measurements: for the SLF+HA group the mean slope was 0.06 mm/year and for the SLF-HA group 0.20 mm/year (p = 0.22). The change in the angle of inclination during follow-up was also consistently smaller in HA-coated cups. Using regression methods the SLF+HA group had a mean slope of 0.08 degrees/year and the SLF-HA group 0.44 degrees/year and the SLF-HA group 0.44 degrees/year (p = 0.023). Partial HA coating appeared to have no effect on the clinical outcome or on the rate of wear of polyethylene, but there was a trend towards a reduced rate of proximal migration, and a significant reduction in rotational migration and the number of radiolucent lines. This suggests that HA coating enhances the stability of this acetabular component.

Is stem length important in uncemented endoprostheses?

In an uncemented total hip replacement where the femoral stem is thinner than the medullary canal it may be hypothesized that the distal portion of the stem has no mechanical function. In this study an uncemented total hip replacement has been modelled mathematically using finite element analysis and mechanical tests of a similar system have been carried out loading implants in cadaveric proximal femora. Two implants have been tested mechanically; one with a full length stem and the second with the stem shortened, but three implants have been modelled with an additional intermediate length stem analysed. Additionally the finite element analysis has been done with a high neck resection and a standard level resection. The finite element model showed that the full length stem produced lower interface contact stress levels under the proximal neck, particularly when the nec was resected, and this was borne out by the mechanical testing.