Intramedullary Interlocking Research Articles

Effect of Denosumab Injection in Early Union and Consolidation o f Callus in Aseptic Tibial Shaft Non-union

Fractures of the tibial shaft is one of the most common fractures than any other long bone fractures in the human body. Surgical treatment offers better functional outcome than a conservative management. Reamed intramedullary interlocking (IMIL) nailing is the treatment of choice for most of the closed tibial shaft fractures. Despite after a good surgical fixation non-union still persists after reamed IMIL nailing. Plate augmentation and bone grafting with nail in situ was found to have superior results and union rates than any other methods, but the average union time was almost 3 to 5 months. To enhance faster union and recovery here we have used Injection Denosumab 60 mg Sc post operatively during follow up. So, the aim of the study is to find the efficacy of injection Denosumab in enhancing early union and consolidation of callus. It is a comparative prospective study involving 43 patients treated for aseptic non-union of tibial shaft fractures following reamed intramedullary interlocking nailing between 2020 and 2023. All the patients treated by reamed intramedullary interlocking nailing who met the inclusion and exclusion criteria were included in the study. Group A was managed with plate augmentation and bone grafting following non-union IMIL nailing and Group B was managed with Plate augmentation bone grafting with Injection Denosumab Sc post operatively. Both the groups were followed up post operatively for period of one year. Total of 43 patients were included in the study. The average duration of union in GROUP A -14.82 weeks and in GROUP B- 9.45 weeks. Excellent results were obtained in both the groups. There was no complication such as malunion, non-union, implant loosening, nerve palsy, infection and plate/IMIL nail breakage. Augmentation plating, decortication and autogenous iliac crest bone grating is a better treatment option compared to exchange nailing in case of tibial shaft aseptic non-union following IMIL nailing. Using injection denosumab 60mg Sc postoperatively after plate augmentation and bone grafting offers early union and early consolidation of callus. Keywords Tibial Shaft Fractures, Intramedullary Interlocking Nailing, Plate Augmentation, Bone Grafting

EVALUATION OF THE FUNCTIONAL OUTCOME OF INTRAMEDULLARY INTERLOCKING NAIL FIXATIONS FOR HUMERAL SHAFT FRACTURES

Background And Objective: Humeral shaft fractures are commonly treated by orthopaedic surgeons and account for approximately 3% of all fractures. Antegrade interlocked humerus nailing for stabilisation of humerus fractures was introduced many years ago and is a valid treatment option for stabilising the shaft of humerus fractures. As complications, such as non-union, malunion, fracture disease, and difculty in nursing and rehabilitation in polytrauma cases, are less likely with this procedure, intramedullary interlocking (IMIL) nailing successfully bridges the gap between functional bracing and plating. The scoring system of the University of California Los Angeles (UCLA) is used to assess the functional outcome of intramedullary interlocking nailing for humerus shaft fractures and any associated complications of the above-mentioned procedure. Method: Thirty patients between the ages of 18 and 65 who were admitted to the orthopaedics department in R.L. Jalappa Hospital, part of the Sri Devaraj Urs Medical College, with a fracture of the humerus shaft and met the inclusion and exclusion criteria were included in the study. Their demographic data, history, clinical examination, and details of investigations were recorded in study proforma, and they were then taken for anterograde IMIL nailing. The recovery and ambulation time as well as complications of the procedure, such as pain, infection, joint stiffness, iatrogenic fractures, and radial nerve palsy, were documented, and the patients were followed up with one, three, and six months after surgery. Result: Among the 30 patients treated with IMIL nailing, the complications were as follows: Two patients showed shoulder stiffness and delayed union, one patient had a surgical site infection and shoulder stiffness, one patient had only shoulder stiffness, one patient had an iatrogenic fracture of the lateral epicondyle of the humerus, and one patient had implant breakage secondary to trauma after xation. Functional outcomes were evaluated using the UCLA scoring, in which 24 (80%) patients had a good outcome regarding pain relief, 24 (80%) had an excellent functional outcome, and 24 (80%) patients had excellent post-surgery muscle power and motion at their six-month follow-up. Intramedullary Conclusion: interlocking nailing is a safe and effective treatment modality for humeral shaft fractures with an excellent functional outcome. This is shown by a mean UCLA score of 31.73 ± 3.609 at follow-ups six months after surgery. In addition, IMIL nailing is associated with a low incidence of complications, with the most likely complication being shoulder stiffness

New interlocking intramedullary nail for treating acute midshaft clavicular fractures in adults: A retrospective study.

The aim of this study was to retrospectively examine the radiological and functional results of midshaft clavicle fractures that were treated with a new, interlocking intramedullary nail, and employing a different locking option. Between January 2018 and January 2020, 24 displaced midshaft clavicle fractures were operated with new, interlocking intramedullary nail. Fractures were classified according to the AO/orthopedic trauma association classification, according to which there were 22 15.2.B (wedge) and 2 15.2.C (comminuted) fractures. The mean patient age was 35.5±14.2 (range: 18-63) years. Eighteen (75%) of the patients were male and six (25%) were female. Follow-up data were recorded at a minimum of 1 year (range 12-36 months), with an average of 21.5 months (SD±8). The mean interval between the injury and surgery was 4.1 (SD±2.3; range: 1-9) days. Full shoulder movements had been achieved by all patients, relative to the contralateral side. The mean constant score was 95.6 (SD±4.2; range 90-100), and the mean visual analog scale score was 0.8 (SD±0.8; range: 0-3). Union was achieved in all patients. The mean union time was 9.5 (SD±1.8; range 6-12) weeks as assessed by radiograph. Average shortening of the clavicle relative to the contralateral side was 3.4% (SD±1.1; range 1.1-6.3). One patient experienced implant irritation, implant removal was performed after 14 months. No implant migration, hardware loosening, implant breakage, or neurovascular damage occurred. One hypertrophic scarring developed. One wound detachment developed at the 3rd post-operative week. We think that this new intramedullary nail is a good alternative for wedge type fractures in adult, acute, displaced, and midshaft clavicle fractures.

The efficacy of augmentative anti-rotational plating plus decortication and autogenic bone grafting for aseptic nonunion after intramedullary nailing of femoral shaft fracture

Abstract Background: Femoral interlocking intramedullary (IM) nailing fixation is an effective method for the treatment of femoral shaft fractures. Aseptic nonunion of femoral shaft fracture after IM nailing is uncommon. Currently, the treatment for aseptic femoral shaft nonunion is controversial. The aim of this study was to investigate the clinical effect of augmentative antirotational plating plus decortication and autogenic bone grafting for aseptic femoral shaft nonunion after IM nailing failure. Methods: A retrospective study was conducted on 25 cases of aseptic femoral shaft fracture nonunion treated with IM nailing from January 2015 to August 2019. All patients were treated by leaving the nail in situ, debridement of nonunion sites, decortication, autogenous iliac bone grafting, and augmentative antirotational plating fixation. The time to fracture union and complications were recorded. Results: All patients were followed up for 12–18 months. The union rate after revision surgery was 100%. The average union time was 5.5 months (range, 4-10). Subjective pain symptoms had disappeared in all patients. There were no incision infections or internal fixator fatigue fractures. Average scores of the physical function and bodily pain components of the SF-36 were 95.5 (range, 91-98) and 94.1 (range, 90-97), respectively. No other obvious complications occurred postoperatively. Conclusion: Augmentative antirotational plating plus decortication and autogenic bone grafting is an excellent choice for treating femoral shaft fracture nonunion after IM nailing; this approach has an overall high union rate and few complications.

Application of Rehabilitation Nursing Combined with Psychological Nursing in the Treatment of Nonunion Patients after Traumatic Fracture of Limbs with Interlocking Intramedullary Nail Fixation

Application of Rehabilitation Nursing Combined with Psychological Nursing in the Treatment of Nonunion Patients after Traumatic Fracture of Limbs with Interlocking Intramedullary Nail Fixation

Comparative study between intramedullary interlocking nailing and minimally invasive percutaneous plate osteosynthesis for distal tibia extra-articular fractures

<p class="abstract"><strong>Background: </strong>Treatment of distal tibia fractures poses significant challenge to orthopedic surgeon because of poor blood supply and paucity of soft tissue coverage. There is considerable controversy regarding the superior option of treatment for distal tibia fracture between the minimally invasive percutaneous plate osteosynthesis (MIPPO) technique and intramedullary interlocking (IMIL) nailing for extra-articular distal tibia fractures. The aim of our study is to compare the functional outcome between the two treatment methods.</p><p class="abstract"><strong>Methods:</strong> This was the prospective comparative study of 50 patients with distal third tibia fractures divided into two groups. First group of patients were treated with MIPPO technique while second group of patients were managed by IMIL nailing. Patients were followed up in outpatient department to assess the functional outcomes, malunion, delayed union, non-union, superficial and deep infection between the two groups.</p><p class="abstract"><strong>Results: </strong>Average time taken by patients for full weight bearing in group A was 17.6 weeks as compared to 16.7 weeks in group B. All patients were able to bear weight prior to complete union of fracture. By the process of weight bearing, we believed that it would promote secondary bone healing. On taking X-rays during follow up of included patients starting of radiological union was observed carefully by looking for bridging callus, haziness of fracture line. Appearance of callus was taken average time of 12.5 weeks in group A and 12.1 weeks in group B.</p><p class="abstract"><strong>Conclusions: </strong>Both procedures have shown the reliable method of fixation for distal extra-articular tibia fractures preserving the soft tissue, bony vascularity and fracture hematoma that provide a favourable biological environment for fracture healing. Considering the results of the study, we have slightly more preference for the MIPPO technique.</p>

Comparative study between intramedullary interlocking nailing and minimally invasive percutaneous plate osteosynthesis for distal tibia extra-articular fractures

PurposeTreatment of distal tibia fractures poses significant challenge to orthopedic surgeon because of poor blood supply and paucity of soft tissue coverage. There is considerable controversy regarding the superior option of treatment for distal tibia fracture between the minimally invasive percutaneous plate osteosynthesis (MIPPO) technique and intramedullary interlocking (IMIL) nailing for extra-articular distal tibia fractures. The aim of our study is to compare the functional outcome between the two treatment methods. MethodsThis was the prospective comparative study of 100 patients with distal third tibia fractures divided into two groups. The first group of patients were treated with MIPPO technique while the second group of patients were managed by IMIL nailing. Patients were followed up in outpatient department to assess the functional outcomes, malunion, delayed union, nonunion, superficial and deep infection between the two groups. Statistical analyses were performed using the SPSS software (version 16.0). ResultsAverage malunion (degrees) in the MIPPO group was 5 (3–7) ± 1.41 vs. 10.22 (8–14) ± 2.04 in the IMIL group (p = 0.001). Similarly postoperative knee pain in the IMIL group was 10% vs. 2% in the MIPPO group (p = 0.001). In terms of superficial infection and nonunion, the results were 8% vs. 4% and 2% vs. 6% for the MIPPO and IMIL group, respectively (p = 0.001). ConclusionBoth procedures have shown the reliable method of fixation for distal extra-articular tibia fractures preserving the soft tissue, bony vascularity and fracture hematoma that provide a favourable biological environment for fracture healing. Considering the results of the study, we have slightly more preference for the MIPPO technique.

Результат лечения пациентки с поражением бедренных костей множественной миеломой

Introduction Multiple myeloma (MM) is a malignant tumor that causes widespread bone damage. The bone is involved in 90 % of MM patients, and 60% of patients develop pathologic fractures. Material and methods We report a case of combined surgical treatment and chemotherapy of a multiple myeloma patient who sustained a pathological diaphyseal fracture of the left femur and later presented with a lytic myeloma lesion in the right femur. Closed reduction and interlocking intramedullary (IM) nailing of the left femur was performed for the patient who was diagnosed with bone destruction in the shaft of the right femur a few months later. The right femur was fixed with interlocking IM nail for prophylaxis. Results The left femur consolidated at 6 months. The patient had no pain in the right femur, and enlargement in the bone destruction was not seen in the femur. The patient could ambulate with a cane with signs of deforming arthritis in the adjacent joints of the lower limbs. Discussion Three common surgical approaches used for bone tumors being complicated or not complicated by a pathologic fracture include nailing/plating, bone replacement and joint arthroplasty. Bone tumor replacement with oncological endoprostheses can be produced in specialized oncological orthopaedic units and is not available with regular trauma and orthopaedic services for different reasons. The operating orthopedic surgeon is to choose the appropriate implant to address the tumor involvement. Conclusion Interlocking IM nailing can be the method of choice for a pathologic fracture or for prophylactic bone fixation with appropriate indications identified with the Mirels's scoring system. Intramedullary nailing offers the advantage of minimally invasive stability for the operated limb and early weight-bearing in contrast to plate fixation treatment for fractures and prophylactic plating.

Treatment of diaphyseal forearm fracture with interlocking intramedullary nailing: A pilot study

IntroductionThe present study was done to assess the functional outcome and complications of interlocking intramedullary (IM) radius ulna nailing to treat radio-ulna fractures in adults. MethodologyThirty adult patients with diaphyseal or segmental fractures of radius and ulna were included and treated with IM nailing. Grace and Eversmann rating system was used to assess functional evaluation and grip strength was measured using grasp dynamometer. ResultsMean age of the 30 eligible patients was 33.5 years, and males comprised 77% of the study population. Intra-operative complications like nail impaction and proximal screw locking problem for radius was present in one patient each. Increased swelling in three patients (10%) and posterior interosseous nerve palsy in one patient (3%) were observed post-operatively. In the post-operative period, all patients were able to move fingers, had 100° elbow range of motion and good grip strength. Pronation and supination till 80° was present in 80% and 57% of the patients respectively. Wrist flexion and dorsiflexion till 90° was present in 80% and 57% of the patients. Fracture union was confirmed radiologically in all cases at a mean of 3.6 weeks. Functional outcome was excellent in 73% and good in 13%. Grip strength was judged to be excellent in all cases. ConclusionsExcellent and good functional outcomes were obtained in 86%, and no case developed mal-union or delayed union. Based on our results, IM nail for surgical treatment of radial and ulnar diaphyseal fractures can be used.

Does the fracture of the lateral wall affect the degree of collapse and the degree of sliding of the cephalic plate, in pertrochanteric fractures treated by intramedullary interlocking? Radiological study and review of the literature

BackgroundLateral wall fracture has been recognized as an important sign of instability of pertrochanteric fractures. The aim of the present study is to assess the relationship between lateral wall fractures, helical blade telescoping and neck shortening in fractures treated with intramedullary nailing. Material and methodA descriptive radiological study was performed at our institution. Patients who suffered a pertrochanteric fracture, treated at Hospital 12 de Octubre by intramedullary nailing were included. All fractures were classified according to Evans and AO systems. Preoperative and postoperative radiological assessment was carried out including a lateral wall fracture classification, helical blade telescoping and femoral neck shortening. Results210 patients were included, 48% had a fracture of the femoral lateral wall. Helical blade telescoping was higher in lower lateral wall fractures with respect to higher fractures. Difference was statistically significant. Neck shortening was higher in fractures with femoral lateral wall disruption; despite not have found any significant differences comparing to fractures with intact lateral wall (p = 0.39). Multivariate analysis showed statistically significant association between helical blade telescoping, neck shortening and lateral wall fracture. ConclusionsThere is evidence of a higher helical blade telescoping and neck shortening in pertrochanteric fractures with lateral wall fracture treated with intramedullary nails, especially in those with most unstable patterns such us fractures of the lateral wall distal to the vastus ridge.

Перестроечный перелом дистального метаэпифиза большеберцовой кости как редкое осложнение интрамедуллярного остеосинтеза с блокированием

Introduction This article describes a clinical case of a stress fracture of the distal tibial metaepiphysis following a high-energy tibial shaft fracture stabilized with interlocking intramedullary (IM) nail to identify an underlying cause of the traumatic event. Objective To demonstrate the occurrence of a stress fracture after adequate interlocking IM nailing of a traumatic fracture due to systemic osteoporosis that presented no clinical manifestations prior to injury. Material and methods Magnetic resonance imaging was performed to diagnose the stress fracture. Bone mineral density and laboratory markers of bone metabolism were measured to identify underlying causes of the stress fracture. Consolidation of the traumatic fracture fixed with interlocking IM nail was re-evaluated with a radiograph of the fracture site. Results The stress fracture was seen off the IM nail on MRI scans. Osteoporosis was diagnosed with bone densitometry using dual energy X-ray absorptiometry, and deoxypyridinoline, a bone resorption marker and vitamin D deficiency were identified with laboratory tests. No signs of fracture union were seen radiologically. Conclusion A stress fracture of the distal tibial metaepiphysis detected 3 months after a tibial shaft fracture fixed with interlocking IM nail can be considered an insufficiency fracture caused by primary (idiopathic) systemic osteoporosis that was asymptomatic prior to the high-energy injury.

Osteogenesis and Histostructure of Femoral Muscles When Modeling a Femoral Fracture with Immediate or Delayed Osteosynthesis Using an Interlocking Intramedullary Antegrade Rod

Interlocked intramedullary osteosynthesis is the most common method for treating femoral shaft fractures. The aim — to reveal specifi c characteristics of the histostructure of canine femoral muscles when healing femoral fractures under osteosynthesis using interlocking intramedullary reinforcement with an antegrade metal rod. Femoral shaft fractures were modelled in 9 mongrel dogs. The fractures were fi xed with an intramedullary rod. In Group I (n=4), osteosynthesis was started immediately after bone injury. In Group II (n=5), osteosynthesis was started 4 days after fracture (delayed osteosynthesis). M. biceps femoris and M. quadriceps femoris were studied. In Group I and Group II, bone healing occurred following 42 and 70 days, respectively. A unifi ed bone marrow cavity and cortical layer had been formed by day 70 and day 100 in Group I and Group II, respectively. The histostructure of M. quadriceps femoris in Group I remained largely unchanged throughout the experiment, while M. biceps femoris underwent the process of structural reorganization on days 42 and 70 of the experiment. The Group of delayed osteosynthesis demonstrated changes in the histostructure of both muscles, including an increased diversity of fi bre diameters, an increased number of nuclei in myocytes, fi brosis of the interstitial space and perimysial arterial vessels. These changes were more pronounced in M. biceps femoris. Three months after injury, the histostructure of the muscles under study, even in the Group of delayed osteosynthesis, had no signifi cant differences and tended to the intact norm. In femoral fractures, the earliest possible fi xation of bone fragments with an inter locking antegrade intramedullary rod is recommended. A complete bone healing in such cases occurs a month earlier than in those with delayed osteosynthesis. The femoral muscles of the anterior group are injured to a lesser extent than those of the posterior group.

A comparative study of extra-articular distal tibia fractures managed by intramedullary nailing vs locking plate

Introduction: Distal tibial fractures are common long bone fractures that occur mainly due to a high velocity trauma. These are difficult to treat because of its subcutaneous location and poor blood supply. Many studies have been published on modalities of treatment of distal tibia fractures. Available options are Intramedullary nails, locking plates and external fixators. The aim of our study was to compare intramedullary interlocking (IMIL) nailing and locking plate (LP) for the treatment of these fractures. Materials and methods: This is a prospective study consisting data of 20 patients with distal tibial fractures operated for IMIL nailing and LP. Patients were followed up for radiological and clinical outcome using The American Orthopaedic Foot and Ankle Society (AOFAS) score. Results: The functional outcome was assessed by AOFAS score. Overall 10 patients obtained an excellent result (50%) and 8 obtained a good result (40%) and 2 obtained fair result (10%). IMIL nailing shows lower rate of delayed wound healing and superficial infection and plating may avoid malunion and knee pain. Discussion: The study suggests superiority of IMIL nailing over LP in terms of less rates of infections, early rate of union, early weight bearing. Whereas LP is better in anatomical and fixed reductions of the fracture and less knee pain. Hence the modality of treatment should be based on the patient’s injury pattern, surgeon’s expertise and clinical condition.

Evaluation of the Outcome of Tibial Shaft Fracture by Close Reduction and Internal Fixation with Interlocking Intramedullary Nail

Evaluation of the Outcome of Tibial Shaft Fracture by Close Reduction and Internal Fixation with Interlocking Intramedullary Nail

Can isolated tibia intramedullary interlocking nailing in fracture distal 1/3rd both bone leg prevent fracture malalignment: will concurrent fibula fixation help?

<p class="abstract"><strong>Background:</strong> Different stand point prevails till date concerning fibular osteosynthesis in distal third both bone fracture fixation. This study was done to assess the post op alignment of distal third both bones fracture without fixing Fibula.</p><p class="abstract"><strong>Methods:</strong> A total of 30 patients who had distal 1/3rd extra articular tibia and fibula fractures were included in the study from July 2016 to April 2019. Tibial nailing was done in all cases with care is taken particularly to prevent malalingment of distal fragment. Radiological malalignment were assessed post operatively.<strong></strong></p><p class="abstract"><strong>Results:</strong> Of 30 patients, 5 patients had excellent results and 21 patients had good results, only 4 patients had fair results with valgus and varus malalignment, however these patients did not have any clinical problems associated with these malalignment at one year follow up. No patients had poor results. Valgus tibial malalignment is observed more frequently when fibular fracture is at proximal level.</p><p class="abstract"><strong>Conclusions:</strong> The level of Fibular fracture is important to determine when the fixation of this bone is indicated. Fixing ipsilateral tibial fracture with intramedullary interlocking (IMIL) nailing without fibular synthesis produce no gross change in alignment provided adequate care is taken for intra operative centering of the nail in both AP and lateral views.</p>

Comparative study of the efficacy of gentamicin-coated intramedullary interlocking nail versus regular intramedullary interlocking nail in Gustilo type I and II open tibia fractures

PurposeOpen tibia fracture is prone to infection, consequently causing significant morbidity and increasing the hospital stay, occupational loss and onset of chronic osteomyelitis. Intramedullary nailing is one choice for treating tibia shaft fractures. To improve the delivery of antibiotics at the tissue-implant interface, many methods have been proposed as a part of prophylaxis against infection. This study was conducted to study the role of gentamicin-impregnated intramedullary interlocking (IMIL) nail in the prevention of infection in Gustilo type I and II open tibia fractures and to compare the results with regular intramedullary nail. MethodsThe study included 28 patients with open tibia fractures (Gustilo type 1 or type 2); of them 14 underwent regular IMIL nailing and the other 14 were treated with gentamicin-coated nailing. Randomization was done by alternate allocation of the patients. Follow-up was done postoperatively (day 1), 1 week, 6 weeks, and 6 months for bone union, erythrocyte sedimentation rate (ESR), hemoglobin and C-reactive protein (CRP). Statistical significance was tested using unpaired t-test. A p value less than 0.05 was considered significant. ResultsThere were 4 cases of infection in controls (regular IMIL nail) and no infection among patients treated with gentamicin-coated nail during the follow up (X2 = 4.66, p = 0.031). At 6 months postoperatively, CRP (p = 0.031), ESR (p = 0.046) and hemoglobin level (p = 0.016) showed significant difference between two groups. The bone healing rate was better with gentamicin-coated nail in comparison to regular IMIL nail at 6 months follow-up (p = 0.016). ConclusionGentamicin-coated IMIL nail has a positive role in preventing infection in Gustilo type I and II open tibia fractures.

融合式股骨近端交锁髓内钉治疗老年股骨近端骨折的临床研究

融合式股骨近端交锁髓内钉治疗老年股骨近端骨折的临床研究

Functional Outcome of Patients with Comminuted Femoral Shaft Fractures Treated By Interlocking Intra Medullary Nailing

Functional Outcome of Patients with Comminuted Femoral Shaft Fractures Treated By Interlocking Intra Medullary Nailing

Antibiotic-Coated Interlocking Intramedullary Nail for the Treatment of Long-Bone Osteomyelitis.

* Antibiotic-coated interlocking intramedullary nails provide both infection control or prophylaxis and osseous stability to fractures, nonunions, and fusions, and there is evidence from animal models and patients to support their use.* These nails have been successfully used in a variety of anatomic locations, including the tibia, femur, humerus, knee, and ankle.* These nails may be prepared in the operating room using simple techniques, and new antimicrobial implant coatings are being developed that may have considerable utility when they become available.

HEALING PATTERN OF INTERLOCKED INTRAMEDULLARY NAILED HUMERAL SHAFT FRACTURE

Design: Study on the cases of the united interlocked intramedullary (IM) nailed humeral shaft fractures. Objective: To assess the healing pattern of nailed humeral shaft fracture and to compare it with the results of the other previous authors’ nail-treated large bone fractures. Background data: Based on the relevant previous studies related with healing patterns of the interlocked IM nail-managed humeral shaft fractures, the current age-matched study on the participating callus for union was conceived. The comparative study on the healing patterns between the fractures of non-weight-bearing long bone — the humerus — and other large weight-bearing long bones have never been carried out previously. Materials and methods: Eighty-nine cases of the humeral shaft fractures, fixated with antegrade interlocked IM standard Kuentscher nail were subjected to the study. The patients’ ages ranged from the late teens to 9th decade of life. For the antegrade nailing, two entry points were chosen; conventional entry point in the early series, and rotator cuff interval in the late series. Results: External callus was very rarely formed [12 cases (13.4%)]. It was formed at post-fixation 6.5 weeks on average in cases with unreduced displaced fragment, and proximal interlocking. Radiographic union occurred at post-fixation 17.6 weeks on an average by primary osteonal callus. Conclusion: It was concluded that in most cases union was obtained primarily by the contact or gap healing irrespective of the patients’ ages, and that periosteal participation was very rare or negligible. Use of smaller diameter nail or new development of less rigid IM nail without external nail shape change is thought desirable to induce periosteal callus in early healing stage.