Use of external fixator versus flexible intramedullary nailing in closed pediatric femur fractures: comparing results using data from two cohort studies

Risk of complications following surgical fixation of femoral diaphyseal fractures in children aged 4 to 12 years: A systematic review and meta-analysis

INTRODUCTION

There is debate regarding the optimal surgical technique for fixing femoral diaphyseal fractures in children aged 4 to 12 years. The National Institute for Health and Care Excellence (NICE) and the American Academy of Orthopaedic Surgeons (AAOS) have issued relevant guidelines, however, there is limited evidence to support these. The aim of this study was to conduct a systematic review and meta-analysis to compare the complication rate following flexible intramedullary nailing (FIN), plate fixation and external fixation (EF) for traumatic femoral diaphyseal fractures in children aged 4 to 12.

METHODS

We searched MEDLINE, EMBASE and CENTRAL databases for interventional and observational studies. Two independent reviewers screened, assessed quality and extracted data from the identified studies. The primary outcome was the risk of any complication. Secondary outcomes assessed the risk of pre-specified individual complications.

RESULTS

Nine randomised controlled trials (RCTs) and 19 observational studies fulfilled the eligibility criteria. Within the RCTs, five analysed FIN (n = 161), two analysed plates (n = 51) and five analysed EF (n = 168). Within the observational studies, 13 analysed FIN (n = 610), seven analysed plates (n = 214) and six analysed EF (n = 153). The overall risk of complications was lower following plate fixation when compared to FIN fixation (RR 0.45, 95% CI 0.28 to 0.73, p = 0.001) in the observational studies. The overall risk of complications was higher following EF when compared to FIN fixation in both RCTs (RR 1.94, 95% CI 1.25 to 3.01, p = 0.003) and observational studies (RR 1.97, 95% CI 1.50 to 2.58, p<0.001). The overall risk of complications was higher following EF when compared to plate fixation in both RCTs (RR 7.42, 95% CI 1.84 to 29.98, p = 0.005) and observational studies (RR 4.39, 95% CI 2.64 to 7.30, p<0.001).

CONCLUSION

Although NICE and the AAOS recommend FIN for femoral diaphyseal fractures in children aged 4 to 12, this study reports a significantly decreased relative risk of complications when these injuries are managed with plates. The overall quality of evidence is low, highlighting the need for a rigorous prospective multicentre randomised trial at low risk of bias due to randomisation and outcome measurement to identify if any fixation technique is superior.

The Bisaccia and Meccariello technique in pediatric femoral shaft fractures with intramedullary titanium nail osteosynthesis linked external-fixator (IOLE): validity and reliability

Background:

Over the last 20 years, the incidence of pediatric femoral shaft fractures was increased, due to changes in the children’s daily activities. The healing times are different according to the chosen treatment and to other factors such as age, type of fracture, the involvement of the soft tissues, and concomitance with other injuries. The Bisaccia and Meccariello technique (Intramedullary titanium nail Osteosynthesis Linked External-fixator -IOLE) was born to prevent rotationally and lengthening malunion or nonunion in the treatment of pediatric femoral shaft fractures.

Hypotheis:

The aim or the objective of this paper is to compare the IOLE with the two most used methods for the treatment of femoral fractures in children.

Methods:

From 2000 to 2016, 58 pediatric patients with femoral shaft fractures were surgically treated and enrolled in the study. The ranged age of the patients was between 3 and 15 years. Twenty-two patients were treated with endomedullary titanium nails (TEN), 22 with external axial or modular external fixators and 14 patients treated with IOLE technique. The IOLE technique, in brief, is the hybridization of titanium intramedullary nails with a modular external fixator. It is divided into three phases, the first revenue given the length of the femur with the external fixator; the second, the rotations are dominated by the elastic nails; and the third finally they are hybridized on the external fixator. Comparing the three groups, radiographic images were taken to assess fracture reduction and consolidation.

Results:

At the final follow-up, statistically significant differences in not weight-bearing times were found in favor of the IOLE group. There were no statistical differences between three groups in terms of significant rotation defects, angulation, growth, and/or nonunion.

Conclusions:

The Bisaccia- Meccariello technique (IOLE) showed to lead to healing the pediatric femoral shaft fracture of the femur but allows an early weight-bearing to these patients and normal life like that.

Treatment of pediatric femoral shaft fractures with elastic stable intramedullary nails versus external fixation: A meta-analysis

BACKGROUND

There is currently a debate about whether elastic stable intramedullary nails (ESIN) or external fixation (EF) is the best surgical method for treating pediatric femoral shaft fractures. We performed a meta-analysis to determine which surgical method leads to higher treatment satisfaction, lower complication rates, and reduced treatment time, to investigate whether ESIN is the preferred surgical method for treatment of pediatric femoral shaft fractures.

PATIENTS AND METHODS

Relevant databases were searched for comparative studies of ESIN versus EF for the treating pediatric femoral shaft fractures. Literature reports and quality evaluations were extracted, followed by a systematic review using RevMan 5.3 software. Treatment satisfaction at the last follow-up, primary complications, secondary complications, and relevant time indicators (operation time, hospital stay, clinical healing time, bone healing time) were analyzed.

RESULTS

A total of 22 reports were included in this meta-analysis. We found no statistical differences in the treatment satisfaction at the last follow-up between ESIN and EF for the treatment of pediatric femoral shaft fractures. A low rate of postoperative re-fracture (RR=3.58, 95% CI (1.85, 6.92), p=0.0001) and postoperative infection (RR=9.25, 95% CI (5.32, 16.11), p<0.00001), and a high risk of skin irritation (RR=0.15, 95% CI (0.06, 0.37), p<0.00001) were found in the ESIN group. No significant differences between the two approaches were found regarding malunion. A low rate of limb-length discrepancy (RR=2.41, 95% CI (1.40, 4.17), p=0.002), hospitalization (SMD=0.84, 95% CI (0.24, 1.43), p=0.006), clinical healing time (SMD=0.95, 95% CI (0.56, 1.33), p<0.00001) and bone healing time (SMD=0.89, 95% CI (0.39, 1.40), p=0.005) were found in the ESIN group, as compared to that in the EF group. No significant differences were found in fixation failure, activity limitation of the joint, and operation time between the two strategies.

DISCUSSION

ESIN should be the primary choice for the treatment of pediatric femoral shaft fractures since it has a reliable curative effect and results in a shorter hospital stay, faster fracture healing, and fewer complications. EF is recommended for fractures with serious injury of the soft tissue to avoid intramedullary infection. Double-blind high-quality randomized studies with larger sample sizes are warranted to confirm our conclusions.

LEVEL OF EVIDENCE

IV.

Pediatric Femur Fractures

Trauma is the leading cause of death and disability in children. Orthopaedic trauma has led to more than 84,000 hospital admissions annually and costs nearly a billion dollars. Femoral diaphyseal fractures account for nearly 2% of all bony injuries in children and are the most common orthopaedic injury requiring hospitalization. These injuries occur at an annual rate of 19 per 100,000, with an associated cost of millions of dollars. Emergency department (ED) visits for musculoskeletal injuries account for 10%-15% of the 100 million annual visits to U.S. pediatric EDs. Treatment of femur fractures in children vary on the basis of the mechanism of injury, the patient's age, weight, the fracture pattern, family circumstances, and cost. Treatment ranges from noninvasive to invasive and includes traction, casting, internal fixation, and external fixation. Complications can include infection, delayed or malunion, leg length discrepancy, ossification, and refracture. Attention to pain control and anxiety management becomes a major focus for nursing. Pediatric femur fracture can have a devastating impact on the child and the family and requires monitoring for 12-24 months. This injury is significant and can be a life-changing event for the child and the entire family. A case study is used as an example of the extent of the problem with pediatric patients and highlights the long-term effect of this injury.

Closed reduction with crossed Kirschner wire fixation for displaced supracondylar femoral fractures in young children

Supracondylar femoral fractures are uncommon in children, but may result in various deformities. Though many approaches have been used to manage them, there is no literally approved standard yet.From 2015 to 2017, 12 young children at the average age of 2.5 years old (range 3.6-1.6) with displaced supracondylar fractures were admitted to our department and received closed reduction with crossed Kirschner wire (K-wire) fixation as treatment. After the surgeries, we performed follow-up to every patient at the average length of 26 months (range 24-30) and used the Knee Society Score scale to evaluate the outcome.Fracture healing was observed within 10 weeks for all patients and walking was resumed between 10 to 13 weeks. No patient reported a valgus deformity more than 10°, neurovascular injury or knee infection. The average limb length discrepancy was 0.4 cm at the end of our follow-up. Every patient had perfect score on the Knee Society Score scale.Our study suggests that closed reduction with percutaneous crossed Kirschner wire is a favorable method for displaced supracondylar femoral fractures in young children.

Biomechanical Analysis of Retrograde Flexible Intramedullary Nail Constructs in a Simulated Pediatric Femur Fracture Model

BACKGROUND

Various flexible intramedullary nail (FIMN) constructs for pediatric femur fractures are described; however, no biomechanical study has compared stability of medial-lateral entry versus all-lateral entry retrograde nailing. Our purpose is to compare the rotational and bending stiffness of 2 different FIMN constructs and 2 different materials in a simulated pediatric femur fracture model.

METHODS

Eighty adolescent-sized composite femurs were used to simulate transverse (40 femurs) and oblique (40 femurs) mid-diaphyseal fractures. Retrograde FIMN of the femurs was performed using either 3.5 mm titanium (Ti) or 3.5 mm stainless-steel (SS) flexible nails in 2 configurations: 2 "C"-shaped nails (CC) placed through medial and lateral entry sites or 1 "C"-shaped nail and 1 "S"-shaped nail (CS) placed through a single lateral entry site. Models were first tested in 10 cycles of axial rotation to ±1 N m of torque at a rate of 0.5 degrees/s under 36 kg of compression. Axial compression was performed and bending stiffness defined as the force required to achieve 10 degrees varus at the fracture site.

RESULTS

No differences were noted in rotational stiffness comparing Ti and SS nails regardless of nail configuration or fracture pattern. Comparable rotational stability was found for CC and CS configurations with SS implants for both fracture patterns. The CS construct (0.60 N m/degree) was stiffer in rotation than the CC construct (0.41 N m/degree) with Ti implants in the transverse fracture model (P<0.005). SS nails provided greater bending stiffness than Ti nails in both oblique and transverse fracture patterns, regardless of nail construct. The all-lateral entry (CS) construct demonstrated statistically significant greater bending stiffness regardless of implant material or fracture pattern (P<0.03).

CONCLUSIONS

An all-lateral entry (CS) FIMN construct demonstrated greater bending stiffness in both fracture patterns and materials. Ti and SS implants have comparable rotational stiffness in all fracture patterns and materials; however, SS nails were superior at resisting bending forces in both fracture patterns. CS nail configuration and SS implants demonstrated superior bending stiffness and rotational stiffness when compared with the more commonly used CC construct and Ti implants.

LEVEL OF EVIDENCE

NA (biomechanical study).