TEN versus external fixator in the management of pediatric diaphyseal femoral fractures: evaluation of the outcomes

Elastic stable intramedullary nail fixation versus submuscular plate fixation of pediatric femur shaft fractures in school age patients: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Studies of clinical outcomes that compare the elastic stable intramedullary nail (ESIN) with the submuscular plate (SMP) were controversial. The meta-analysis was performed to summarize existing evidence, aiming to determine whether ESIN was superior to SMP in pediatric femur shaft fractures.

METHODS

Search strategies followed the recommendations of the Cochrane collaboration. Electronic searches such as PubMed, Embase, Web of Science, Cochrane were systematically searched for publications concerning ESIN and SMP from the inception date to March 2023. Two investigators independently searched, screened, and reviewed the full text of the article. Disagreements generated throughout the process were resolved by consensus, and if divergences remain, they were arbitrated by a third author.

RESULTS

This study included 8 articles, comprising a total of 561 patients with a similar baseline. Compared to the SMP, the ESIN had shorter operation time (mean difference = -16.16; 95% CI = -22.83 to -9.48, P < .00001), and less intraoperative blood loss (mean difference = -53.62; 95% CI = -58.89 to -48.36, P < .00001), but had a higher incidence of implant irritation (odds ratio [OR] = 6.49; 95% CI = 3.01 to 13.98, P < .0001), lower limb malalignment (OR = 2.60; 95% CI = 1.12 to 6.04, P = .96) and overall complications(OR = 4.14; 95% CI = 2.51 to 6.84, P < .0001). And there was no significant difference in radiation time, length of hospital stay, limb length discrepancy, infection rate, delayed union rate and unplanned revised surgery rate (P > .05).

CONCLUSIONS

Compared to the SMP, the ESIN offers shorter operative time, and less blood loss. However, the SMP is superior to ESINs in complication rates, especially regarding implant irritation and malalignment. Both methods could achieve excellent satisfactory functional outcomes. Thus, the SMP is an alternative choice in the pediatric femur shaft fracture.

Management of long bone fractures in patients with pycnodysostosis

Pycnodysostosis is a rare genetic condition that leads to generalised bony sclerosis and increased fracture risk. Orthopaedic specialists play a crucial role in managing affected children due to their susceptibility to frequent fractures. We had a case of a middle childhood female patient with pycnodysostosis and a femur fracture. Initially, an attempt using the Titanium Elastic Nailing System was made, but the sclerotic metaphyseal bone made it challenging. So, we opted for a 4.5 mm locked compressive plate, with multiple drill bits as a backup due to potential drill breakage. Though elastic nailing is preferred for paediatric long bone fractures, surgeons must be prepared for extremely sclerotic cortices and a narrow medullary canal when dealing with patients with pycnodysostosis. Open fixation and multiple drill bits in the toolkit are essential to overcome the potential obstacles during the procedure.

Case report: Reconstruction of distal medial tibial epiphysis using iliac crest apophyseal autograft

Background

Salter-Harris type VI physeal fracture is a rare injury. This case study aims to present a novel method for treating a rare entity of Salter-Harris type Salter-Harris VI physeal injury of the medial malleolus.

Case presentation

A 6-year-old boy with Salter-Harris type VI physeal injury was successfully treated using the two-stage procedure. In the first stage, the patient was treated with intravenous antibiotics, a series of debridement and lavage followed by a skin graft that left a defect in the medial malleolus. In the second stage, an autogenous iliac crest apophyseal graft was transplanted to reconstruct the medial malleolus, and the ankle joint was stabilized by an external fixator. An additional anticipatory Langenskiold procedure was performed for the physeal bar resection. Although the complete radiological development of medial malleolus compared to the contralateral side was not evident at the last follow-up, the functional and cosmetic outcomes were satisfactory.

Conclusion

The reconstruction of medial malleolus using an autologous iliac crest apophyseal graft and stabilization of the ankle joint with an external fixator is a novel reconstruction technique in treating Salter-Harris type VI physeal injury of the medial malleolus. This technique provides satisfactory functional and cosmetic outcomes in such a fracture pattern; however, a further clinical study using a larger sample size is warranted in order to find the definitive outcome of the technique.

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.

Comparison of Open Reduction and Internal Fixation with Plate and Titanium Elastic Intramedullary Nail in Treating Pediatric Humeral Fracture

Objective

To investigate the therapeutic efficacy of titanium elastic intramedullary nail (TEN) and open reduction and internal fixation with plate (ORIF) in the treatment of humeral fracture in children.

Methods

A retrospective study was carried out in a total of 69 patients who were admitted to the hospital from January 2013 to December 2018. These patients, including 41 males and 28 females, were aged from 6 to 12 years old with a median of 8 years. These patients were diagnosed with humeral fracture and underwent the surgery of ORIF (n = 22) or TEN (n = 47). The intraoperative bleeding, operation time, length of stay (LOS), and fracture healing time were compared between the two groups. The therapeutic effect was assessed by the shoulder range of motion, the elbow range of motion, the UCLA shoulder function score, and the Mayo elbow performance score (MEPS) 6 months after the surgery.

Results

The intraoperative bleeding (97.20 ± 27.83 mL vs 185.60 ± 37.50 mL, P < 0.05), the operation time (53.70 ± 11.87 min vs 73.50 ± 13.33 min, P < 0.05), and the fracture healing time (9.30 ± 4.23 weeks vs 13.45 ± 3.67 weeks, P < 0.05) in the TEN group was significantly decreased than those in the ORIF group. There was no significant difference in the LOS between the two groups. The length of follow‐up is 3 and 6 months. The shoulder range of motion (110.88° ± 15.82° vs 98.37° ± 16.22° at 3 months and 162.88° ± 17.29° vs 117.65° ± 19.38° at 6 months, both P < 0.05), the elbow range of motion (105.23° ± 2.81° vs 87.12° ± 4.73° at 3 months and 137.47° ± 4.82° vs 109.67° ± 5.83° at 6 months, both P < 0.05), and the UCLA shoulder function score (28.58 ± 4.74 vs 21.64 ± 7.23 at 3 months and 33.05 ± 3.27 vs 25.78 ± 3.87 at 6 months, both P < 0.05), and the MEPS (80.76 ± 3.53 vs 65.33 ± 9.43 at 3 months and 97.48 ± 1.23 vs 88.22 ± 3.65 at 6 months, both P < 0.05) in the TEN group were greater than those in the ORIF group. In the TEN group, complications occurred in three of 47 cases (6.38%), including one case (2.13%) of bone nonunion and two cases (4.25%) of irritation response around the nail. In the ORIF group, complications occurred in four of 22 cases (18.18%), including one case (4.55%) of delayed healing, one case (4.55%) of deep infection, and two cases (9.08%) of radial nerve injury. The complication rate was not significantly different between the two groups.

Conclusion

TEN can be a good technique for the treatment of humeral fracture in children, with the advantages of less intraoperative bleeding, shorter operative time, quicker healing, and better recovery of shoulder range of motion and elbow range of motion.

Dilemma for Fracture Fixation of Paediatric Ipsilateral Neck with Shaft Femur Fracture

BACKGROUND

Ipsilateral femoral neck with shaft fracture (IFNSF) in the paediatric population is a rare injury. This high-impact trauma is often associated with other orthopaedic and systemic injuries. Prognosis is usually guarded as both these osseous injuries are serious and exist together. We report two such patients of IFNSF.

METHODS

Two children with IFNSF were admitted at our hospital in 2018. The first patient had an associated head injury, while in the second patient, the shaft femur fracture was open. We report on the treatment and results in these two patients. Both the patients were serially assessed and followed 2 years after the injury.

RESULTS

Union was achieved in neck and shaft femur fractures in both the patients by 3 months. Complications like avascular necrosis (AVN) of the femoral head, coxa vara, non-union or malunion of fractures, limb length discrepancy, knee and hip stiffness were not seen in either of the patients.

CONCLUSION

IFNSF is a rare injury pattern seen in children, usually associated with concomitant orthopedic and other systemic injuries. Early operative stabilization is the preferred modality of treatment. For an undisplaced neck fracture, a provisional temporary fixation of a relatively less displaced neck fracture, definitively stabilizing the shaft fracture, and thereby returning to fix neck fracture is advocated. For displaced neck fractures, a direct open reduction is advocated. Anatomical fixation with separate implants and a relatively longer immobilization can provide the best-expected results. Long-term follow-up is needed to foresee any complications.

LEVEL OF EVIDENCE

V (case series). Therapeutic.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-020-00315-z.

Operative Choice for Length-Unstable Femoral Shaft Fracture in School-Aged Children: Locking Plate vs. Monolateral External Fixator

BACKGROUND

Locking plate (LP) is a good choice in the treatment of length-unstable femoral shaft fracture in children. Monolateral external fixator (EF) has been reported for this condition for decades. This study aims to compare the clinical outcomes of school-aged children with length-unstable femoral shaft fracture treated with LP vs. EF.

METHODS

Patients aged 5-11 years old with length-unstable femoral shaft fractures treated at our institute from January 2014 to January 2018 were retrospectively reviewed and categorized into LP and EF groups. The preoperative data, including baseline information of the patients, radiographic parameters, and types of surgical procedure, were collected from the hospital database, and postoperative data, including complications, were collected during the follow-up visits.

RESULTS

Overall, 36 patients (average, 8.2 ± 2.1 years; male, 20; female, 16) in the LP group and 35 patients (average, 8.3 ± 2.3 years; male 20, female 15) in the EF group were included. There was significantly less operative time for EF (45.4 ± 7.8 min) compared with LP (67.8 ± 11.3 min) (P < 0.001). As for the frequency of fluoroscopy, there was a significant difference between the EF (13.9 ± 2.4) and LP (16.5 ± 3.2) groups (p < 0.001). The rate of major complications was not significantly different between these two groups. There was a significant difference between the EF group (11.2 ± 5.8 mm) and the LP group (7.5 ± 1.6 mm) group concerning limb length discrepancy (P < 0.001).

CONCLUSION

Both LP and EF produce satisfactory outcomes in school-aged children with length unstable femoral shaft fractures. External fixation remains a viable choice without the necessity of secondary surgery for hardware removal.

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.

Validity of the Best Practice Tariff in paediatric major trauma: A retrospective cohort study from a level 1 children's major trauma centre

INTRODUCTION

The Best Practice Tariff (BPT) in major trauma awards Major Trauma Centres (MTCs) a financial incentive when predefined standards of care are met. However, no tailored criteria exist with regards to the reimbursement policy in paediatric major trauma. In this study, we aim to examine the utility of the paediatric Major Trauma BPT and identify predictors of additional resource utilisation.

MATERIALS AND METHODS

This cohort study encompassed all paediatric major trauma calls (N = 682) presenting to a designated combined adult and paediatric MTC between July 2014 and June 2017. Patient demographics, admission pattern, injury parameters, length of stay (LOS) and the need for operative management were collected. Patients approved for the BPT uplift payment (BPT group) were compared with the cohort of children not qualifying (non-BPT group).

RESULTS

Overall, less than a quarter (23.2%) of the trauma population qualified for the BPT. The proportion of patients requiring operative intervention and CT scanning in the BPT group was significantly higher (p<0.001). These children also attained a higher ISS (median, 13.5 vs. 0, p <0.001) and required longer hospitalisation. Following a Receiver Operator Characteristic (ROC) curve analysis, a cut off ISS score > 8 demonstrated an excellent predictive value in identifying children qualifying for BPT (true positive and false positive rates: 90% and 10.7%). However, a subgroup analysis including the more severely injured children (ISS >8) not qualifying for the uplift payment revealed that equally substantial resource went into their management - 42.9% needed surgical intervention and 57.1% a CT scan.

DISCUSSION

This study demonstrated that BPT in paediatric major trauma is a valuable reimbursement; however, our findings also unveiled a cohort deemed ineligible for BPT despite the high costs accrued. Re-evaluation of the remuneration criteria of paediatric major trauma networks with an alternative, more inclusive reimbursement policy is needed.

Conservative Treatment or Surgical Treatment: A Case Report and Literature Review of Multiple Fractures of the Lower Extremities in a Child with Insensitivity to Pain

Congenital pain insensitivity is a rare genetic disease and its clinical manifestations are many. In orthopaedics, common complications of this disease include painless fracture and Charcot's arthropathy. We followed up a case of multiple fractures of the lower extremity in two years, during which time he came to the clinic for five painless fractures of the lower extremity in a total of six parts. A mutation was found on the NTKRI gene (chr1:156813923(hg19), NM_001007792.1: c.1221938C > T). We have developed a combination of surgery and conservative treatments for his condition, focusing on the mental state of the child and considering comprehensive treatment to be the best option for this type of patient. Occult fractures caused by pain insensitivity are often treated only as fractures, however their complications require routine examination and cleaning, suitable protective shoes, splint fixation, stretching, guided exercise planning, and early treatment of injuries. Due to the risk of fracture in the future, it is important that parents pay attention to the behavior and psychology of the child, such as not letting the child participate in exercise with a risk of injury, protective measures while playing, engaging in psychological counseling, and inducing interest in mental activity. These interventions will play a very important role in preventing the recurrence of fracture.

Comparison of efficacy between internal fixation of minimally invasive elastic stable intramedullary nail and plate in the treatment of pediatric femoral shaft fracture

Objective:

To compare and analyze the clinical effects of internal fixation of minimally invasive elastic stable intramedullary nail and plate in the treatment of pediatric femoral shaft fracture.

Methods:

A total of 120 children with femoral shaft fractures who were admitted to our hospital from December 2016 to April 2018 were enrolled. The children were divided into an observation group and a control group by random number table, with 60 children in each group. The children in the observation group underwent internal fixation of minimally invasive elastic stable intramedullary nail, while those in the control group underwent open reduction based on internal fixation of plate. The surgical status and postoperative complications of the two groups were observed and compared, and Kolmert knee function scoring criteria were used for assessing the surgical effects of children.

Results:

The operation duration, intraoperative blood loss, hospitalization duration, fracture healing time and time of off-bed loaded activity of the observation group were significantly shorter than those of the control group, and the differences were statistically significant (P<0.05). The excellent and good rate of fracture healing in the observation group was 100%, which was higher than that of the control group, 83.33%, and the difference was statistically significant (P<0.05). The total incidence rate of complications in the observation group was 8.33%, which was lower than that of the control group, 10.00%, but the difference was not statistically significant (P>0.05).

Conclusion:

Pediatric femoral shaft fractures can be treated with internal fixation of minimally invasive elastic intramedullary nail, and it has advantages of significant curative effect, small trauma and fast postoperative recovery, which is conducive to fracture healing and worth promoting.

Vitamin C May Help to Reduce the Knee's Arthritic Symptoms. Outcomes Assessment of Nutriceutical Therapy

INTRODUCTION

Osteoarthritis (OA) is a chronic joint disease characterized by degeneration of the articular cartilage, changes in the physico-chemical properties of the synovial fluid and macroscopical modifications of the joint. Patients with Classes I and II of Knee OA can be treated with pharmacologic therapy. Vitamin C is key for both preventing inflammatory arthritis and maintaining healthy joints with OA.

AIM

The aim of our paper is to verify the effectiveness of the addition of vitamin c in nutriceutical drugs for the therapy of the knee arthritis in the young adult.

RESULTS

Group B has a lower VAS score at 6 and 12 months with p<0.05. Not statistical difference we found in KSS during all follow up. A better quality of life was founded in Group B at 12 months in group B(p<0.05) and less use of pain killers/monthly(p<0.05).

CONCLUSION

There is no denying that vitamin C benefits everybody, whether they have arthritis or not. Therefore, it is a good idea to maintain a healthy balance of vitamin C. Without a doubt, vitamin C benefits most people with early OA.