Elastic intramedullary nailing in unstable fractures of the paediatric tibial diaphysis: a systematic review

Outcomes and complications following flexible intramedullary nailing for the treatment of tibial fractures in children: a meta-analysis

INTRODUCTION

Tibial shaft fractures are common occurrence in children and surgical treatment is sometimes required, particularly in unstable or open fractures, and in polytrauma. The aim of this study was to investigate the available evidence on the efficacy and safety of flexible intramedullary nailing (FIN) for both open and closed tibia fractures in children, exploring the main surgical outcomes and rate of complications.

MATERIALS AND METHODS

Pubmed/Medline, Scopus and Cochrane Central databases were searched following the PRISMA guideline. Studies reporting on the outcomes of FIN for paediatric tibia shaft fractures were included. Weighted means were evaluated for surgical outcomes. Meta-analysis of proportion and odd ratios were used to analyse total complication rates and differences between open and closed fractures.

RESULTS

Twenty-eight studies (835 patients) were included; the mean age was 11.0 ± 3.0 years. The mean follow-up was 22.5 ± 13.5 months; the mean time to full weight-bearing was 7.5 ± 3.7 weeks. The total complication rate was 28.1% (minor = 20.7%, major = 6.3%); this was greater in open fractures (13.6% vs 5.1%, p = 0.007). The rate of union was 97.5%, with a mean time to union of 11.9 ± 7.2 weeks. Malunion was found in 8.5% cases, delayed union in 3.8%, non-union in 1.4%, symptomatic hardware in 5.1%, leg-length discrepancy in 5.0%, superficial infections in 2.3%, deep infections in 1.0%, compartment syndromes in 1.4%, and refracture in 0.2%. Almost all patients returned to unrestricted physical activity.

CONCLUSIONS

FIN offers excellent outcomes for the treatment of paediatric tibia shaft fractures. Patients presenting with an open fracture have a higher but acceptable complication rate. Comparative studies are needed to clarify if other treatments have superior outcomes.

Elastic Stable Intramedullary Nailing for Treatment of Pediatric Tibial Fractures: A 20-Year Single Center Experience of 132 Cases

Objective: The aim of this study was to analyze the outcomes and complications in children treated with elastic stable intramedullary nailing (ESIN) for tibial fractures. Methods: The study included 132 patients (92 males) with a median age of 11 years (IQR 10, 15) treated with ESIN for displaced tibial shaft fractures or dia-metaphyseal distal tibial fractures from March 2002 to March 2022. The median follow-up was 118.5 months (IQR 74.5, 170). The primary outcome was success rate, while secondary outcomes were the time of bone healing, length of hospital stay, and associated injuries. Demographic data, type and nature of fracture, indication for surgery, healing time, operative time, complications of treatment, and time to implant removal were recorded. Results: Complete radiographic healing was achieved at a median of 7 weeks (IQR 6, 9). Most of the patients (n = 111; 84.1%) had fractures localized in the shaft of the tibia. The most common injuries were acquired by road traffic accidents (n = 42) and by a fall in the same level (n = 29), followed by injuries from sport activities (n = 21) or motorbike accidents (n = 18). Associated injuries were reported in 37 (28%) children. Fractures were closed in the majority of the children (n = 100; 76%), while 32 (24%) children presented with an open fracture. Children with open fractures were significantly older than children with closed fractures (13.5 years (IQR 10, 15) vs. 11 years (IQR 8.5, 14.5); p = 0.031). Furthermore, children with open fractures had a significantly longer hospital stay (7 days (IQR 5, 9) vs. 3 days (IQR 3, 6); p = 0.001), a higher rate of associated injuries (n = 14 (43.7%) vs. n = 23 (23%); p = 0.022), and a higher rate of postoperative complications (n = 7 (21.9%) vs. n = 8 (8%); p = 0.031). No intraoperative complications were recorded. A total of 15 (11.4%) postoperative complications were recorded. Most complications (60%) were minor complications, mostly related to the wound at the nail insertion site and were managed conservatively. A total of six (4.5%) patients required reoperation due to angulation of the fragments (n = 5) or refracture (n = 1). Conclusion: ESIN is a minimally invasive bone surgery technique and is a highly effective treatment for pediatric tibial unstable fractures with a low rate of complications. Based on the given results, surgical stabilization of the tibial fractures using titanium intramedullary nailing can be safely performed without casting with early physiotherapy.

Biomechanical Performance of BoneHelix® Compared with Elastic Stable Intramedullary Nailing (ESIN) in a Pediatric Tibia Fracture Model

Tibial shaft fractures are common injuries in the pediatric and adolescent populations. Elastic stable intramedullary nailing (ESIN) is the treatment of choice for cases that require surgical stabilization. A new intramedullary device, BoneHelix^® (BH), may be an alternative for use with fractures that cannot be satisfactorily stabilized with ESIN. This study aimed to assess the biomechanical performance of BH compared with ESIN in a porcine tibia fracture model, observing cyclic fatigue and load to failure. Computed tomography was used to monitor the implant position and to rule out unintended damage. No implant or bone failure occurred during the fatigue testing. An increase in the cumulative plastic displacement was observed in both test groups over the loading cycles applied. Both implant–bone constructs displayed a trend toward closure of the osteotomy gap. During the load-to-failure test, the average loads at failure in specimens instrumented with ESIN and BH were 5364 N (±723) and 4350 N (±893), respectively, which were not statistically significant (p = 0.11). The values of both groups were two to three times higher than the estimated maximal load (2000 N) during physiological weight bearing. The biomechanical results thus indicate equivalent performance and stability by the implants tested.

Treatment of Unstable Pediatric Tibial Shaft Fractures with Titanium Elastic Nails

Background and objectives: Pediatric tibial shaft fractures often have satisfactory outcomes after closed reduction and casting. However, surgical treatment may be required in unstable or open fractures. Titanium elastic nails (TENs) are a good option for the surgical treatment of pediatric tibial fractures due to their advantages such as short hospitalization periods, easy applicability, early weight bearing, and early union. In this study, we evaluated radiological and functional outcomes in pediatric patients with tibial shaft fractures that underwent fixation with TENs. Materials and methods: A total of twenty tibial shaft fractures that were treated with TENs in our clinic between 2013 and 2017 were retrospectively reviewed. The mean age at injury was 8.9 ± 2.78 (range of 3–14) years. Seven (35%) out of 20 fractures were open fractures, of which one fracture was classified as Grade I and six fractures were classified as Grade II. In each patient, antegrade nailing was performed by inserting a TEN in the medial and another TEN in the lateral side of the proximal metaphysis. Clinical outcomes including union, alignment, leg-length inequality, and complications were evaluated using modified Flynn’s criteria. Results: The mean time to union was 10.85 ± 3.39 (range of 6–20) weeks. No patient had a sagittal or coronal angulation of over 10°. One patient had a leg-length inequality of 10 mm. Among three patients with open fractures, two of them had superficial wound infections and the other patient had a deep wound infection. All the infections were successfully treated with appropriate antibiotic therapies. Four other patients had pin tract irritation that required no intervention. No significant difference was observed between patients with open and closed fractures with regard to the clinical and radiological findings although patients with open fractures had a significantly higher complication rate compared to patients with closed fractures (p < 0.05). No patient had a restricted range of motion of the ankle and knee joints. Twelve (60%) patients had an excellent outcome, and eight (40%) patients had a satisfactory outcome. Conclusions: Intramedullary fixation with TENs provides favorable outcomes and reduced complication rates in the treatment of unstable pediatric tibial shaft fractures that cannot be reduced with conservative treatment modalities or cannot be casted due to the presence of an edema or open wound.

Pediatric tibia and femur fractures in patients weighing more than 50 kg (110 lb): mini-review on current treatment options and outcome

The main objective of this paper is to review the current literature on treatment of tibial and femur fractures in children and adolescents guided by body weight in patients weighing 50 kg (110 lb) or more. A secondary aim of this mini-review was to determine, as per literature review, whether weight  > 50 kg (110 lb) is an identifiable factor associated with increased complication rate. A search of the PubMed/MEDLINE, EMBASE and Cochrane Database of Systematic Reviews databases from 1954 to September 2017 was performed to identify papers related to pediatric tibia and femur fractures in children weighing more than 50 kg (110 lb). Abstracts were screened, and relevant full-text articles were retrieved for further review. Reference sections of identified papers were also screened to identify further literature. All levels of evidence were included. Overall, seven full-text articles dealing with pediatric tibia or femur fractures in patients weighing more than 50 kg (110 lb), and one article reporting on both femur and tibia fractures in this patients' population, have been identified (n = 8 full-text article included). The articles reviewed a total of 679 children. In particular, 48/438 femur shaft fractures (mean weight: 51.7 kg or 113.9 lb) and 91/241 tibia fractures (mean weight: 53.3 kg or 117.5 lb) met the inclusion criteria. The overall rate of complications was 27.9%. In particular, the rate of complication was 51.7 and 29.6% in children with femur and tibia fracture weighing more than 50 kg (110 lb), respectively (p < 0.05). Elastic stable intramedullary nailing (ESIN) has become the treatment of choice for displaced tibia and femur shaft fractures in children between six and 12-15 years of age. Unstable fracture pattern, higher age and higher weight have been reported as potential risk factors associated with poor outcomes in children and adolescents treated with ESIN for displaced long bone fractures of the lower extremity, in particular femur shaft fractures. Despite these findings, data reporting exclusively on ESIN-treated long bone fractures in children weighing 50 kg (110 lb) or more remain scant.

Titanium Elastic Nailing for Pediatric Tibia Fractures: Do Older, Heavier Kids Do Worse?

BACKGROUND

Elastic nailing is a common method of fixation for tibial shaft fractures in skeletally immature individuals. Poor outcomes of titanium elastic nails for femoral shaft fractures have been associated with increasing patient age and weight, especially patients weighing >50 kg. Our objective is to determine if there is an upper weight or age limit to the safe and effective use of titanium elastic nails for tibial shaft fractures in the pediatric population.

METHODS

This is a retrospective cohort study of patients who underwent stabilization of a tibial shaft fracture with titanium elastic nails at a large tertiary-care pediatric trauma center. Data collected included patient demographics, injury characteristics, and radiographic data. Weight groups were stratified as ≥ or <50 kg, and age groups as 14 years or older or less than 14 years old. Malunion was defined as 10 degrees of angulation in either the sagittal or coronal plane. Union was defined as bridging of ≥3 cortices on orthogonal radiographs. A significant difference in time to union was considered to be 3 weeks.

RESULTS

Ninety-five patients were included with a mean age of 12.1 years (range, 6 to 16 y) and a mean weight of 50.2 kg (range, 21 to 122 kg). Malunion rate was similar between weight cohorts: 13.3% (6/45) in the ≥50-kg group and 10% (5/50) in the <50-kg group (P=0.61). Malunion rate was similarly comparable between age groups: 17.6% (6/34) in the 14 years and older group and 8.2% (5/61) in the less than 14-year-old group (P=0.17). There was no statistically significant difference in time to union between weight or age cohorts. In sum, we did not find a significant difference in the rate of malunion or time to healing between younger and older patients or between lighter and heavier patients.

CONCLUSION

The use of titanium elastic nails for tibial shaft fractures, unlike for other long bone fractures, seems not to be precluded in older and heavier patients.

LEVEL OF EVIDENCE

Level III.

Elastic stable intramedullary nailing for severely displaced distal tibial fractures in children

Elastic stable intramedullary nailing (ESIN) has became a well-accepted method of osteosynthesis of diaphyseal fractures in the skeletally immature patient for many advantages, the purpose of this study is to evaluate the preliminary results of this minimally invasive treatment for severely displaced distal tibial diaphyseal metaphyseal junction (DTDMJ) fractures.This study was carried out over a 6-year period. Twenty-one severely displaced DTDMJ fractures treated using ESIN were evaluated clinically and radiographically. Complications were assessed: the patients were evaluated with regard to nonunion, malunion, infection, growth arrest, leg length discrepancy, implant irritation, and joint function.Mean age at the time of surgery was 7.8 years (range between 5.3 and 14.8 years), mean body weight 34.1 kg, all fractures were transverse or mild oblique type, including 3 open fractures, 5 multifragmented fractures, and 4 fractures associated with polytrauma; 6 cases were treated with antegrade ESIN of tibia while 15 cases need combined retrograde fibula and antegrade tibia fixation treatments. Follow-ups were ranging from 11 to 36 months, 19 fractures showed both clinical and radiographic evidence of healing within 5 months; all cases had full range motion of knee and ankle with symmetrical foot progress angle. Nail removal was at a mean 7.1 months, at final follow-up, no growth arrest or disturbances occurred. Five patients had complications; leg length discrepancy had decreased yet affected 2 patients, 2 cases showed delayed union, and 1 case developed restricted dorsal extension at the metatarsophalangeal joint of the hallux.ESIN is the treatment of choice for pediatric severely displaced DTDMJ fractures that cannot be reduced by closed reduction or ones that cannot be casted. The advantages include faster fracture healing, excellent functional and cosmetic results, safe and reliable surgical technique, and lower severe complication rate.

Elastic nailing of tibia shaft fractures in young children up to 10 years of age

INTRODUCTION

Although tibia shaft fractures in children usually have satisfactory results after closed reduction and casting, there are several surgical indications, including associated fractures and soft tissue injuries such as open fractures. Titanium elastic nails (TENs) are often used for pediatric tibia fractures, and have the advantage of preserving the open physis. However, complications such as delayed union or nonunion are not uncommon in older children or open fractures. In the present study, we evaluated children up to 10 years of age with closed or open tibial shaft fractures treated with elastic nailing technique.

METHODS

A total of 16 tibia shaft fractures treated by elastic nailing from 2001 to 2013 were reviewed. The mean patient age at operation was 7 years (range: 5-10 years). Thirteen of 16 cases were open fractures (grade I: 4, grade II: 6, grade IIIA: 3 cases); the other cases had associated fractures that necessitated operative treatments. Closed, antegrade intramedullary nailing was used to insert two nails through the proximal tibial metaphysis. All patients were followed up for at least one year after the injury. Outcomes were evaluated using modified Flynn's criteria, including union, alignment, leg length discrepancies, and complications.

RESULTS

All fractures achieved union a mean of 16.1 weeks after surgery (range: 11-26 weeks). No patient reported knee pain or experienced any loss of knee or ankle motion. There was a case of superficial infection in a patient with grade III open fracture. Three patients reported soft tissue discomfort due to prominent TEN tips at the proximal insertion site, which required cutting the tip before union or removing the nail after union. At the last follow-up, there were no angular or rotational deformities over 10° in either the sagittal or coronal planes. With the exception of one case with an overgrowth of 15 mm, no patient showed shortening or overgrowth exceeding 10mm. Among final outcomes, 15 were excellent and 1 was satisfactory.

SUMMARY

Even with open fractures or soft tissue injuries, elastic nailing can achieve satisfactory results in young children, with minimal complications of delayed bone healing, or infection.

Do minimally displaced, closed tibial fractures in children need monitoring for compartment syndrome?

INTRODUCTION

Acute compartment syndrome (ACS) may be seen following tibial fractures in adults. Although the risk of this complication is thought to be lower in children (especially in those under the age of 12 years) it is routine practice in many units to admit all children with this injury for observation. The aim of this study was to ascertain whether all children under the age of 12 presenting with fractures of the tibia merited admission and to provide recommendations on how to manage these patients based on our experience with this injury.

PATIENTS AND METHODS

We retrospectively studied the clinical and radiographic progress of consecutive patients presenting to our institution with tibial fractures over a 5-year period.

RESULTS

A total of 159 tibial fractures were seen in the study period. The mean age of patients treated was 5.8 years. 81% of the injuries occurred in the diaphyseal region and 60% involved the tibia only. A total of 9% of injuries were open and overall 66% of fractures were managed non-operatively. No cases of ACS were seen.

DISCUSSION

Based on our experience we provide a treatment algorithm detailing how children in the under 12 age group presenting with tibial fractures may be managed. Patients with minimally displaced fractures involving the tibia only, whose pain is adequately controlled and who can safely mobilise with suitable parental supervision may be safely discharged from the emergency department in a back slab with early follow up. Although no children under the age of 12 in the present study developed ACS following a fracture of the tibia, certain features such as a history of a high energy injury, displaced fractures or co-existing fibular fractures should raise suspicion that this complication may ensue. In these cases admission and observation may be warranted.

Management of paediatric tibial fractures using two types of circular external fixator: Taylor spatial frame and Ilizarov circular fixator

BACKGROUND

The use of circular fixators for the treatment of tibial fractures is well established in the literature. The aim of this study was to compare the Ilizarov circular fixator (ICF) with the Taylor spatial frame (TSF) in terms of treatment results in consecutive patients with tibial fractures that required operative management.

METHOD

A retrospective analysis of patient records and radiographs was performed to obtain patient data, information on injury sustained, the operative technique used, time duration in frame, healing time and complications of treatment. The minimum follow-up was 24 months.

RESULTS

Ten patients were treated with ICF between 2000 and 2005, while 15 patients have been treated with TSF since 2005. Two of the 10 treated with ICF and 5 of the 15 treated with TSF were open fractures. All patients went on to achieve complete union. Mean duration in the frame was 12.7 weeks for ICF and 14.8 weeks for the TSF group. Two patients in the TSF group had delayed union and required additional procedures including adjustment of fixator and bone grafting. There was one malunion in the TSF group that required osteotomy and reapplication of frame. There were seven and nine pin-site infections in the ICF and TSF groups, respectively, all of which responded to antibiotics. There were no refractures in either group.

CONCLUSION

In an appropriate patient, both types of circular fixator are equally effective but have different characteristics, with TSF allowing for postoperative deformity correction. Of concern are the two cases of delayed union in the TSF group, all in patients with high-energy injuries. We feel another larger study is required to provide further clarity in this matter.

LEVEL OF EVIDENCE

Level II-comparative study.