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Liu W, Li W, Bai R, Xu X, Zhao Z, Wang Y. Elastic Stable Intramedullary Nailing Versus Plate Internal Fixation for Pediatric Diaphyseal Femur Fractures: A Systematic Review and Meta-analysis. Indian J Orthop 2024; 58:484-494. [PMID: 38694693 PMCID: PMC11058146 DOI: 10.1007/s43465-024-01125-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 02/11/2024] [Indexed: 05/04/2024]
Abstract
Background Elastic stable intramedullary nailing (ESIN) and plates are currently the main internal fixation for treating Pediatric Diaphyseal Femur Fractures (PDFF), and the optimal choice of internal fixation is controversial. The purpose of this meta-analysis is to compare the surgical outcomes and complications of the two fixation methods. Materials and Methods MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published up to March, 2023, that compared ESIN and plate fixation techniques for treating PDFF. Pooled analysis identified differences in surgical outcomes between ESIN and plate, mainly regarding surgical outcomes and postoperative complications, such as time at surgery, fracture healing time, blood loss and related complications. Results We included 10 studies with 775 patients with PDFF in our review. Of these, 428 and 347 were treated with ESIN and Plate, respectively. In terms of postoperative complications, ESIN led to a shorter surgery time [MD = - 28.93, 95% CI (- 52.88 to - 4.98), P < 0.05], less blood loss [MD = - 66.94, 95% CI (- 87.79 to - 46.10), P < 0.001] and more fracture healing time [MD = 2.65, 95% CI (1.22-4.07), P < 0.001]. In terms of postoperative complications, ESIN led to fewer fections (RR = 0.77, 95% CI 0.37, 1.60, P = 0.48), fewer angulation deformities (RR = 0.80, 95% CI 0.35, 1.83, P = 0.60) and more prominent implants (RR = 3.36, 95% CI 1.88, 6.01, P < 0.001), more delayed unions (RR = 4.06, 95% CI 0.71, 23.06, P = 0.11). Conclusions ESIN and Plate have similar rates of complications besides a prominent implant rate, while ESIN has a shorter period of operation and less intraoperative bleeding. Although both options are suitable, the results of this study support the use of ESIN rather than plates in the treatment of PDFF in terms of complication rates. In clinical applications, surgeons should choose the appropriate treatment method according to the actual situation.
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Affiliation(s)
- Wanlin Liu
- Department of Orthopaedic, The Second Affiliated Hospital of Inner Mongolia, Medical University, Hohhot, 010030 Inner Mongolia China
| | - Wenqiang Li
- Department of Inner Mongolia Medical University, Hohot, 010030 Inner Mongolia China
| | - Rui Bai
- Department of Orthopaedic, The Second Affiliated Hospital of Inner Mongolia, Medical University, Hohhot, 010030 Inner Mongolia China
| | - Xiangyu Xu
- Department of Inner Mongolia Medical University, Hohot, 010030 Inner Mongolia China
| | - Zhenqun Zhao
- Department of Orthopaedic, The Second Affiliated Hospital of Inner Mongolia, Medical University, Hohhot, 010030 Inner Mongolia China
| | - Yan Wang
- Department of Orthopaedic, The Second Affiliated Hospital of Inner Mongolia, Medical University, Hohhot, 010030 Inner Mongolia China
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Neto MA, Paulino MF, Amaro AM. Effect of Plate Configuration in the Primary Stability of Osteotomies and Biological Reconstructions of Femoral Defects: Finite-Element Study. Bioengineering (Basel) 2024; 11:416. [PMID: 38790284 PMCID: PMC11117963 DOI: 10.3390/bioengineering11050416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/17/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND/OBJECTIVE Osteosynthesis is an alternative treatment for stabilizing femur-bone traumas. The initial stability of the fixation systems is one of the biomechanical parameters affecting implant failure and bone union, especially in surgeries of intercalary reconstructions after the removal of bone tumors. This study aimed to investigate the initial biomechanical effect of using one or two osteosynthesis plate configurations for femoral fixation and the effect of fastening the allograft to the osteosynthesis plate in the case of femoral allograft reconstructions. METHODS Three finite-element models of a femur with three different fixation conditions for a transverse osteotomy in the middle of the diaphysis, i.e., using one and two osteosynthesis plates and an intercalary allograft, were constructed. An eight-hole compression plate and a six-hole second plate were used to simulate osteosynthesis plates. The plate screws were tightened previously to the loading, and the tightening sequences simulate the bolt-tightening procedure in a surgical environment. The models were imported into the ADINA System for nonlinear analysis, using compression loads applied over the femur head. RESULTS Models with the dual fixation systems had the most outstanding compression stiffness. The femur head movement in the dual plate system was 24.8% smaller than in the single plate system. A statistical analysis of a region of interest (VOI) placed in the femur diaphysis showed that the biomechanical effect of using the dual plate system is smaller in the osteotomy region than at the femur head, e.g., a displacement average decrease of only 5% between the two systems, while the maximum value decreases by 26.8%. The allograft fixation to the second osteosynthesis plate leads to an improvement in the system stability. CONCLUSIONS The results presented in this work show that including the bolt analysis in the femoral diaphysis osteotomy fixation will allow for capturing the nonlinear behavior of the osteotomy region more realistically. The stability of the intercalary reconstruction of the femoral diaphysis was higher when the allograft was fastened to the second osteosynthesis plate.
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Affiliation(s)
- M. A. Neto
- University of Coimbra, CEMMPRE, ARISE, Department of Mechanical Engineering, 3030-788 Coimbra, Portugal; (M.F.P.); (A.M.A.)
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Qiao F, Shang X, Jiang F. Closed reduction and intramedullary nails for acute completely displaced femoral diaphysis fracture in children aged 2-6. Front Pediatr 2024; 12:1346456. [PMID: 38665374 PMCID: PMC11043553 DOI: 10.3389/fped.2024.1346456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/02/2024] [Indexed: 04/28/2024] Open
Abstract
Background The management of femoral fractures in children aged two to six years is still controversial. The purpose of this study was to assess the results of closed reduction and elastic stable intramedullary nail (ESIN) fixation in completely displaced fractures of the femoral diaphysis in children in this age group. Methods A retrospective review of all children with acute completely displaced fractures of the femoral diaphysis in children aged 2-6 years treated from 2013 to 2020 was performed. A total of 34 patients were treated who met the inclusion criteria: Group 1: 21 fractures (transverse and short oblique); Group 2: 13 fractures (long oblique and spiral) that underwent closed reduction and elastic stable intramedullary nail (ESIN) fixation. No differences existed between the 2 groups with respect to age, extremity, sex, time to treatment, mechanism of injury, or fracture displacement. Demographic characteristics and radiographs were reviewed, and the following parameters were documented: surgery time, time to union, return to activities, range of motion of knee joints, and complications. Major complications were defined as those with presumptive long-term side effects or those requiring a reoperation. No major complications were observed in the two groups. All included fractures were treated by a single senior paediatric surgeon. The mean follow-up period was 28.4 months (range 24-45 months). The level of significance was set at p < 0.05. Results Thirty-four children with acute completely displaced fractures of the femoral diaphysis were included: Group 1: 21 fractures; Group 2: 13 fractures. The patients included 15 girls (44.1%) and 19 boys (55.9%), with an average age of 4.4 years (range 2.8 to 6.5 years). The mean follow-up period was 28.4 months (range 24.2-45.0 months). The demographic characteristics did not differ between the two groups of patients. Overall, successful closed reduction and elastic stable intramedullary nail (ESIN) fixation could be achieved in all 34 patients. The mean surgical time was 40.4 and 43.0 min in Group 1 and Group 2, respectively (p = 0.857). Fluoroscopy time was not significantly different between the two groups (37.0 vs. 36.1 s, respectively; p = 0.247). Cosmetic results were described as good and satisfactory by all patients. There were no refractures and no incidences of nonunion or growth arrest in the proximal epiphysis. Only two patients suffered from a superficial infection, which was resolved after the pins were shortened and oral antibiotics were administered. Conclusion Closed reduction and elastic stable intramedullary nail (ESIN) fixation can be successfully used to treat completely displaced fractures of the femoral diaphysis in children aged two to six years. This technique is efficient and minimally invasive, and the results are satisfactory.
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Affiliation(s)
- Fei Qiao
- Department of Pediatric Orthopaedic, Dalian Women and Children’s Medical Group, Dalian, Liaoning, China
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Singh A, Bierrum W, Wormald J, Ramachandran M, Firth G, Eastwood D. Plate fixation versus flexible intramedullary nails for management of closed femoral shaft fractures in the pediatric population: A systematic review and meta-analysis of the adverse outcomes. J Child Orthop 2023; 17:442-452. [PMID: 37799319 PMCID: PMC10549696 DOI: 10.1177/18632521231190713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 07/13/2023] [Indexed: 10/07/2023] Open
Abstract
Purpose Fractures of the femoral diaphysis are associated with a risk of morbidity in children. Various fixation methods have been developed, but with only limited evidence to support their use. This systematic review assesses the evidence regarding clinical outcomes of closed femoral diaphyseal fractures in children treated with plate fixation or flexible intramedullary nails. Methods A PROSPERO-registered, PRISMA-compliant systematic review and meta-analysis were conducted. MEDLINE, Embase, and Web of Science (WoS) databases were searched from inception to February 2023. Inclusion criteria included clinical studies reporting adverse outcomes following surgical treatment of pediatric closed femoral diaphyseal fractures using plate fixation and flexible intramedullary nails. The ROBINS-I and RoB 2 tools evaluated the risk of bias. Results Thirteen papers (2 prospective randomized controlled trials and 11 retrospective cohorts) reported 805 closed diaphyseal femoral fractures in 801 children (559 males, 242 females). There were 360 plate fixations and 445 flexible intramedullary nails. Two cases of osteomyelitis and one nonunion were reported. Meta-analysis showed that plate fixation had a lower risk of soft tissue infection (relative risk 0.26 (95% confidence interval 0.07-0.92)). There was no difference in the following outcomes: malunion (relative risk 0.68 (95% confidence interval 0.32-1.44)); unplanned reoperation (relative risk 0.59 (95% confidence interval 0.31-1.14)), and leg-length difference (relative risk 1.58 (95% confidence interval 0.66-3.77)). The risk of bias was high in all studies. Conclusions An analysis of 805 fractures with minimal differences in meta-analyses is considered high quality even when the quality of the evidence is low. The findings are limited by important flaws in the methodology in the published literature. Well-designed multicentre prospective studies using standardized core outcomes are required to advise treatment recommendations. Level of evidence III.
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Affiliation(s)
- Abhinav Singh
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Orthopaedic Surgery, Imperial College NHS Healthcare Trust, London, UK
| | - William Bierrum
- Department of Acute Internal Medicine, University College London Hospital NHS Trust, London, UK
| | - Justin Wormald
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Gregory Firth
- Department of Orthopaedic Surgery, Barts Health NHS Trust, London, UK
| | - Deborah Eastwood
- Department of Orthopaedic Surgery, Great Ormond Street Hospital, London, UK
- University College London, London, UK
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Strait RT, Pankey C. Submuscular Plating Versus Elastic Intramedullary Nailing in Children with Femoral Shaft Fracture; a systematic review and meta-analysis. J Clin Orthop Trauma 2023; 42:102203. [PMID: 37529550 PMCID: PMC10388584 DOI: 10.1016/j.jcot.2023.102203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/27/2023] [Accepted: 06/24/2023] [Indexed: 08/03/2023] Open
Abstract
Introduction Elastic stable intramedullary nailing (ESIN) is currently the technique of choice for pediatric femoral fractures. Submuscular plating (SMP) allows reliable healing associated with an early range of motion. The following systematic review and meta-analysis was carried out to reveal the functional and surgical outcomes of SMP and ESIN for fixation of pediatric femoral fractures and to aid in the decision-making processes for those who perform these procedures. Methods An extensive systematic literature review was implemented from inception to 23 February 2022. All clinical studies included had patients that were younger than 18 years old with femoral shaft fractures that compared outcomes between SMP and ESIN. Studies including patients with pathological fractures, closed femoral physis, multiple fractures, or refractures were excluded. Results This meta-analysis included six articles encompassing 568 patients. Of them, 206 patients were treated with SMP, while 362 were subjected to ESIN procedure. There was significantly more blood loss among patients treated with SMP (MD -45.45; 95% -61.62, -29.27; p < 0.001). The risk of postoperative adverse surgical events was significantly higher among patients subjected to the ESIN (RR 2.97 19.5; 95% 1.27, 6.98; p = 0.01). The mean hospital stay was significantly shorter among patients subjected to ESIN (SMD -1.47; 95% -2.43, -0.51; p = 0.003). Patients subjected to SMP showed significantly more EFOs when comparing Flynn Scores (OR 0.24; 95% 0.09, 0.64; p = 0.004). There was no significant difference between SMP and ESIN regarding the mean operation time, limb length discrepancy, and mean time to union. Conclusions Children with femoral shaft fractures can be managed effectively and safely with SMP. There was a similar surgical outcome between SMP and ESIN, but SMP had more EFOs. While SMP was associated with a low risk of postoperative adverse surgical events, it was associated with a more significant blood loss and prolonged hospital stays.
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Affiliation(s)
- Robert Taylor Strait
- West Virginia School of Osteopathic Medicine, 400 Lee Street North, Lewisburg, 24901, West Virginia, United States
| | - Christopher Pankey
- West Virginia School of Osteopathic Medicine, 400 Lee Street North, Lewisburg, 24901, West Virginia, United States
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Baghdadi S, Mahmoud MAH, Flynn JJM, Arkader A. Unplanned Return to the Operating Room (UpROR) After Pediatric Diaphyseal Femoral Fractures. J Pediatr Orthop 2022; 42:e120-e125. [PMID: 34923506 DOI: 10.1097/bpo.0000000000002032] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Femoral fractures are the most common cause of fracture-related admissions. Unplanned return to the operating room (UpROR) is a major event and imposes a substantial burden on the family and health care system. The purpose of this study was to determine the incidence of complications and early UpROR during the first 6 months following treatment of femoral fractures and their risk factors. METHODS In an institutional review board-approved study, a retrospective review of all patients who were treated for a femoral fracture during a 10-year period at a pediatric tertiary care center was performed. Patients less than 18 years old with a diaphyseal fracture and complete records were included, and nondiaphyseal or pathologic fractures, as well as underlying metabolic or genetic disorders, were excluded. All clinic visits in the first 6 months after treatment were reviewed, and all complications and UpRORs were extracted. Patients were grouped based on their age (below 5, 5 to 11, above 11 y old) at initial treatment, and statistical tests were used to infer differences between groups. RESULTS Overall, 841 fractures in 832 patients were included, with a mean age of 5.5±4.8 years fracture, of which 72% were male. A total of 106 complications (12.6%) and 45 UpRORs (5.3%) were encountered during the study period. Patients with and without UpROR had similar demographics and injury and treatment characteristics. Loss of reduction was the most common reason for UpROR (58%), followed by implant-related complications. Flexible nails had the highest risk of UpROR among patients who were initially treated surgically (P=0.03). CONCLUSIONS Our findings indicate that children under the age of 5 years have a 5% risk of UpROR in the first 6 months after the fracture, mainly for repeat spica casting due to loss of reduction. Patients aged 5 years or older have an ∼6% risk of UpROR, mainly related to complications of flexible nails. The findings of this study are important when consulting families on different treatments of diaphyseal femoral fractures. LEVEL OF EVIDENCE Therapeutic level III-retrospective cohort study.
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Affiliation(s)
- Soroush Baghdadi
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia
| | | | - John Jack M Flynn
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alexandre Arkader
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Salonen A, Laitakari E, Berg HE, Felländer-Tsai L, Mattila VM, Huttunen TT. Incidence of femoral fractures in children and adolescents in Finland and Sweden between 1998 and 2016: A binational population-based study. Scand J Surg 2022; 111:14574969221083133. [PMID: 35333132 DOI: 10.1177/14574969221083133] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND OBJECTIVE Femoral fractures in children have significant impact for patients, family, and trauma resources as they usually require hospitalization and surgical treatment. The aim of this study was to determine the incidence and trends of femoral fractures among children and adolescents hospitalized between 1998 and 2016 in Finland and Sweden. METHODS All patients younger than 17 years of age in Finland and Sweden with a femoral fracture treated surgically between 1998 and 2016 were included in the study. Data were collected from National Hospital Discharge Registries. Patients were classified by gender and age into four groups. The annual incidences per 100,000 were calculated using annual mid-year population census data obtained from the Official Statistics of Finland and Sweden. RESULTS In total, 6410 patients younger than 17 years of age diagnosed with femoral fracture were included in this study. The total incidence per 100,000 femoral fractures was 13.3 in Finland and 11.0 in Sweden. The incidence of femoral fractures decreased during the study period in all age groups, except for teenage Finnish girls. Most of the fractures were located in femoral shaft. Fractures of the upper and distal femur were rare. Male predominance was detected in all age groups older than 1 year. CONCLUSIONS The incidence of femoral fractures decreased in all age groups except in teenage Finnish girls. Majority of femoral fractures were located in femoral shaft with male predominance. In children younger than 1 year of age, female predominance was found.
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Affiliation(s)
- Anne Salonen
- Department of Pediatric and Adolescent Surgery, Pediatric Clinic and Pediatric Research Centre, Tampere University Hospital, Elämänaukio 2, 33520 Tampere, Finland
| | - Elina Laitakari
- Department of Pediatric and Adolescent Surgery, Pediatric Clinic and Pediatric Research Centre, Tampere University Hospital, Tampere, Finland
| | - Hans E Berg
- The Division of Orthopedics and Biotechnology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Li Felländer-Tsai
- The Division of Orthopedics and Biotechnology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Ville M Mattila
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Tuomas T Huttunen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland Tampere University Heart Hospital, Tampere University Hospital, Tampere, Finland
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van Cruchten S, Warmerdam EC, Kempink DRJ, de Ridder VA. Treatment of closed femoral shaft fractures in children aged 2-10 years: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2021; 48:3409-3427. [PMID: 34338819 PMCID: PMC9532337 DOI: 10.1007/s00068-021-01752-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 07/18/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To review current literature on treatment of closed femoral shaft fractures in children of 2-10 years old, with subgroup analysis of children aged 2-6 years, comparing intramedullary nailing (IMN) to conservative treatment modalities. METHODS We included clinical trials and observational studies that compared traction and subsequent casting (TSC), spica casting and IMN for treatment of femur shaft fractures in children of 2-10 years of age. Subgroup analysis of children aged 2-6 years was performed. RESULTS Compared to treatment with immediate spica casting, IMN led to significantly less coronal angulation (mean difference (MD): 2.03 degrees, confidence interval (CI) 1.15-2.90), less sagittal angulation (MD: 1.59 degrees, CI 0.82-2.35) and lower rates of LLD (Risk difference (RD): 0.07, CI 0.03-0.11). In terms of rehabilitation, IMN leaded to shorter time until walking with aids (MD: 31.53 days, CI 16.02-47.03), shorter time until independent ambulation (MD: 26.59 days, CI 22.07, 31.11) and shorter time until full weight bearing (MD: 27.05 days, CI 6.11, 47,99). Compared to TSC, IMN led to a lower rate of malunion (RD: 0.31, CI 0.05-0.56), shorter hospital stays (MD: 12.48 days, CI 11.57, 13.39), time until walking with aids (MD: 54.55, CI 40.05-69.04) and full weight bearing (MD: 27.05 days [6.11, 47,99]). CONCLUSION Although a lack of quality evidence, this systematic review showed a clear tendency to treatment with elastic intramedullary nails of femoral shaft fractures in children of 2-10 years of age. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Stijn van Cruchten
- UMC Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
- , Kromme Nieuwegracht 15, 3512 HC, Utrecht, The Netherlands.
| | - Eefke C Warmerdam
- Reinier Haga Orthopedisch Centrum, Toneellaan 2, 2725 NA, Zoetermeer, The Netherlands
| | - Dagmar R J Kempink
- Erasmus MC/Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
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Antabak A, Boršćak N, Čagalj M, Ivelj R, Bumči I, Papeš D, Ćavar S, Bogović M, Bulić K, Luetić T. TREATMENT OF PEDIATRIC FEMORAL FRACTURES IN THE CITY OF ZAGREB. Acta Clin Croat 2020; 59:686-695. [PMID: 34285439 PMCID: PMC8253082 DOI: 10.20471/acc.2020.59.04.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 10/29/2018] [Indexed: 11/24/2022] Open
Abstract
Femur fractures in children can be treated with a number of operative and conservative methods. Numerous factors determine which method is optimal for a specific fracture. The aim of this research was to analyze distribution of femur fractures in children living in the urban communities of Zagreb and Zagreb County by localization, type and frequency of treatment methods used according to age and fracture mechanism. The research included 103 children aged up to 18 years, treated for femur fractures at the Zagreb University Hospital Centre and Zagreb Children’s Hospital. Data were collected from these institutions and a retrospective study covered the 2010-2015 period. The cause of fracture and diagnosis were coded with the help of the International Statistical Classification of Diseases and Related Health Problems. Operative treatment was applied in 55% of cases, which is contrary to previous researches. The highest incidence of femur fractures was recorded in the 0- to 4-year age groups, accounting for 49.1% of all fractures. These fractures mostly occurred due to falls and were more often treated with non-operative methods. All other age groups were mostly treated with operative methods. Coxofemoral immobilization and traction were used as non-operative methods, whereas flexible intramedullary nailing was the most frequently used operative method. The treatment depended on age, complexity of the fracture, fracture type, fragment displacement, and associated injuries. The cause was also an important factor on choosing the treatment method. Non-operative treatment was mostly used for fractures caused by falls (64.71% of cases due to falls) and operative treatment was mostly used for fractures caused by traffic accidents (79.4% of cases due to traffic accidents). It is a wide-known opinion that the best treatment for femur fractures in children is non-operative treatment. However, recent studies have shown that the use of operative methods in femur fracture treatment is growing. Our cohort of children treated during a five-year period (2010-2015) also underwent operative treatment more often than non-operative one. Two non-operative and eight operative methods were used. With such a large number of methods, it is clear that there is no unique method for all fractures. However, it is clear that the trend of using operative treatment is connected to the perennial trend of considerable sociodemographic and socioeconomic changes in urban settings such as Zagreb. Lifestyle changes directly affect the prevalence of femur fractures among children, as well as approach to treatment choice. General opinion is that most of fractures that occur at an early age can be treated with non-operative methods. Our research on femur fractures in children confirmed this rule. The youngest age group that had the highest incidence of fractures (49.1% of all fractures) was treated with non-operative methods in 75% of cases. Operative methods prevailed in other age groups. Similar results have been published by other authors. In conclusion, nearly half of all femur fractures (49.1%) occurred at a young age (0-4 years). Diaphysis fractures were most common. Most of the fractures that occurred during the 2010-2015 period were treated with operative methods, mostly in children aged 5-9 years. Out of eight different operative methods, elastic stable intramedullary osteosynthesis was most frequently used (60%). Coxofemoral immobilization and traction were used as non-operative methods.
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Affiliation(s)
| | - Nikolina Boršćak
- 1Zagreb University Hospital Centre, Department of Surgery, Division of Pediatric Surgery, Zagreb, Croatia; 2University of Zagreb, School of Medicine, Zagreb, Croatia; 3Zagreb Children's Hospital, Department of Surgery, Division of Traumatology, Zagreb, Croatia
| | - Marija Čagalj
- 1Zagreb University Hospital Centre, Department of Surgery, Division of Pediatric Surgery, Zagreb, Croatia; 2University of Zagreb, School of Medicine, Zagreb, Croatia; 3Zagreb Children's Hospital, Department of Surgery, Division of Traumatology, Zagreb, Croatia
| | - Renato Ivelj
- 1Zagreb University Hospital Centre, Department of Surgery, Division of Pediatric Surgery, Zagreb, Croatia; 2University of Zagreb, School of Medicine, Zagreb, Croatia; 3Zagreb Children's Hospital, Department of Surgery, Division of Traumatology, Zagreb, Croatia
| | - Igor Bumči
- 1Zagreb University Hospital Centre, Department of Surgery, Division of Pediatric Surgery, Zagreb, Croatia; 2University of Zagreb, School of Medicine, Zagreb, Croatia; 3Zagreb Children's Hospital, Department of Surgery, Division of Traumatology, Zagreb, Croatia
| | - Dino Papeš
- 1Zagreb University Hospital Centre, Department of Surgery, Division of Pediatric Surgery, Zagreb, Croatia; 2University of Zagreb, School of Medicine, Zagreb, Croatia; 3Zagreb Children's Hospital, Department of Surgery, Division of Traumatology, Zagreb, Croatia
| | - Stanko Ćavar
- 1Zagreb University Hospital Centre, Department of Surgery, Division of Pediatric Surgery, Zagreb, Croatia; 2University of Zagreb, School of Medicine, Zagreb, Croatia; 3Zagreb Children's Hospital, Department of Surgery, Division of Traumatology, Zagreb, Croatia
| | - Marko Bogović
- 1Zagreb University Hospital Centre, Department of Surgery, Division of Pediatric Surgery, Zagreb, Croatia; 2University of Zagreb, School of Medicine, Zagreb, Croatia; 3Zagreb Children's Hospital, Department of Surgery, Division of Traumatology, Zagreb, Croatia
| | - Krešimir Bulić
- 1Zagreb University Hospital Centre, Department of Surgery, Division of Pediatric Surgery, Zagreb, Croatia; 2University of Zagreb, School of Medicine, Zagreb, Croatia; 3Zagreb Children's Hospital, Department of Surgery, Division of Traumatology, Zagreb, Croatia
| | - Tomislav Luetić
- 1Zagreb University Hospital Centre, Department of Surgery, Division of Pediatric Surgery, Zagreb, Croatia; 2University of Zagreb, School of Medicine, Zagreb, Croatia; 3Zagreb Children's Hospital, Department of Surgery, Division of Traumatology, Zagreb, Croatia
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Milligan D, Henderson L, Tucker A, Ballard J. Elastic nail fixation versus plate fixation of paediatric femoral fractures in school age patients - A retrospective observational study. J Orthop 2020; 19:153-157. [PMID: 32025124 PMCID: PMC6997651 DOI: 10.1016/j.jor.2019.11.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 11/24/2019] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION The management of paediatric femoral fractures continues to spark debate in published literature, with poor quality evidence guiding current guidelines on the optimum treatment in children. Many centres report excellent results for both elastic intramedullary nailing and plate fixation of diaphyseal femoral fractures. This study aimed to investigate the outcomes of femoral fractures treated with elastic nail fixation versus those treated with plate fixation in a tertiary children's trauma unit, and discuss the advantages and disadvantages of each technique. MATERIALS AND METHODS A retrospective review of all femoral fractures undergoing fixation at a level one paeditric trauma and tertiary referral unit, between 1st April 2009 and 30th April 2017, was performed.Clinical notes and radiographs were reviewed to determine patient demographics and injury, operative and hospital stay data. Radiological union, defined as bridging callus present on at least three out of four cortices on orthogonal radiographs, was determined at 12 weeks. Outcomes were determined using the Flynn Criteria. Patients were followed up for a minimum of 2 years. Data was statistically analysed, and a p value < 0.05 was considered significant. RESULTS There were a total of 28 patients- 14 in each treatment group. Patients undergoing elastic nail fixation were significantly older than plate fixation (9.7 ± 1.9 Vs 7.7 ± 1.8; p = 0.008). A male preponderance was noted (21/28), with no difference between groups (10 Vs 11; p = 1.00). Plate fixation demonstrated a tendency towards shorter length of stay (6.3 ± 2.1 Vs 7.8 ± 3.0; p = 0.134), earlier radiological union at 12 weeks (14 Vs 10; p = 0.098), lower postoperative analgesia requirements (0.82 ± 0.45 Vs 1.12 ± 0.97; p = 0.200), and better outcomes, as determined by the Flynn criteria. CONCLUSIONS In the authors opinion, plate fixation is a safe, effective alternative to elastic nail fixation with equivocal outcomes as determined by the Flynn Criteria. Plate fixation may offer advantages in shorter length of stay, reduced postoperative pain and earlier weightbearing. Further large scale, prospective research is required to determine whether these are borne out in practice.
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Affiliation(s)
- D. Milligan
- C/O Fracture Clinic, Royal Belfast Hospital for Sick Children, Falls Road, Belfast, Northern Ireland, BT12 6BE, UK
| | - L. Henderson
- C/O Fracture Clinic, Royal Belfast Hospital for Sick Children, Falls Road, Belfast, Northern Ireland, BT12 6BE, UK
| | - A. Tucker
- C/O Fracture Clinic, Royal Belfast Hospital for Sick Children, Falls Road, Belfast, Northern Ireland, BT12 6BE, UK
| | - J. Ballard
- Royal Belfast Hospital for Sick Children, Falls Road, Belfast, Northern Ireland, BT12 6BE, UK
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Vitiello R, Lillo M, Donati F, Masci G, Noia G, De Santis V, Maccauro G. Locking plate fixation in pediatric femur fracture: evaluation of the outcomes in our experience. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:110-115. [PMID: 30715008 PMCID: PMC6503420 DOI: 10.23750/abm.v90i1-s.8109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 01/14/2019] [Indexed: 02/08/2023]
Abstract
Background and Aim: Femoral shaft fracture is a common traumatic musculoskeletal injures in pediatric population. The treatment of diaphyseal femoral fractures depends on age patient and pattern fracture. We present our record about the use of locking plate fixation and their outcomes. Method: We conduct a retrospective analysis in 22 patients, surgically treated for 26 diaphyseal femur fracture between 2008 and 2013. The mean age was 13 years. All the patients underwent a clinical and radiological follow-up for two years. We recorded time to weight bearing, time to union, complication (malalignment, dysmetria, infection), time to resumption to sport, plate removal, parents’ satisfaction. Results: All the patients had a minimal clinical e radiological follow-up of 24 months. The average fracture healing time was of 7.4 weeks. All the patients had a full hip and knee range of movements. Fifteen patients developed minor malalignment (varo-valgus or procurvatum femur) without clinical effects. No cases of infections. The mean time to a full weight bearing was 12 weeks and the return to sportive activity was 24 weeks. Four patients required a plate and screws removal. The average result of parents’ satisfaction was 8/10. Conclusions: Locking plate fixation is to be considered a successful way of treatment for pediatric femur fractures, especially in patients older than 6 years, head-injured or in the treatment of polytrauma. The anatomic and functional outcomes are comparable to those of other fixation techniques for this kind of fracture. (www.actabiomedica.it)
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Abstract
INTRODUCTION The insertion of 2 elastic stable intramedullary nails (ESINs) is a common treatment for pediatric femur fractures. However, the use of this technique in length-unstable or metadiaphyseal fractures has historically been associated with higher complication rates. To improve stability, the addition of a third ESIN has been assessed biomechanically and clinically, but the addition of a fourth nail has only been evaluated biomechanically. The purpose of this study is to report our surgical technique and radiographic outcomes using a quartet of ESINs in pediatric femur fractures. METHODS A retrospective review was performed of pediatric patients with length-unstable or metadiaphyseal femur fractures who were treated with 4 ESINs by a single surgeon from 2008 to 2013. Nails were inserted in a retrograde manner, 2 each from medial and lateral starting points. Patients were followed clinically and radiographically until the union and routine removal of hardware. Primary outcomes included fracture union, sagittal, and coronal plane alignment, and complications. RESULTS Fourteen patients underwent quartet ESIN placement. Two patients were excluded: one for early loss to follow-up and another with a diagnosis of osteogenesis imperfecta. The average patient age was 9.3 years (range, 4 to 14 y) and weight was 47 kg (range, 21 to 95 kg). All fractures achieved radiographic union at mean 5.5 months (range, 2 to 9 mo). Hardware was removed at a mean of 9.4 months (range, 2 to 22 mo) following implantation. At final mean follow-up of 18 months, patients and families reported no functional limitations. There were no hardware failures or revision surgeries. There were no limb length discrepancies or malalignment at the time of final radiographic follow-up. There were 2 minor complications-1 patient with pain secondary to nail migration resulting in prominence at the knee and another with refracture following a fall. The stable refracture occurred before complete fracture union and hardware removal and went on to the union without the need for any additional treatment. CONCLUSIONS Treatment with a quartet of ESINs should be considered for skeletally immature children with length-unstable or metadiaphyseal femur fractures. In this series, all fractures achieved union without major complications or hardware failure. This modification to traditional elastic nailing techniques is an option for the surgeon to consider as an alternative to rigid intramedullary nailing, submuscular plating, or external fixation. LEVEL OF EVIDENCE Level IV.
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Talbot C, Davis N, Majid I, Young M, Bouamra O, Lecky FE, Jones S. Fractures of the femoral shaft in children: national epidemiology and treatment trends in England following activation of major trauma networks. Bone Joint J 2018; 100-B:109-118. [PMID: 29305459 DOI: 10.1302/0301-620x.100b1.bjj-2016-1315.r3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to describe the epidemiology of closed isolated fractures of the femoral shaft in children, and to compare the treatment and length of stay (LOS) between major trauma centres (MTCs) and trauma units (TUs) in England. PATIENTS AND METHODS National data were obtained from the Trauma and Audit Research Network for all isolated, closed fractures of the femoral shaft in children from birth to 15 years of age, between 2012 and 2015. Age, gender, the season in which the fracture occurred, non-accidental injury, the mechanism of injury, hospital trauma status, LOS and type of treatment were recorded. RESULTS A total of 1852 fractures were identified. The mean annual incidence was 5.82 per 100 000 children (95% confidence interval (CI) 5.20 to 6.44). The age of peak incidence was two years for both boys and girls; this decreased with increasing age. Children aged four to six years treated in MTCs were more likely to be managed with open reduction and internal fixation compared with those treated in TUs (odds ratio 3.20; 95% CI 1.12 to 9.14; p = 0.03). The median LOS was significantly less in MTCs than in TUs for children aged between 18 months and three years treated in both a spica (p = 0.005) and traction (p = 0.0004). CONCLUSION This study highlights the current national trends in the management of closed isolated fractures of the femoral shaft in children following activation of major trauma networks in 2012. Future studies focusing on the reasons for the differences which have been identified may help to achieve more consistency in the management of these injuries across the trauma networks. Cite this article: Bone Joint J 2018;100-B:109-18.
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Affiliation(s)
- C Talbot
- Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK
| | - N Davis
- Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK
| | - I Majid
- Royal Manchester Children's Hospital
| | - M Young
- University of Manchester, Trauma Audit and Research Network, Salford, Manchester M6 8HD, UK
| | - O Bouamra
- University of Manchester, Trauma Audit and Research Network, Salford, Manchester M6 8HD, UK
| | - F E Lecky
- University of Sheffield, School of Health and Related Research, Western Bank, Sheffield S10 2TN, UK
| | - S Jones
- Royal Manchester Children's Hospital
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Schneidmueller D, von Rüden C, Bühren V. Alternative Operationstechniken zur Behandlung von Femurschaftfrakturen bei Kindern und Jugendlichen. ACTA ACUST UNITED AC 2017. [DOI: 10.1007/s10039-017-0268-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Changes in the Treatment of Pediatric Femoral Fractures: 15-Year Trends From United States Kids' Inpatient Database (KID) 1997 to 2012. J Pediatr Orthop 2017; 36:e81-5. [PMID: 26327403 DOI: 10.1097/bpo.0000000000000633] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The options for treating femoral fractures in children and adolescents have evolved over the last 2 decades to include a variety of nonoperative and operative methods. The purpose of this study was to identify changes in the types of treatment for pediatric femoral fractures in the United States from 1997 to 2012. METHODS From discharge estimates for 1997, 2000, 2003, 2006, 2009, and 2012 in the Kids' Inpatient Database, data were extracted using the International Classification of Diseases, 9th revision, and Clinical Modification for pediatric femoral fracture treatments. Patients included were 0 to 17 years old and were categorized into 5 age groups: younger than 1, 1 to 4, 5 to 9, 10 to 14, and 15 to 17 years. RESULTS A total of 74,483 estimated discharges were recorded for pediatric patients with femoral fractures in the database for years 1997, 2000, 2003, 2006, 2009, and 2012. A total of 12,986 pediatric femoral fractures were estimated for 1997 and 9813 for 2012, which was statistically different (P<0.0001). Significantly fewer fractures were treated with closed reduction alone in 2012 than in 1997 in age groups 5 to 9, 10 to 14, and 15 to 17 years. Children aged 5 to 9 had more frequent open reduction and internal fixation in 2012 than in 1997, whereas adolescents aged 15 to 17 had less frequent open reduction and internal fixation in 2012 than in 1997. CONCLUSIONS Although the number of femoral shaft fractures overall has decreased, the frequency of operative treatment has increased significantly in patients 5 to 9 years of age. Knowledge of these trends can guide educational efforts and resource allocation, but further study is necessary to determine procedure-specific (eg, nailing, plating, external fixation) trends and their clinical and economic impacts. LEVEL OF EVIDENCE Level III-case series.
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Rapp M, Kaiser MM, Grauel F, Gielok C, Illing P. Femoral shaft fractures in young children (<5 years of age): operative and non-operative treatments in clinical practice. Eur J Trauma Emerg Surg 2015; 42:719-724. [PMID: 26335539 DOI: 10.1007/s00068-015-0570-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 08/24/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Femoral shaft fractures comprise around 4 % of all long-bone fractures in childhood. There is controversy about the treatment of fractures in children below 5 years, between those preferring non-operative methods, such as casting or traction, and those supporting elastic stable intramedullary nailing (ESIN). METHODS This retrospective study evaluates the day-by-day treatment of femoral shaft fractures in children aged 6-60 months in four major paediatric surgery trauma centres in Germany from 1 January 2004 to 31 December 2011 by chart review. We analysed all patient-related data, causes of fracture, fracture type, treatment method and potential post-treatment complications. RESULTS We identified 225 patients (male to female 2:1) with femoral shaft fractures. Around 2/3 of these resulted from falls of less than 1 m or 1-3 m, the most frequent result (>40 %) being a long spiral fracture. All 19 children below 1 year of age were treated by casting or traction. Between the ages of 12 and 24 months (n = 56), different treatment concepts were preferred (1/5 ESIN, 2/5 traction and 2/5 spica casting). Between 24 and 36 months, operative and non-operative therapies were equally distributed. In children older than 36 months (n = 64), most fractures were treated by ESIN: six children by external fixation and 14 by other treatments like spica casting, plate osteosynthesis or a combination of methods. 42 changes of treatment were performed: traction to spica casting or secondary operative treatment and 21 complications occurred (nails left in place for too long, skin defects or wound infections). CONCLUSIONS Spica casting of femoral shaft fractures or, in some cases, traction is still the preferred treatment in the first and second years of life. In the third year, children are treated operatively as well as non-operatively, although now there is no current evidence of better short-term outcomes in operatively treated children. But elastic stable intramedullary nailing is the standard treatment for femoral shaft fractures in children older than 3 years of age.
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Affiliation(s)
- M Rapp
- Department of Paediatric Surgery, Hospital of Kassel, Mönchebergstr. 41-43, 34125, Kassel, Germany.
| | - M M Kaiser
- Department of Paediatric Surgery, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - F Grauel
- Department of Paediatric Surgery, Charité Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - C Gielok
- Department of Paediatric Surgery, Haunersches Children's Hospital, Lindwurmstrasse 4, 80337, Munich, Germany
| | - P Illing
- Department of Paediatric Surgery, Hospital of Kassel, Mönchebergstr. 41-43, 34125, Kassel, Germany
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Abstract
BACKGROUND Complex, high-energy pediatric femur diaphyseal fractures cannot be treated reliably by conventional methods: casting is not suitable for polytrauma and large children, external fixation is associated with a high rate of malalignment and refractures, elastic nails are unsuitable for unstable fractures and metaphyseal areas, and lateral trochanteric entry rigid nails cannot address proximal and distal fragments and need relatively large medullary canals. A few centers have reported that submuscular bridge plating (SBP) is associated with minimal complications, but these findings require confirmation. QUESTIONS/PURPOSES We asked whether SBP (1) reproducibly leads to union in unstable fractures with a low complication rate, (2) leads to reasonable alignment and leg length equality (3), is unaffected by age, weight, or location of fracture, and (4) is associated with no or minimal refracture after hardware removal. METHODS We retrospectively reviewed 60 fractures in 58 patients with pediatric diaphyseal femoral fractures treated with SBP from 1999 to 2011. The average age was 9 years. Forty (67%) of the fractures were unstable. Minimum followup was 2.4 months (average, 15.5 months; range, 2.4-50.6 months). RESULTS All fractures healed well and all patients returned to full activity. Two of the 58 patients (3%) had major complications leading to unplanned surgeries: one implant failure and one deep infection in an old open fracture. None of the patients developed clinically important malalignment or leg length discrepancy. Implant removal was performed in 49 patients without complications. CONCLUSIONS SBP provided reliable fixation and healing for complex pediatric femur fractures and can have a broader application in the orthopaedic community. SBP is our preferred method for unstable fractures or fractures of the proximal and distal shaft.
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