Closed Ender nailing of adolescent femoral shaft fractures

Clinical outcomes and complications of titanium versus stainless steel elastic nail in management of paediatric femoral fractures-a systematic review

Femoral shaft fractures in children account for approximately 1.6% of all fractures. These fractures can be treated both operatively and non-operatively. Surgical fixation is more common in the age group above 6 years. Elastic intramedullary nails have become the most popular surgical modality of treatment over the last few decades. However, there is continuous debate about which type of elastic nails (titanium and stainless steel) provides better clinical outcomes with less complication. The main purpose of this study was to systematically search for and critically appraise articles comparing clinical outcomes and complications of titanium elastic nail system (TENS) and stainless steel elastic nail system (SSENS) in management of femoral fractures in the paediatric age group. A comprehensive search of MEDLINE, EMBASE, and Cochrane library databases was performed using specific search terms and limits. Applying strict eligibility criteria, the identified studies were screened. Five studies were identified and reviewed. All of the identified studies were non-randomised comparative studies apart from one randomised controlled study. Studies provide contradictory evidence with regard to time to fracture union and time to full weight bearing. Only one study commented on time to nail removal and found that it is shorter in the TENS group. Two studies showed significantly higher rate of malunion in the TENS group, whereas the rest showed no difference. There was no difference in the rates of delayed union or infection between the two groups and no consistent difference in the rates of skin irritation. Three studies compared Flynn's outcome score and found no difference apart from one study which found better scores in the SSENS group. There is no consistent evidence to indicate the advantage of one type of elastic nails over the other in management of paediatric femoral shaft fractures; however, the overall trend is in favour of SSENS especially being cheaper than TENS. Critical appraisal of the studies identified significant methodological deficiencies, and further prospective randomised trials are recommended for more potent evidence.

Complications of titanium and stainless steel elastic nail fixation of pediatric femoral fractures

BACKGROUND

In vitro mechanical studies have demonstrated equal or superior fixation of pediatric femoral fractures with use of titanium elastic nails as compared with stainless steel elastic nails, and the biomechanical properties of titanium are often considered to be superior to those of stainless steel for intramedullary fracture fixation. We are not aware of any clinical studies in the literature that have directly compared stainless steel and titanium elastic nails for the fixation of pediatric femoral fractures. The purpose of the present study was to compare the complications associated with the use of similarly designed titanium and stainless steel elastic nails for the fixation of pediatric femoral fractures.

METHODS

A group of fifty-six children with femoral fractures that were treated with titanium elastic nails was compared with another group of forty-eight children with femoral fractures that were treated with stainless steel elastic nails. Both nail types were of similar design, and a similar retrograde insertion technique was used. The groups were compared with regard to complications as well as insertion and extraction time. Major complications were defined as malunion with sagittal angulation of >15 degrees and coronal angulation of >10 degrees, nail irritation requiring revision surgery, infection, delayed union, and rod breakage. Minor complications were defined as nail irritation or superficial infection not requiring surgery.

RESULTS

The malunion rate was nearly four times higher in association with the titanium nails (23.2%; thirteen of fifty-six) as compared with the stainless steel nails (6.3%; three of forty-eight) (p = 0.017, chi-square test; odds ratio = 4.535 [95% confidence interval, 1.208 to 17.029]). The rate of major complications was 35.7% (twenty of fifty-six) for titanium nails and 16.7% (eight of forty-eight) for stainless steel nails. The rates of minor complications were similar for the two groups, as were the insertion times and extraction times. The supplier price of one titanium nail ranges from $259 to $328, depending on size, whereas the price of one stainless steel nail would be $78 in current United States dollars.

CONCLUSIONS

Our results indicate that the less expensive stainless steel elastic nails are clinically superior to titanium nails for pediatric femoral fixation primarily because of a much lower rate of malunion.

Use of flexible intramedullary nails in pediatric femur fractures

Flexible intramedullary nails are now routinely used for stabilization of pediatric femur fractures. Few data are available regarding patients' postoperative range of motion, weight-bearing status, activity levels, use of immobilization, and radiographic leg length discrepancy measured via routine scanograms. Patients who underwent placement of flexible intramedullary nails for a pediatric femur fracture at a single institution from 1998 to 2003 were identified retrospectively. Ninety-one patients were identified with 94 femur fractures. The complication rate was 17% for the 94 fractures, with 8 patients requiring an unplanned return to surgery. The complication rate was significantly higher for patients aged 10 years or older (34%) as compared with that for younger patients (9%). Average time to full weight bearing was 10 weeks, time to radiographic union averaged 10.7 weeks, and time to return to preoperative level of activity averaged 4.9 months. Immediate postoperative weight bearing status was nonweight bearing in 57%. Immobilization or support was used postoperatively in 60% of the patients. Postoperatively, patients had minimal loss of range of motion in hip internal and external rotation and knee extension. Hip and knee flexion rapidly improved postoperatively with an average loss of hip flexion of 0 degree by 3 months and an average loss of knee flexion of 4 degrees by 6 months. Postoperatively, limb length discrepancy was greater than 1 cm in 7 patients at 6 months, 11 patients at 12 months, 3 patients at 18 months, and 2 patients at 2 years. Two patients had persistent limb length discrepancy of greater than 2 cm, but only one patient required an epiphysiodesis for his limb length inequality. Although the end results are favorable, complications are relatively frequent, particularly in older children.

Biomechanical comparison of flexible stainless steel and titanium nails with external fixation using a femur fracture model

There are several options available for surgical stabilization of pediatric femoral shaft fractures. The purpose of this study was to compare the stability afforded by Ender stainless steel nails, titanium elastic nails, and one-plane unilateral external fixators for the fixation using a synthetic adolescent midshaft femur fracture model. The anterior-posterior (sagittal plane) bending, lateral (coronal plane) bending, torsional, and axial stiffness values were calculated using 6 different fixation configurations. These included pairs of 3.5-mm-diameter Ender nails with and without distal locking, 3.5- and 4.0-mm-diameter titanium elastic nails as well as single- and double-stacked monolateral external fixators. Eight synthetic femur models, 4 each with simulated transverse and comminuted fracture patterns, were sequentially tested for stability afforded by the various fracture fixation configurations. External fixation exhibited significantly greater control of anterior-posterior angulation compared with all flexible-nailing systems. Although Ender nails were slightly superior to titanium nails in control of sagittal plane angulation, this was not statistically significant. Compared with the external fixation constructs, all 4 flexible nail constructs demonstrated higher torsional stability. For prevention of axial shortening, all fixation methods were similar for the transverse fracture pattern, whereas external fixation was superior to flexible nails in the comminuted fracture model. No significant benefit was demonstrated with double stacking of external fixators. These findings may help guide clinicians choose the optimal fixation method for treatment of pediatric femoral shaft fractures.

Acute synovitis of the knee resulting from intra-articular knee penetration as a complication of flexible intramedullary nailing of pediatric femur fractures: report of two cases

Management of pediatric femur fractures using flexible intramedullary nail fixation is widely accepted. Few complications have been reported in the literature; these include primarily malunions and nonunions. The authors present two cases of a previously unreported complication-acute synovitis of the knee following intra-articular penetration of the knee joint by migration of a flexible nail.

Elastic stable intramedullary nailing for unstable femoral fractures in children: preliminary results of a new method

BACKGROUND

Many femoral fracture patterns in children cannot be stabilized sufficiently by intramedullary nailing only. Such fractures may require additional cast bracing or cerclage wiring after nailing. To overcome this problem, pediatric Ender nails that can be interlocked were designed to achieve better fracture stabilization.

METHOD

Seventeen children (age, 2.5 to 15 years) were treated with this method for unstable traumatic fractures of the femur. The average follow-up period was 11.8 months.

RESULTS

All fractures healed within 4 weeks in the mean. There were no major complications.

CONCLUSION

This new method prevents shortening and axial deviation of the fractured femur. Start of postoperative mobilization and increase of weight-bearing is mainly determined by the child.

Displaced fractures of the femoral shaft in children. Unique features and therapeutic options

The decision analysis for managing femoral shaft fractures in children should included such factors as the possibility of child abuse, overgrowth, and the potential for remodeling. Direct and indirect costs must be understood. Factors to consider in determining treatment include the age of the child, the extent of the soft tissue injury, and associated injuries. Non-operative methods, universally used in the past to treat these injuries, still are indicated, but operative modalities should be considered for a greater number of pediatric femoral fractures. Early enthusiasm for external fixation and rigid intramedullary rodding has been tempered by a greater awareness of their particular complications. The role of flexible intramedullary rodding, however, is expanding.