Complications of Elastic Stable Intramedullary Nailing for treating paediatric long bone fractures

Treatment of long bone fractures in children by elastic stable intramedullary nailing: Outcome and challenges in a unit with restricted technical platform

Introduction

Elastic stable intramedullary nailing (ESIN), developed by the Nancy school in France, is the gold standard for surgical treatment of long bone fractures in children. In Africa, few works have been devoted specifically to this technique.

Objective

This study aimed to describe the outcome and to present the challenges with this technique in the treatment of long bone fractures in children.

Patients and Methods

This was a prospective and descriptive study over 4 years including patients aged 0-15 years old operated using ESIN.

Results

Sixty-two patients underwent ESIN, of whom 44 patients (70.96%) were for femur fractures, nine patients (14.52%) for tibia and fibula fractures and nine patients (14.52%) for humerus fractures. The majority of the patients treated with ESIN were children older than 6 years. Nine patients (14.51%) and 13 patients (20.98%) underwent ESIN following polytrauma and multiple fractures, respectively. Seven patients (11.29%) were operated on through-closed ESIN method. The unavailability of image intensifier (38.71%) and the presence of bone callus (40.32%) were the major reasons for using the open ESIN method. Thirty-three patients (53.23%) had minor or major complications. The majority of patients had satisfactory therapeutic outcomes.

Conclusion

ESIN gives good results, even when the fracture site is approached.

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.

Çocuk femur ve tibia şaft kırıklarında kapalı redüksiyon ve titanyum elastik çivileme

Amaç: Bu çalışmada femur ve tibia diyafiz kırıklarında titanyum elastik çivileme (TEÇ) ile tedavi edilen çocuk hastaların klinik ve radyolojik sonuçlarının değerlendirilmesi amaçlanmıştır. Gereç ve Yöntem: TEÇ uygulanan 49 (15 kız, 34 erkek) femur diyafiz kırığı (FK grubu) ve 35 (12 kız, 23 erkek) tibia diyafiz kırığı (TK grubu) geriye dönük olarak incelendi. Ameliyata kadar geçen süre (gün), hastanede kalış süresi (gün), kemik kaynama süresi (ay) ve implant çıkarma süresi (ay) kayıt altına alındı. Son kontrolde, bacak uzunluk farkı (mm), açılanma, kalça ve diz eklemi hareket açıklıkları ölçüldü. Klinik skorlama için Flynn skorlaması kullanıldı. Bulgular: Yaş ortalaması FK grubunda 7,96, TK grubunda ise 9,34 yıl idi. Ortalama takip süresi FK grubunda 51,3 ay, TK grubunda ise 58,3 ay idi. Ortalama hastanede yatış süresi her iki grup için 1,4 gün olarak bulundu. Ortalama kırık kaynama süreleri FK ve TK grubunda sırasıyla 9,7 hafta ve 10,7 haftaydı. Ortalama implant çıkarma süreleri ise FK ve TK grubunda sırasıyla 7,1 ay ve 6,22 ay idi. Flynn skorları FK grubunda 3 hastada kötü, 6 hastada başarılı ve 40 hastada mükemmel; TK grubunda ise 1 hastada kötü, 2 hastada başarılı ve 32 hastada mükemmel olarak hesaplandı. Tüm hastalarda kemik kaynaması sağlandı. Sonuç: Titanyum elastik çivi ile kanal içi sabitleme yüksek tatmin edici klinik sonuçları ve düşük komplikasyon oranı ile birlikte çocuk femur ve tibia şaft kırıklarında başarılı bir tedavi yöntemidir.

Open Reduction of Displaced Radial Neck Fractures in Children by Internal Fixation Techniques: Comparison of Percutaneous Kirschner Wiring and Elastic Stable Intramedullary Nailing

BACKGROUND

Although most paediatric radial neck fractures can be treated with closed reduction, some severely displaced fractures require open reduction. The purpose of this study is to compare the effects of ESIN and KW fixation in open reduction of radial neck fracture in children.

METHODS

Twenty-four patients with mean age of 8.5 years were included. Four of the patients had a Judet type III fracture and 20 had a Judet type IV fracture. Ten patients who underwent percutaneous KW fixation were assigned to group A, while 14 patients who underwent ESIN fixation were assigned to group B. Variables of interest included age, sex, fracture type, associated lesions, surgical time, fracture reduction, cost, follow-up, healing time, X-rays, clinical outcomes, and complications.

RESULTS

There were no significant between-group differences in sex, age, additional injuries, fracture type, and quality of reduction. Costs were significantly lower in Group A. Fracture healing was achieved in 23 of 24 patients (10/10 in group A and 13/14 in group B). In a postoperative elbow function assessment based on the Steele and Graham classification, 80% of patients in group A had a score of excellent or good, compared to 78.6% of patients in group B. Two cases of nail shifting and joint protrusion were observed in group B, one of which also presented with nonunion during follow-up.

CONCLUSIONS

Both KW and ESIN may achieve good clinical outcomes, but KW is associated with lower costs, easier implant removal (without the need for a secondary surgery), and lower iatrogenic complications.

Making Hardware Removal Unnecessary by Using Resorbable Implants for Osteosynthesis in Children

Introduction: Following osteosynthesis, children generally require a second surgery to remove the hardware. This becomes unnecessary, by using resorbable implants. Limiting the number of required surgeries and their associated risks, this technique provides critical aspects of minimally invasive surgery. This review focuses on resorbable implants for osteosynthesis for the treatment of fractures in children and discusses their clinical features. Method: We provide an overview of the two most common technologies used in resorbable osteosynthesis materials: polymer- and magnesium-based alloys. Clinical examples of osteosynthesis are presented using polymer-based ActivaTM products and magnesium-based Magnezix^® products. Results: Polymer-based implants demonstrate surgical safety and efficacy. Due to their elasticity, initial placement of polymer-based products may demonstrate technical challenges. However, stability is maintained over the course of healing. While maintaining good biocompatibility, the rate of polymer-resorption may be controlled by varying the composition of polyesters and copolymers. Similarly, magnesium-based implants demonstrate good mechanical stability and resorption rates, while these characteristics may be controlled by varying alloy components. One of the significant shortcomings of magnesium is that metabolism results in the production of hydrogen gas. Both technologies provide equally good results clinically and radiographically, when compared to non-resorbable implants. Conclusion: Resorbable osteosynthesis materials demonstrate similar therapeutic results as conventional materials for osteosynthesis. Resorbable implants may have the potential to improve patient outcomes, by sparing children a second surgery for hardware removal.

Compared outcomes of femoral shaft fracture treatment in school-age children in Sub-Saharan Africa: Primary open reduction and intramedullary K-wire fixation versus traction followed by spica cast

BACKGROUND

Elastic stable intramedullary nailing has become the treatment of choice for femur shaft fractures in school-age children in developed world. However, in the sub-Saharan Africa, this management is still challenging because of the lack of fluoroscopy in more hospitals. We performed either primary open reduction and intramedullary K-wire fixation (PORIKF) or conservative treatment. The aim of this study was to compare the clinical and functional outcomes of these two procedures employed.

PATIENTS AND METHODS

This retrospective study included 62 children with 64 fractures (10 years on an average; range: 6-15 years) treating for femoral shaft fractures either by PORIKF (n = 21; 23 fractures) or skin traction followed by spica cast (n = 41) between 2008 and 2017. Outcomes were assessed using Flynn criteria. Comparisons were made by Fisher and Student's t-test with a significant P < 5%.

RESULTS

Outcomes were satisfactory in 21 cases (91%) in the PORIKF group compared with 32 (78%) in the conservative group (P = 0.3012). The average hospital stay was 18.6 days in the PORIKF group, whereas it was 20 in the conservative group (P = 0.0601). The mean time for bone union was 13.9 weeks in the PORIKF group and 13.2 weeks in the conservative group, (P = 0.4346). There was a statistically significant difference between the two groups in terms of major complications (P = 0.0177). One patient had osteomyelitis in the PORIKF group. Unacceptable shortening >2 cm was observed only in the conservative group. The average time to return to daily activities was 30 days shorter in the PORIKF group when compared to conservative group (P < 0.05).

CONCLUSION

PORIKF provides better results than conservative treatment. Open reduction did not increase the rate of infectious complication.

Cyclic Damage Accumulation in the Femoral Constructs Made With Cephalomedullary Nails

Background: The purpose of this study was to evaluate the risk of peri-prosthetic fracture of constructs made with cephalomedullary (CM) long and short nails. The nails were made with titanium alloy (Ti-6Al-4V) and stainless steel (SS 316L).

Methods: Biomechanical evaluation of CM nail constructs was carried out with regard to post-primary healing to determine the risk of peri-implant/peri-prosthetic fractures. Therefore, this research comprised of, non-fractured, twenty-eight pairs of cadaveric femora that were randomized and implanted with four types of fixation CM nails resulting in four groups. These constructs were cyclically tested in bi-axial mode for up to 30,000 cycles. All the samples were then loaded to failure to measure failure loads. Three frameworks were carried out through this investigation, Michaelis–Menten, phenomenological, and probabilistic Monte Carlo simulation to model and predict damage accumulation.

Findings: Damage accumulation resulting from bi-axial cyclic loading in terms of construct stiffness was represented by Michaelis–Menten equation, and the statistical analysis demonstrated that one model can explain the damage accumulation during cyclic load for all four groups of constructs (P > 0.05). A two-stage stiffness drop was observed. The short stainless steel had a significantly higher average damage (0.94) than the short titanium nails (0.90, P < 0.05). Long titanium nail group did not differ substantially from the short stainless steel nails (P > 0.05). Results showed gender had a significant effect on load to failure in both torsional and bending tests (P < 0.05 and P < 0.001, respectively).

Interpretation: Kaplan–Meier survival analysis supports the use of short titanium CM nail. We recommend that clinical decisions should take age and gender into consideration in the selection of implants.

Treatment of Closed Tibia Shaft Fractures in Children: A Systematic Review and Meta-Analysis

Tibia fractures are among the most common long-bone fractures in children. Despite this, there is no current consensus on the optimal treatment strategy for closed displaced tibia shaft fractures in the pediatric patient population. The aim of this study is to compare the reported complications and outcomes of reduction and cast immobilization versus flexible intramedullary nailing in the treatment of pediatric tibia shaft fractures. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement when conducting and reporting this prospectively registered systematic review. Eleven studies were included. Quality of the studies was assessed using the Coleman methodology score. Mantel-Haenszel cumulative odds ratios were used to compare the risk of complication between different methods of treatment. Eleven studies including 1,083 patients with diaphyseal fractures of the tibia met the inclusion criteria. The most common fracture type was simple 42-A (782; 91%). Majority (75%) of the patients were treated nonoperatively. The total complication rate was higher among operatively treated patients (24 vs. 9%; p < 0.05). Satisfactory fracture alignment had to be restored surgically in 5% of the primarily nonoperatively treated patients. The evidence levels of the included studies were II (1), III (2), and IV (7). Three-fourths of closed diaphyseal fractures of the tibia in children are still treated with reduction and cast immobilization. Flexible intramedullary nailing is associated with significantly higher complication rate than nonoperative treatment.

Flexible intramedullary nailing of femoral shaft fractures: closed versus open reduction

Children's femoral shaft fractures are commonly treated with flexible intramedullary nailing after closed or open reduction, but there is little information concerning indications for open reduction. The purpose of this study was to determine radiographic and clinical features likely to lead to open reduction before flexible intramedullary nailing. Record review identified 158 femoral shaft fractures treated with flexible intramedullary nailing. In addition to patient demographics and mechanism of injury, data obtained included surgeon name, estimated blood loss, type of reduction, type and diameter of nail, type of operating table, the use of percutaneous reduction techniques or supplemental casting, time to and duration of surgery, total time in operating room, and time to union. Fracture ratios were calculated based on established radiographic protocol. Of 158 fractures, 141 were treated with closed reduction and 17 with open reduction. The anteroposterior fracture index (1.3 ± 0.4, P = 0.0007), surgeon (P = 0.002), and flattop operating table (0.05) were associated with open reduction. Smaller lateral diameter of bone at the fracture site, transverse fracture, and surgeon were all found to be independent risk factors for open reduction; patient characteristics, including age, sex, and BMI, did not seem to influence the choice of open reduction. Fractures with a lower fracture index or pattern resembling a transverse fracture rather than oblique or spiral had an increased risk of converting to an open reduction. Surgeon preference and use of flattop tables also had a significant influence on how the fracture was treated.

Antegrade Elastic Intramedullary Nailing Insertion Technique Results in Higher Incidence of Symptomatic Implants in Pediatric Ulnar Fractures

Retrograde and antegrade nailing techniques are the two options available to a surgeon when using elastic stable intramedullary nailing; however, the literature comparing these two nailing techniques is scarce. Thus, we conducted a retrospective review of all pediatric and adolescent ulnar fractures treated with elastic stable intramedullary nailing at our facility. We hypothesize that the clinical outcomes (implant and wound complications) and the time between surgery and radiographic union will be similar for both techniques.

Methods

A retrospective chart review of pediatric ulnar fracture patients treated at our facility was performed. Demographic and health information associated with the injury were collected, and the clinical outcomes of the two techniques were compared.

Results

A total of 53 patients with 54 fractures were included in this study. Antegrade nail insertion was used to treat 59.2% fractures. Radiographic union was achieved in all patients. Nail insertion technique was not associated with postoperative wound complications, time to radiographic union or implant removal, or significant deficits in upper extremity rotation (P > 0.05). Antegrade nailing resulted in a symptomatic implantation 3.97 times more frequently than compared with retrograde nailing (P = 0.036).

Discussion

Antegrade nailing demonstrates a similar healing profile but higher implant complications compared with the retrograde nailing technique in pediatric ulnar fractures.

Elastic stable intramedullary nailing for treatment of pediatric forearm fractures: A 15-year single centre retrospective study of 173 cases

OBJECTIVE

The aim of this study was to analyze the outcomes and complications in children treated with elastic stable intramedullary nailing (ESIN) for forearm fracture.

METHODS

The study included 173 patients (126 men and 47 women; median age: 11 years (range: 3-17 years) treated with ESIN for forearm fracture between May 2002 and May 2018. Immobilization was not performed after the surgery. The median follow-up was 68 months (range: 3-161 months). The etiology, healing time, and complications were recorded.

RESULTS

All patients achieved complete radiographic healing at a median of 6.8 weeks (range: 4-11 weeks). The most common injuries were sport related (n=65) and by falling from standing height (n=57), followed by injuries from bicycle riding, motorbike accidents, road traffic accidents, and fights. Fifteen (8.76%) postoperative complications were recorded: eight entry-site skin irritations, two cases of skin infection, two refractures, and one case each of nail migration, injury of ulnar nerve, and pseudoarthrosis. All complications, except cases of refractures and pseudoarthrosis, were treated conservatively, with no long-term consequences for the patients. Patients with refractures and pseudoarthrosis were reoperated, and complete function of the extremities was fully restored.

CONCLUSION

ESIN for treatment of forearm fractures in children shows good functional and cosmetic results. This is a minimally invasive, cast-free, simple, and reproducible technique, with a low complication rate. Owing to these excellent objective and subjective results, surgical stabilization of the forearm fracture using ESIN is recommended in children and adolescents.

LEVEL OF EVIDENCE

Level IV, Therapeutic study.

Biomechanical and Clinical Comparative Study of the New Elastic Stable Intramedullary Nailing "MJ-FLEX Orthofix"

BACKGROUND

The objectives of this study were first to compare the results of osteosynthesis with standard Metaizeau (MS) nails versus Metaizeau Junior Flex or MJF Orthofix (MJF) in terms of the stability of long-bone fractures in children, and to study the preoperative and postoperative safety of these new nails. We also carried out an analysis by computer modeling of a femur, in order to compare the biomechanical stability of the 2 nails. The interest in the MJF nails lies in the improvements they bring in terms of stability for long-bone fractures in pediatric patients, as well as the simplification of the surgical procedure.

METHODS

A study by numerical computer modeling of a femur was conducted to compare the biomechanical stability of the 2 assemblies with MS versus MJF nails. A retrospective single-center study of 137 fractures treated with MS and MJF was added to this biomechanical study. The onset of angular misalignment during follow-up was identified by radiographic measurements.

RESULTS

The biomechanical study showed greater stiffness of MJF in the frontal and sagittal plane and in torsion for modeled comminuted and simple transverse fractures. Use of MJF nails significantly reduced the risk of frontal and sagittal misalignment, by a factor of 5 and 12, respectively. The amplitude of this misalignment was also significantly reduced by 30% in the frontal plane with the MJF nail. The use of MJF compared with MS significantly diminished not only the quantity of preoperative radiation by 66% but also operative time by 30%. The complication rate in our population was 33.4% with a 6-fold lower risk of complications with MJF.

CONCLUSIONS

MJF nails provide greater stability in the frontal and sagittal plane with regard to both the onset and amplitude of misalignment in the treatment of long-bone fractures in children. This improvement was confirmed by the biomechanical study. Preoperative and postoperative safety was also better with these new nails, and surgery was easier.

Distance of the fracture from the radiocarpal surface in childhood: does it determine surgical technique? A retrospective clinical study: A STROBE compliant observational study

Unstable distal metaphyseal and dia-metaphyseal fractures of the radius may have treated with a variety of operative techniques, Kirschner wires (K-wires), dorsally inserted titanium elastic stable intramedullary nailing (DESIN), and short titanium elastic stable intramedullary nailing (SESIN) in children.The aim of this study was to evaluate the differences in clinical and radiographic outcomes between these methods.Between January 2009 and December 2017 196 children were treated for forearm fractures in the distal third of the distal radius. Gender of the patients, different types of surgical techniques, number of postoperative X-rays, date of metal removal and degree of axis deviation after the metal removal were studied. Distance of the fracture line from the radiocarpal surface, the width of the distal epiphysis of the radius, and the cumulative width of the distal epiphysis of the ulna and radius were analyzed.Out of the 196 children, stabilization of the fracture was achieved by K-wire in 139, by DESIN in 44, and by SESIN in 13 patients. The average time of metal removal was significantly shorter (3.8 months), following stabilization with K-wire. In children treated with K-wire, axial deviation of <5° was seen in 118 patients, 5° to 10° deviation in 15 patients, while deviation was above 10° in 6 children. In the DESIN group, <5° axial deviation was found in 37 patients and 5° to 10° in seven patients. In all 13 children treated with SESIN, axial deviation was measured to be <5°. The fracture distance from the radiocarpal surface was on average 23.7 and 45.6 mm in the children treated with K-wire and DESIN, respectively.Fracture distance from the radiocarpal surface might determine the type of surgical technique required. If the distance of the fracture line is less than the width of the distal radius, osteosynthesis with a K-wire is recommended, while if the distance of the fracture is more than the cumulative width of the radius and the ulna, then DESIN may provide better results. The use of SESIN may be indicated when the area of the growth plate is injured.

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.

Update on leg fractures in paediatric patients

Leg fractures are common and further increasing in prevalence in paediatric patients. The diagnosis is readily made in most cases. Choosing the best treatment is the main issue. Non-operative treatment is the reference standard for non-displaced or reducible and stable fractures but requires considerable expertise and close monitoring, as well as an immobilisation period that far exceeds 3 months in many cases. Some surgical teams therefore offer elastic stable intra-medullary nailing (ESIN) as an alternative to children who do not want to be immobilised for several months. Internal fixation is required for unstable or irreducible leg fractures. ESIN is often used as the first-line method, based on its very good risk/benefit ratio. For fractures that do not lend themselves to ESIN, optimal stabilisation can be achieved by choosing among the other available options (screw-plate fixation, rigid intra-medullary nailing or external fixation) on a case-by-case basis. Close monitoring during the first few days is crucial to ensure the early detection of compartment syndrome. The other complications and sequelae are non-specific.

Rust score-An adequate rehabilitation guide for diaphyseal femur fractures managed by TENS

INTRODUCTION

The optimal mode of treatment among the wide variety of surgical and nonsurgical treatment options for children between 5 and 15 years of age continues to be controversial. Elastic stable intramedullary nailing of long bone fractures in the skeletally immature has gained widespread popularity because of its clinical effectiveness and low risk of complications.

METHODS AND METHODOLOGY

From Jan 2015 to August 2016, 35 patients including 37 limbs with diaphyseal fractures of the femur in the age group 5-15 years were managed by Titanium Elastic nailing and their clinico-radiological and functional outcome was assessed at 1 year post operatively as per the Flynn's criteria. RUST score was used as a guide for post-operative rehabilitation.

RESULTS

37 patients were managed by TENS nailing including 28 males and 9 females. The outcome in proximal, middle or distal fractures of the shaft were found to be similar and the difference was statistically insignificant. Similarly, the difference in the outcomes as per fracture patterns was also found to be statistically insignificant. Partial weight bearing was allowed after a score of 6 was achieved and full weight bearing after a score of 8.

CONCLUSION

As per the Flynn's criteria, 75% of the patients (28 out of 37) were found to have an excellent outcome while 7 had a satisfactory outcome and two had a poor outcome. RUST score can be used as an effective guide for post op rehabilitation.

Submuscular plates versus flexible nails in preadolescent diaphyseal femur fractures

PURPOSE

To compare patient characteristics, operative time, estimated blood loss (EBL), postoperative length of hospital stay (LOS) and complications after insertion and removal of submuscular plates (SMPs) versus flexible nails (FNs) for paediatric diaphyseal femur fractures.

METHODS

We reviewed records of 58 children (mean age, 7.7 years SD 2.0) with diaphyseal femur fractures who underwent treatment with SMPs (n = 30) or FNs (n = 28) from 2005 to 2017 (mean follow-up, 22 months SD 28). Patients with pathological fractures or musculoskeletal comorbidities were excluded. Alpha = 0.05.

RESULTS

Insertion of FNs was associated with shorter operative time (ß = -24 mins) and less EBL (ß = -38 mL) (both, p < 0.001) compared with insertion of SMPs, after adjusting for fracture type and time from beginning of study period. Removal of FNs was also associated with shorter operative time (ß = -15 min) compared with removal of SMPs (p < 0.001). EBL during removal was similar between groups (p = 0.080). The FN group had a shorter LOS after insertion (ß = -0.2 d) compared with the SMP group (p = 0.032). Four patients treated with SMPs and three treated with FNs developed surgical site infections. Two patients treated with SMPs and seven treated with FNs experienced implant irritation that resolved with removal. No other complications occurred.

CONCLUSION

Compared with SMPs, FNs were associated with shorter operative time (for insertion and removal), less EBL (for insertion) and shorter post-insertion LOS in patients with diaphyseal femur fractures.

LEVEL OF EVIDENCE

III.

Intramedullary nailing of forearm shaft fractures by biodegradable compared with titanium nails: Results of a prospective randomized trial in children with at least two years of follow-up

There are disadvantages in Elastic Stable Intramedullary Nailing (ESIN) of forearm-shaft fractures, such as the need of implant removal. Biodegradable Intramedullary Nailing (BIN) is a new technique developed for these fractures. We hypothesized that there is no difference in rotational ROM between the patients treated by BIN vs. ESIN. A randomized, controlled clinical trial included patients, aged 5-15 years, requiring surgery for forearm-shaft fractures. Biodegradable polylactide-co-glycolide (PLGA) nails (Activa IM-Nail™, Bioretec Ltd., Finland) were used in 19 and titanium nails (TEN^®, SynthesDePuy Ltd., USA) in 16 patients. Rotational ROM of forearm after two years was the primary outcome. Elbow and wrist ROM, pain and radiographic bone healing were secondary outcomes. Forearm rotation was mean 162° and 151° in BIN and ESIN groups, respectively (P = 0.201). No difference between the groups was found in any other ROMs. Three cases in the ESIN vs. none in the BIN group reported pain (P = 0.113). There was no clinically significant residual angulation in radiographs. Two adolescents in the BIN group vs. none in the ESIN (P = 0.245) were excluded because of implant failure; another two with complete bone union suffered from re-injury. Therefore, satisfactory implant stability among older children needs to be studied.

Surgical approach for elastic stable intramedullary nail in pediatric radius shaft fracture: a systematic review

When using elastic stable intramedullary nailing in children's distal radius shaft fractures, the surgical approach can either be lateral or dorsal. The aim of this article was to carry out a systematic review of the literature comparing the two types of approaches in terms of complications. An electronic search of databases was performed. Titles of articles were screened, and abstracts and full text were read. Data were extracted in terms of demographics and complications. The dorsal approach had a 2.6% rate of extensor pollicis longus tendon rupture, whereas the lateral approach had a 2.9% rate of transient superficial radial nerve palsy and 0.3% rate of permanent damage. These complications should be considered when deciding between the two surgical approaches.

Cortical erosion after elastic stable intramedullary nail fixation for pediatric long bone fractures: Case series according to the site

BACKGROUND

Elastic stable intramedullary nail (ESIN) is widely used for treatment of long bone fractures in children. However, migration of the nail or cortical bone erosion in children has been reported. This study was conducted to investigate the incidence of cortical erosion according to the site and cortical erosion type.

MATERIALS AND METHODS

A total of 221 normally developing children (223 fractures) who were treated with ESIN for fractures of the long bones without cortical breakage at immediate postoperative radiography and with the ESIN in position for more than 6 months were included. Two pediatric orthopaedic surgeons reviewed all the radiographs. Cortical bone erosion was defined when the two investigators agreed that there was cortical breakage by the ESIN.

RESULTS

Penetration of nails through the bone cortex was observed in 25 patients (11.2%). Fifteen patients (6.7%) showed cortical erosion at the diaphysis and ten patients (4.5%) showed protrusion of the tip of the ESIN at the metaphysis-diaphysis junction. The average time for hardware removal in patients with cortical erosion was 14.2 months.

CONCLUSION

Cortical bone erosion by ESIN could occur in pediatric long bones without any iatrogenic problem or disease related to the bony structure. Erosion at diaphysis was more common than at metaphysis-diaphysis junction. Cortical erosion should be considered in children who retain their ESIN for a long time.

Redefining Optimal Nail to Medullary Canal Diameter Ratio in Stainless Steel Flexible Intramedullary Nailing of Pediatric Femur Fractures

PURPOSE

The ideal canal fill for flexible intramedullary fixation of pediatric femoral shaft fractures is considered to be 80% based upon relatively few clinical studies. The purpose of this study is to assess the relationship between the summed nail to intramedullary canal diameter (ND/MCD) ratio and alignment at radiographic union following flexible intramedullary nailing (FIMN) of pediatric femoral shaft fractures.

METHODS

An Internal Review Board approved, retrospective review of a consecutive series of patients who sustained a femoral shaft fracture treated by retrograde, stainless steel FIMN was performed at a single level 1 pediatric trauma center from 2005 to 2012. Preoperative radiographs were analyzed to determine fracture pattern, location, and isthmic canal diameter. ND/MCD ratio was calculated using the sum of the known nail diameters and the measured isthmic diameter. Radiographs at bony union were reviewed to measure shortening, coronal angulation, and sagittal angulation. ND/MCD ratio was analyzed to determine correlative factors with final radiographic outcomes.

RESULTS

In total, 261 children underwent retrograde FIMN at an average age of 8.2 years (range, 2.2 to 17.0 y). ND/MCD ratio of ≥80% was seen in 108 (41.4%) patients. When compared with those with <80% ND/MCD ratio, there were no significant differences in age (8.8 vs. 8.0 y), sex (76.9% vs. 71.0% males), or body mass index (18.5 vs. 17.2 kg/m). There were significantly more length unstable fractures in the <80% ND/MCD ratio group (49.4% vs. 29.7%; P<0.01). Radiographic outcome was no different with respect to coronal angulation (2.7 vs. 3.0 degrees), sagittal angulation (3.0 vs. 3.2 degrees), or shortening (2.5 vs. 4.1 mm). ND/MCD ratio of ≥70% was seen in 176 (67.4%) patients and, when compared with the <70% ND/MCD ratio group, there were no differences in shortening (3.3 vs. 3.9 mm), coronal angulation (2.8 vs. 3.0 degrees), or sagittal angulation (3.0 vs. 3.4 degrees). Finally, 6.9% of the population (18 patients) had ND/MCD ratios <60% and did not demonstrate a significant increase in shortening, coronal, or sagittal angulation compared with groups with higher ND/MCD ratios. No group had an increased rate of infection, implant removal, nonunion, or need for reoperation.

CONCLUSIONS

In a large series of consecutive patients treated with retrograde stainless steel FIMN there does not appear to be any correlation between the ND/MCD ratio and radiographic outcome. Stainless steel flexible IM nails seem to maintain fracture alignment without an increase in complications at lower ND/MCD ratios than previously reported as "optimal."

LEVEL OF EVIDENCE

Level III.

Comparison of three fixation methods in treatment of tibial fracture in adolescents

BACKGROUND

Tibial fractures are the most common musculoskeletal injury in adolescents. The optimal management of tibial fractures in adolescents is controversial. In this study, we compared the outcomes including complications of three fixation methods in tibial fractures of adolescents and explored the factors associated with the complications.

METHODS

A retrospective cohort study about 83 diaphyseal tibial fractures in 79 children and adolescents, who were treated with plate fixation (PF), elastic stable intramedullary nail fixation (ESINF), or external fixation (EF), was conducted. After adjustment for age, weight, energy of the injury, polytrauma, fracture level and pattern, and extent of comminution, treatment outcomes were compared in accordance with the length of the hospital stay, time to union, and complication rates including many factors.

RESULTS

The mean age of the patients was 13.4 years, and their mean weight was 44.2 kg. There was a loss of reduction in two of 33 fractures treated with ESINF and four of 13 treated with EF (P < 0.001). At the time of final follow-up, three patients (two treated with EF and one treated with ESINF) had ≥2.0 cm of shortening. Four of the 32 patients (33 fractures) treated with ESINF underwent a reoperation (two due to loss of reduction and one each because of delayed union and nonunion). Six patients treated with EF required a reoperation (four due to loss of reduction, one for malunion and one for replacement of a pin complicated by infection). Two fracture treated with PF required refixation attributing to nonunion and malunion. A multivariate analysis with adjustment for baseline differences showed that EF was associated with a 7.56-times (95% confidence interval 3.74-29.87) greater risk of loss of reduction and/or malunion than ESINF.

CONCLUSIONS

All three treatments had satisfactory outcomes, and EF was correlated with the highest rate of complications in our series of adolescents treated with a tibial fracture. However, we cannot currently recommend that all fractures might be suitable for ESINF. The choice of fixation will remain influenced by surgeon preference in term of expertise and experience, patient and fracture characteristics, and patients and family preferences.

Elastic stable intramedullary nailing in paediatric forearm fractures: the rate of open reduction and complications

The aim of this study was to evaluate the rate of open reduction and complications of elastic stable intramedullary nailing (ESIN) in treating unstable diaphyseal forearm fractures in children. We performed a retrospective review of a consecutive series of 102 paediatric patients with a mean age of 9 years (range: 7-14 years) who underwent ESIN of unstable closed forearm fractures at three different centres. Closed reduction of one or both bones was achieved in 68 (67%) patients and open reduction was required in 34 (33%) patients. The rate of open reduction in single-bone fractures (52.2%) was significantly higher than that in both-bone fractures (27.8%) (P=0.04, Fisher's exact test). All the fractures united within 3 months. There were six refractures following nail removal. Five patients had superficial wound infections. Seven patients developed neuropraxia of the sensory branch of the radial nerve. All resolved spontaneously within 3 months of the surgery. ESIN is an effective technique in treating unstable diaphyseal forearm fractures. The need for open reduction should be decided promptly following failed attempts of closed reduction. Single-bone fractures are more likely to require open reduction than both-bone fractures. The radius should be reduced and stabilized first. If open reduction is required, this should be performed through a volar approach rather than a dorsal one.

Short, double elastic nailing of severely displaced distal pediatric radial fractures: A new method for stable fixation

RATIONALE

Short double elastic nailing is a minimal invasive, modified ESIN (elastic stable intramedullary nailing) technique for severely displaced distal radial fracture in children. The aim of this technical report is to introduce our new method and evaluate the final results of the procedure.

PATIENT CONCERNS

We reviewed retrospectively 24 patients who underwent short double elastic nailing due to distal radial fractures between November 2012 and December 2015. Indications for surgery included closed, severely displaced, unstable metaphyseal or diametaphyseal fractures of the radius.

INTERVENTION

The fractures were stabilized by 2 prebent short elastic titanium nails inserted from the distal side of the fracture. In cases of associated ulnar fracture, a classic anterograd ESIN nailing was also performed. Patients were mobilized immediately in a removable short splint which was removed after 1 to 2 weeks. There has been no additional splinting or casting.

OUTCOMES

There were 17 males and 7 females with an average age of 9.8 years (range, 4-16 years). The right hand was involved in 16 cases and the left hand in 8 cases. The average follow-up was 17.8 months (range, 7-28 months). Of the 24 patients, 3 presented irritation of the skin, which resolved after removal of the radial nail. All the patients regained full range of motion without any complications.

LESSONS

Our technique is an effective, safe, and easily learnable procedure for unstable fractures of the distal third of the radius. It achieves good functional and radiological results, and allows early mobilization without the need of casting. Avoiding the physeal plates, we reduce the risk of iatrogenic postoperative deformity. Further prospective and biomechanical investigations are necessary to verify our experience.

Fracture union in percutaneous Kirschner wire fixation in paediatric tibial shaft fractures

PURPOSE

To evaluate the efficacy of intramedullary Kirschner wires for the treatment of unstable tibial shaft fractures in children.

METHODS

This prospective study was conducted at the Department of Orthopaedic Surgery in Maharishi Markandeshwar Medical College from June 2005 to June 2010. Sixty-six children having closed fracture of the tibial shaft with a mean age of 7.7 years (range, 2-14 years) were recruited from emergency and outpatient department. They were treated with percutaneous intramedullary Kirschner wires. The clinical results of our study were rated on the basis of the criteria of union, nonunion, delayed union or malunion. All children were followed for one year.

RESULTS

Children achieved union in a mean time of 8 weeks (range, 6-10 weeks). Postoperatively, three children (4.55%) had delayed union, one (1.52%) valgus deformity of lower leg, three (4.55%) post- operative knee pain and twelve (18.18%) skin irritation at pin site.Wires were removed after 8-22 weeks without any complications. No patient was lost to follow-up. The results were excellent in 95.45% and good in 4.55% children.

CONCLUSION

This technique is cost-effective, simple, quick to perform, safe and reliable and avoids pro- longed hospitalization with good results.

A meta-analysis of flexible intramedullary nailing versus external fixation for pediatric femoral shaft fractures

To compare the difference in efficacy following flexible intramedullary nailing (FIN) and external fixation (EF) for pediatric femoral shaft fractures. A systematic search was performed on PubMed, Embase, Medline, and Cochrane library for relevant studies. We included controlled trials comparing complications between FIN and EF for pediatric femoral shaft fractures published before 25 November 2014. Modified Jadad scores were utilized to assess the methodological quality of the studies included. The meta-analysis was carried out using Stata 12.0 software. Six studies involving 237 patients were included. On comparison of EF, a low incidence of overall complications [relative risk (RR)=0.30, 95% confidence interval (CI): 0.19-0.46; P<0.001] and pin-tract infection (RR=0.286, 95% CI: 0.13-0.61; P=0.001), but a high risk of soft tissue irritation (RR=1.86, 95% CI: 1.35-2.56; P<0.001) were found in patients treated with the FIN approach. No significant differences in other complications were found. On the basis of current evidence, the use of FIN leads to fewer complications than EF and may be considered as the first-line approach in the treatment of femoral shaft fractures.

Surgical treatment of femoral diaphyseal fractures in children using elastic stable intramedullary nailing by open reduction at Yopougon Teaching Hospital

INTRODUCTION

Elastic stable intramedullary nailing (ESIN) has transformed children's femoral shaft fracture treatment, but this technique requires an image intensifier. Without it, open reduction is used to check fracture reduction and pin passage. The aim of this study was to describe our techniques and to evaluate our results at the middle term.

HYPOTHESIS

The open reduction and ESIN technique provides satisfactory results with few major complications.

PATIENTS AND METHODS

This was a retrospective study that focused on femoral diaphyseal fractures treated in the pediatric surgery unit at Yopougon Teaching Hospital (Abidjan, Côte d'Ivoire) between January 2007 and December 2013. Twenty children older than 6 years of age who underwent open reduction and ESIN without image intensifier assistance were included. Functional outcomes were assessed using Flynn's criteria. Postoperative complications and sequelae were recorded.

RESULTS

At the 16-month follow-up, the results were excellent in 11 (55%) cases, good in eight (40%), and poor in one (5%) case. The mean duration of surgery was 71min (range, 57-103 min). The mean time for bone healing was 11.6 weeks (range, 7-15 weeks) and the average time to nail removal was 6 months. Complications included wood infection (n=3), skin irritation (n=3), knee stiffness (n=2), malunion (n=3), scar (n=5), and leg length discrepancy (n=3).

DISCUSSION

Open reduction and ESIN yielded satisfactory results with few major complications. This method could be an alternative in low-income countries where the image intensifier is often unavailable.

LEVEL OF EVIDENCE

Level IV retrospective study.

Patient positioning on the operative table for more accurate reduction during elastic stable intramedullary nailing of the femur: a technical note

Elastic stable intramedullary nailing is currently considered a clinical practice standard for the treatment of femoral fractures in children in the age-appropriate group. Malreduction, particularly in rotation, due to the closed reduction technique has been reported. We describe a new technique of positioning on a standard operating table that permits better control of rotational alignment during femoral elastic stable intramedullary nailing.