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Li D, Wang X, Lu J, Xue M. Submuscular plating vs. elastic stable intramedullary nailing for diaphyseal femur fractures in children: a systematic review and meta-analysis. Front Pediatr 2023; 11:1256630. [PMID: 38027269 PMCID: PMC10663353 DOI: 10.3389/fped.2023.1256630] [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: 07/11/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives This review evaluates the safety and efficacy of submuscular plating (SMP) vs. elastic stable intramedullary nailing (ESIN) in the treatment of pediatric femur shaft fracture. Method Studies comparing the efficacy and safety of SMP and ESIN in pediatric shaft fracture were retrieved from five databases (PubMed, Embase, Cochrane, OVID, and Web of Science) from inception to March 2023 using a systematic literature search strategy. A total of 13 outcome measures, such as perioperative parameters, clinical outcomes, and radiographic results, were included in the meta-analysis. Results Eight eligible studies involving 491 patients were included in the narrative synthesis. There were no significant differences in baseline characteristics between the two groups. Meta-analysis showed reduced radiation time (RT), soft tissue irritation and angular deformation in the SMP group than in the ESIN group. However, the SMP group had greater estimated blood loss (EBL) than the ESIN group. The duration of surgery, length of hospital stay (LOS), implant removal, complications requiring surgery, Flynn score, incidence of infection, fracture healing time, and limb length discrepancy (LLD) were similar between the two groups. Only one study reported higher incidences of fracture nonunion or delayed healing in the ESIN group. Conclusion SMP is an effective and safe intervention superior to ESIN in reducing soft tissue irritation, angular deformation and radiation time. Given the presence of potential bias and heterogeneity, surgeons should select the treatment that would provide the best outcomes for EBL, LOS, operation time, and bone nonunion or delayed healing based on their experience. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023404118, Identifier PROSPERO (CRD42021228512).
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Affiliation(s)
- Donghui Li
- Department of Pediatric Orthopedic, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Xiangyue Wang
- Department of Radiation, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Jialing Lu
- Department of Pediatric Orthopedic, The Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Mingfeng Xue
- Department of Pediatric Orthopedic, The Second Affiliated Hospital of Jiaxing University, Jiaxing, 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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Hu D, Xu Z, Shi T, Zhong H, Xie Y, Chen J. Elastic stable intramedullary nail fixation versus submuscular plate fixation of pediatric femur shaft fractures in school age patients: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e35287. [PMID: 37773849 PMCID: PMC10545301 DOI: 10.1097/md.0000000000035287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 08/29/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Studies of clinical outcomes that compare the elastic stable intramedullary nail (ESIN) with the submuscular plate (SMP) were controversial. The meta-analysis was performed to summarize existing evidence, aiming to determine whether ESIN was superior to SMP in pediatric femur shaft fractures. METHODS Search strategies followed the recommendations of the Cochrane collaboration. Electronic searches such as PubMed, Embase, Web of Science, Cochrane were systematically searched for publications concerning ESIN and SMP from the inception date to March 2023. Two investigators independently searched, screened, and reviewed the full text of the article. Disagreements generated throughout the process were resolved by consensus, and if divergences remain, they were arbitrated by a third author. RESULTS This study included 8 articles, comprising a total of 561 patients with a similar baseline. Compared to the SMP, the ESIN had shorter operation time (mean difference = -16.16; 95% CI = -22.83 to -9.48, P < .00001), and less intraoperative blood loss (mean difference = -53.62; 95% CI = -58.89 to -48.36, P < .00001), but had a higher incidence of implant irritation (odds ratio [OR] = 6.49; 95% CI = 3.01 to 13.98, P < .0001), lower limb malalignment (OR = 2.60; 95% CI = 1.12 to 6.04, P = .96) and overall complications(OR = 4.14; 95% CI = 2.51 to 6.84, P < .0001). And there was no significant difference in radiation time, length of hospital stay, limb length discrepancy, infection rate, delayed union rate and unplanned revised surgery rate (P > .05). CONCLUSIONS Compared to the SMP, the ESIN offers shorter operative time, and less blood loss. However, the SMP is superior to ESINs in complication rates, especially regarding implant irritation and malalignment. Both methods could achieve excellent satisfactory functional outcomes. Thus, the SMP is an alternative choice in the pediatric femur shaft fracture.
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Affiliation(s)
- Donglai Hu
- Department of Pediatric Surgery, Jinhua Central Hospital, Jinhua, China
| | - Zihang Xu
- Department of Pediatric Orthopedic Surgery, Jinhua Maternity and Child Health Care Hospital, Jinhua, China
| | - Tao Shi
- Department of Pediatric Orthopedic Surgery, Jinhua Maternity and Child Health Care Hospital, Jinhua, China
| | - Hui Zhong
- Department of Pediatric Orthopedic Surgery, Jinhua Maternity and Child Health Care Hospital, Jinhua, China
| | - Yuting Xie
- Department of Pediatric Orthopedic Surgery, Jinhua Maternity and Child Health Care Hospital, Jinhua, China
| | - Junjie Chen
- Department of Pediatric Surgery, Jinhua Central Hospital, Jinhua, China
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Zhang Y, Xue Y, Zhao M, Chen X, Gao Q. Titanium elastic nails vs locking plate in pediatric subtrochanteric femur fractures: A systematic review and meta-analysis. Front Pediatr 2023; 11:1114265. [PMID: 36937961 PMCID: PMC10020654 DOI: 10.3389/fped.2023.1114265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/30/2023] [Indexed: 03/06/2023] Open
Abstract
Objective Titanium elastic nails (TENs) and locking plates (LPs) are currently the main internal fixation for treating pediatric subtrochanteric femur fractures, and the optimal choice of internal fixation is controversial. This study aimed to systematically evaluate the effectiveness and safety of TENs and LPs in treating subtrochanteric fractures in children to provide a theoretical basis and reference for clinical treatment. Methods The literature related to TENs and LPs for treating subtrochanteric fractures in children was searched using the CNKI, PubMed, Cochrane, Embase, and Web of Science, and the search time frame was from the establishment of the database to October 2022. Two evaluators screened the literature according to the inclusion and exclusion criteria and extracted relevant data. Meta-analysis was performed using Stata14.0 software. Results A total of 9 studies with 407 patients with subtrochanteric femur fractures were included in the final screening, including 210 cases with TENs and 197 cases with LPs. Meta-analysis results showed that compared with the locking plate, TEN had a shorter operative time [WMD = -1.3, 95%CI(-1.94,-0.66), p < 0.01], less intraoperative bleeding [WMD = -84.45, 95%CI(-111.09, -57.82), p < 0.01], shorter fracture healing time [WMD = -1.3, 95%CI(-1.94,-0.66), P < 0.01], shorter hospital stays [WMD = -2.80, 95% CI(-4.63,-0.98), p < 0.01], and earlier full weight bearing [SMD = -0.48, 95% CI(-0.91,-0.04), p < 0.05] but more intraoperative fluoroscopy [WMD = 28.23, 95% CI(15.22,41.25), p < 0.05]. The overall complication rate was high [OR = 3.52, 95% CI(1.96,6.34), p < 0.05], and the postoperative period was prone to angulation, rotation, and inversion deformity [OR = 3.68, 95% CI(1.40, 9.68), p < 0.05]. No significant difference in the incidence of lower limb inequality between the two types of internal fixation [OR = 0.83, 95% CI(0.38, 1.85), p > 0.05] and no significant difference in the Harris score of the hip at the last follow-up between the two types of internal fixation [WMD = -0.67, 95% CI(-2.01,0.67), p > 0.05] were found. Conclusion In comparison to LPs, TENs have a shorter operation time, less intraoperative bleeding, and a shorter fracture healing time, and the child can be fully weight-bearing earlier. Locking plates can reduce the operator's x-ray exposure, and the incidence rate of postoperative angulation, rotation, and inversion deformity is low. Therefore, TENs and LPs are the best internal fixation methods for treating subtrochanteric fractures in children.
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Affiliation(s)
- Yaqiang Zhang
- Department of Orthopedics, The 940th Hosptial of Joint Logistics Support Force of Chinese People’s Liberation Army, Gansu, China
| | - Yun Xue
- Department of Orthopedics, The 940th Hosptial of Joint Logistics Support Force of Chinese People’s Liberation Army, Gansu, China
| | - Maosheng Zhao
- Department of Orthopedics, The 940th Hosptial of Joint Logistics Support Force of Chinese People’s Liberation Army, Gansu, China
| | - Xianxia Chen
- Lanzhou University Second Hospital, Gansu, China
| | - Qiuming Gao
- Department of Orthopedics, The 940th Hosptial of Joint Logistics Support Force of Chinese People’s Liberation Army, Gansu, China
- Correspondence: Qiuming Gao
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Edwards TA, Daly C, Donovan RL, Whitehouse MR. Risk of complications following surgical fixation of femoral diaphyseal fractures in children aged 4 to 12 years: A systematic review and meta-analysis. Injury 2022; 53:1020-1028. [PMID: 34782115 DOI: 10.1016/j.injury.2021.11.005] [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: 05/07/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There is debate regarding the optimal surgical technique for fixing femoral diaphyseal fractures in children aged 4 to 12 years. The National Institute for Health and Care Excellence (NICE) and the American Academy of Orthopaedic Surgeons (AAOS) have issued relevant guidelines, however, there is limited evidence to support these. The aim of this study was to conduct a systematic review and meta-analysis to compare the complication rate following flexible intramedullary nailing (FIN), plate fixation and external fixation (EF) for traumatic femoral diaphyseal fractures in children aged 4 to 12. METHODS We searched MEDLINE, EMBASE and CENTRAL databases for interventional and observational studies. Two independent reviewers screened, assessed quality and extracted data from the identified studies. The primary outcome was the risk of any complication. Secondary outcomes assessed the risk of pre-specified individual complications. RESULTS Nine randomised controlled trials (RCTs) and 19 observational studies fulfilled the eligibility criteria. Within the RCTs, five analysed FIN (n = 161), two analysed plates (n = 51) and five analysed EF (n = 168). Within the observational studies, 13 analysed FIN (n = 610), seven analysed plates (n = 214) and six analysed EF (n = 153). The overall risk of complications was lower following plate fixation when compared to FIN fixation (RR 0.45, 95% CI 0.28 to 0.73, p = 0.001) in the observational studies. The overall risk of complications was higher following EF when compared to FIN fixation in both RCTs (RR 1.94, 95% CI 1.25 to 3.01, p = 0.003) and observational studies (RR 1.97, 95% CI 1.50 to 2.58, p<0.001). The overall risk of complications was higher following EF when compared to plate fixation in both RCTs (RR 7.42, 95% CI 1.84 to 29.98, p = 0.005) and observational studies (RR 4.39, 95% CI 2.64 to 7.30, p<0.001). CONCLUSION Although NICE and the AAOS recommend FIN for femoral diaphyseal fractures in children aged 4 to 12, this study reports a significantly decreased relative risk of complications when these injuries are managed with plates. The overall quality of evidence is low, highlighting the need for a rigorous prospective multicentre randomised trial at low risk of bias due to randomisation and outcome measurement to identify if any fixation technique is superior.
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Affiliation(s)
- Tomos A Edwards
- Trauma and Orthopaedic Department, North Bristol NHS Trust, Brunel Building, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, United Kingdom.
| | - Catriona Daly
- Trauma and Orthopaedic Department, Somerset NHS Foundation Trust, Musgrove Park Hospital, Parkfield Drive, Taunton, TA1 5DA, United Kingdom
| | - Richard L Donovan
- Trauma and Orthopaedic Department, North Bristol NHS Trust, Brunel Building, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, United Kingdom; Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - Michael R Whitehouse
- Trauma and Orthopaedic Department, North Bristol NHS Trust, Brunel Building, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, United Kingdom; Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, United Kingdom; National Institute for Health Research, Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol
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Flexible Intramedullary Nail Versus Submuscular Locked Plate with the Cluster Technique in Pediatric Femoral Shaft Fractures Fixation. Indian J Orthop 2021; 56:580-586. [PMID: 35342514 PMCID: PMC8921348 DOI: 10.1007/s43465-021-00571-7] [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: 07/27/2021] [Accepted: 11/11/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE OF THE STUDY The aim of this study is the comparison between the flexible intramedullary nail and submuscular Locked Plate with the cluster technique in fixation of pediatric femoral shaft fractures at the age group between 6 and 12 years old with simple diaphyseal closed or Gustilo open grade I fractures. METHODS Fifty children aged 6-12 years with femoral fractures were enrolled in this study. The children were randomly assigned equally to the two groups for fractures fixation. The follow-up period was 1 year. A comparison of various parameters and outcomes between both groups was documented. RESULTS No significant differences were detected between both groups regarding the age, gender, affected side, mechanisms of fracture, or fracture classifications. The operative time and radiation time were longer in the plating group, while the amount of blood loss was lesser in the nail group. The patients treated with plating had better results concerning knee range of motion, weight-bearing, malalignment, and length discrepancy, with fewer complications and better functional outcomes. CONCLUSION The result of the present study supports the use of submuscular locked plate with cluster technique in the treatment of studied fractures over flexible IMN.
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