Treatment of femoral shaft fractures in children by intramedullary Kirschner wires

Practice Patterns for Management of Pediatric Femur Fractures in Low- and Middle-Income Countries

BACKGROUND

Femoral shaft fractures in children are common in low and middle income countries. In high-income countries, patient age, fracture pattern, associated injuries, child/family socioeconomic status, and surgeon preference dictate fracture management. There is limited literature on treatment patterns for pediatric femur fractures in resource-limited settings. This study surveys surgeons from low (LIC), lower-middle (LMIC), and upper-middle income (UMIC) countries regarding treatment patterns for pediatric femur fractures.

METHODS

Surgeons completed an electronic survey reporting surgeon demographics and treatment preference for pediatric femur fractures. Treatment preferences and indications for treatment were separated into 4 groups: infant (0 to 6 mo); toddler (7 mo to 4 y); child (5 to 12 y); adolescent (12 to 17 y). The survey was available in English, Spanish, and French. Analysis was completed with t test and χ test for continuous and categorical variables, respectively, and weighted Pearson correlation (P<0.05).

RESULTS

Survey respondents consisted of 413 surgeons from 83 countries (20 LIC, 33 LMIC, 30 UMIC). The majority of respondents were fellowship trained (83%) most commonly in pediatrics (26%) and trauma (43%). Most treated >10 pediatric femur fractures per year (68%). Respondents reported treating infant femur fractures nonoperatively using Pavlik harness (19%), spica cast (60%), or traction with delayed spica cast (14%). Decreasing socioeconomic status was associated with higher nonoperative treatment rate in toddlers, children, and adolescents. Respondents commonly utilize bed rest and traction for child femur fractures in LICs (63%) and LMICs (65%) compared with UMICs (35%) (UMIC vs. LMIC P<0.001; UMIC vs. LIC P<0.001). Surgeries in children more commonly involve open reduction with internal fixation (UMIC 19%, LMIC 33%, LIC 40%; P<0.05 between UMIC-LMIC and UMIC-LIC).

CONCLUSION

This is one of the largest surveys describing treatment patterns for pediatric femur fractures in low and middle income countries. Differences are evident including lower operative treatment rate in younger children and lower intramedullary fixation rates in older children. Future studies should investigate the value of treatment options in resource-limited settings.

LEVEL OF EVIDENCE

Level II-prospective comparative study.

Evaluation of musculoskeletal phenotype of the G608G progeria mouse model with lonafarnib, pravastatin, and zoledronic acid as treatment groups

Hutchinson-Gilford progeria syndrome (HGPS) is a uniformly fatal condition that is especially prevalent in skin, cardiovascular, and musculoskeletal systems. A wide gap exists between our knowledge of the disease and a promising treatment or cure. The aim of this study was to first characterize the musculoskeletal phenotype of the homozygous G608G BAC-transgenic progeria mouse model, and to determine the phenotype changes of HGPS mice after a five-arm preclinical trial of different treatment combinations with lonafarnib, pravastatin, and zoledronic acid. Microcomputed tomography and CT-based rigidity analyses were performed to assess cortical and trabecular bone structure, density, and rigidity. Bones were loaded to failure with three-point bending to assess strength. Contrast-enhanced µCT imaging of mouse femurs was performed to measure glycosaminoglycan content, thickness, and volume of the femoral head articular cartilage. Advanced glycation end products were assessed with a fluorometric assay. The changes demonstrated in the cortical bone structure, rigidity, stiffness, and modulus of the HGPS G608G mouse model may increase the risk for bending and deformation, which could result in the skeletal dysplasia characteristic of HGPS. Cartilage abnormalities seen in this HGPS model resemble changes observed in the age-matched WT controls, including early loss of glycosaminoglycans, and decreased cartilage thickness and volume. Such changes might mimic prevalent degenerative joint diseases in the elderly. Lonafarnib monotherapy did not improve bone or cartilage parameters, but treatment combinations with pravastatin and zoledronic acid significantly improved bone structure and mechanical properties and cartilage structural parameters, which ameliorate the musculoskeletal phenotype of the disease.

KIRSCHNER WIRE VERSUS TITANIUM ELASTIC NAILS IN PEDIATRIC FEMORAL SHAFT FRACTURES

OBJECTIVE

To evaluate the effectiveness of intramedullary fixation using the Kirschner-wire (K-wire) compared to the titanium elastic nail (TEN) in pediatric femoral shaft fractures.

METHODS

A sample of 42 pediatric patients with a mean age of 6.55±2.42 years (range 4-11 years) presenting femoral shaft fractures underwent intramedullary fixation using the K-wire or TEN.

RESULTS

There was no significant difference found between groups, of which 16 (38.1%) patients were treated with K-wire and 26 (61.9%) patients were treated with TEN in terms of union duration. Moreover, none of the patients showed nonunion or a delayed union.

CONCLUSIONS

The use of adjusted K-wire instead of TEN in the intramedullary fixation of femoral shaft fractures in selected children may be an advantageous surgical option due to the lower cost, easy accessibility and no need for a second surgery for implant removal. Level of Evidence III, Retrospective Study.

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.

Comparative Study Using Intramedullary K-wire Fixation Over Titanium Elastic Nail in Paediatric Shaft Femur Fractures

BACKGROUND

Fracture shaft femur is common paediatric trauma leading to significant morbidity. Conservative treatments available are associated with prolonged periods of immobilization. Use of flexible intramedullary implant allows early rehabilitation in diaphyseal fractures of femur in children.

AIM

The aim of the present study is to compare fixation of diaphyseal femur fracture by titanium elastic nail and intramedullary K-wires in children.

SETTING AND DESIGN

Prospective randomized study in a tertiary care hospital.

MATERIAL AND METHODS

Fifty-two children between 6 years and 14 years of age with femoral shaft fracture were assigned either in Group I or Group II based on computer generated random numbers. In Group I closed percutaneous intramedullary K- wire fixation and in Group II closed percutaneous intramedullary titanium elastic nail was used to fix the fractures. Partial weight bearing was allowed after 6 weeks of surgery and full weight bearing at clinico-radiological union.

RESULTS

Average time of radiological union was 6 to 10 weeks in both groups. In both the groups two cases had entry site irritation which resolved with early implant removal. One case in both the groups had unacceptable mal-alignment. Both the groups had few cases of limb-length discrepancy, which was in acceptable limit, except two cases of TENS. There was no statistically significant difference between the results of both the groups. But, using K-wires significantly reduced the cost of treatment.

CONCLUSION

Most of such fractures in our society are neglected because of high cost of treatment. Providing a cheaper alternative in form of K-wires may be beneficial for the patients from low socio-economic status.

Percutaneous Kirschner wire (K-wire) fixation for humerus shaft fractures in children: A treatment concept

BACKGROUND

Fractures of the humeral shaft are uncommon, representing less than 10 percent of all fractures in children. Humeral shaft fractures in children can be treated by immobilisation alone. A small number of fractures are unable to be reduced adequately or maintained in adequate alignment, and these should be treated surgically. In the present study, Kirschner wires (K-wire) were used to achieve a closed intramedullary fixation of humeral shaft fractures. The objective of this study was to evaluate the efficacy of intramedullary K-wires for the treatment of humeral shaft fracture in children.

PATIENTS AND METHODS

This prospective study was conducted in the Department of Orthopaedic surgery in M. M. Medical College from June 2005 to June 2010. Sixty-eight children with a mean age of 7.7 years (range, 2-14 years) were recruited from Emergency and out patient department having closed fracture of humerus shaft. All patients were operated under general anaesthesia. All patients were followed for 12 months.

RESULTS

Out of 68 patients, 64 patients underwent union in 42-70 days with a mean of 56 days. Complications found in four patients who had insignificant delayed union which were united next 3 weeks. Intramedullary K-wires were removed after an average of 5 months without any complications. The results were excellent in 94.11% and good in 5% children.

CONCLUSION

This technique is simple, quick to perform, safe and reliable and avoids prolonged hospitalization with good results and is economical.

Percutaneous k-wire fixation for femur shaft fractures in children: a treatment concepts for developing countries

Background:

Fractures shaft femur is a major cause of morbidity and mortality in patients with lower extremity injuries.

Aims:

The aim of this study was to evaluate the efficacy of intramedullary Kirschner wires for the treatment of femoral shaft fracture in children.

Subjects and Methods:

This prospective study was conducted in the Department of Orthopaedic surgery in M. M. Medical College from June 2005 to June 2010. Sixty eight children with a mean age of 7.7 years (range, 2-14 years) were recruited from Emergency and out patient department having closed fracture of femoral shaft. All patients were operated under general anesthesia. All patients were followed for twelve months.

Results:

Out of sixty eight patients, sixty four patients underwent union in 42 to 70 days with a mean of 56 days. Touch down weight bearing was started on 2^nd post-operative day. Complications found in four patients who had insignificant delayed union which were united next three weeks. Intramedullary Kirschner-wires were removed after an average of five months without any complications. The results were excellent in 94.1% (64/68) and good in 5.8% (4/68).

Conclusion:

This technique is simple, quick to perform, safe and reliable and avoids prolonged hospitalization with good results and is economical.

Traction table-related complications in orthopaedic surgery

Traction tables are used in numerous procedures about the hip and femur, including fracture fixation, hip arthroscopy, and less invasive arthroplasty. The use of a traction table is not without risks, however, and significant complications have been described, including injury to the perineal integument and soft tissues, neurologic impairment, and iatrogenic compartment syndrome of the well leg. The orthopaedic surgeon who uses a traction table for the surgical management of femur fracture must be familiar with the associated potential dangers and risks and must develop a plan to avoid traction table-associated complications, such as use of a radiolucent flat-top operating table for obese patients, adequate patient positioning, and the minimum possible surgical time.

Flexible nailing of fractures in children using stainless steel Kirschner wires

Elastic titanium nails are widely used for the established procedure of Elastic Stable Intramedullary Nailing (ESIN), but are costly. Thirty-five diaphyseal fractures in various long bones in children were treated by flexible nailing using stainless steel Kirschner (K) wires. The results were comparable with reports by other authors using titanium nails and stainless steel K wires. Cost-effective K wires and instrumentation are easily available. A stainless steel K wire is 92% cheaper than a Nancy nail and 84% cheaper than a Synthes titanium elastic nail. K wires can be used for flexible nailing of fractures in children with results comparable with those after using titanium nails.

Intramedullary Kirschner wire (K-wire) fixation of femoral fracture in children

PURPOSE

The aim of this study was to evaluate the efficacy of standard intramedullary Kirschner wires (K-wires) for the treatment of femoral shaft fracture in children.

METHODS

We report the results of intramedullary K-wires nailing in 178 children with a mean age of 7.7 years (range, 4-14 years) from 2000 to 2005, retrospectively. A total of 184 diaphyseal femoral fractures were treated with both antegrade and retrograde nailing using the same principles of elastic stable intramedullary nailing (ESIN). The patients were followed for 12 months on average (range, 6-24 months).

RESULTS

No major complication (limb length discrepancy >15 mm, non-union, avascular necrosis, knee joint stiffness) occurred during the observation period. All fractures healed within 7.1 weeks on average (range, 5-12 weeks). Associated injuries were seen in 16.9% of the cases. All but seven fractures were reduced by closed manipulation. Early mobilization and weight bearing was allowed. Intramedullary K-wires were removed after an average of 4.8 months (range, 3-12 months) without any complications.

CONCLUSIONS

In children, intramedullary fixation by using standard K-wires provides effective treatment for the diaphyseal femoral fracture that has excellent clinical results. Each intramedullary K-wire costs US $5, which adds a cost effective advantage to this method of treatment.

Treatment of femoral shaft fractures in children using intramedullary Kirschner wire pinning

From 1996 to 2002 we used intramedullary Kirschner wires to treat 19 femoral shaft fractures in 19 children (11 boys, 8 girls). Their ages ranged from 2 to 13 years (mean 5.8 years). The mean follow-up time was 3 years (range 4 months to 4 years 9 months). The technique was intramedullary pinning using a 2.5- to 3.0-mm Kirschner wire introduced through the greater trochanter followed by spica casting. All cases achieved bone union within 3 months. The mean angular deformity was 1.7 degrees (range 0 degrees -5 degrees ), and one patient had an external rotational deformity. The mean overgrowth was 7.5 mm, but no patient had residual problems during activities of daily living. Our method has the following advantages: no need of traction, leaving bed earlier, ease of nursing, fewer radiographic examinations, less angular deformity. It also has several disadvantages: the need for an operation under general anesthesia, the need for metal removal, and an operation scar. This method can be considered as one option for treating femoral shaft fractures in children.

Internal fixation of femoral shaft fractures in children by intramedullary Kirschner wires (a prospective study): its significance for developing countries

BACKGROUND

To evaluate internal fixation by intramedullary Kirschner wires as a surgical technique in the treatment of femoral shaft fractures in children by a prospective study.

METHODS

17 femoral shaft fractures at various levels in 16 children aged 2-15 years were treated by closed intramedullary Kirschner wiring under image intensifier control between May 2000 and October 2003. No external splint was used.

RESULTS

Fracture union was achieved in 6-14 weeks. Non-weight bearing crutch walking was started 2-3 days after surgery. Full weight bearing started 6-14 weeks. Average operative time was 40 min (range 20-72 min). Wires were removed after 8-22 weeks. There were no infections, no limb length disparity. One child had pin track ulceration. A big child of 14 years had angulation of the fracture.

CONCLUSION

Intramedullary nailing of femoral shaft fractures in children by stainless steel Kirschner wires is an effective method, which compares well with other studies. It is a simple procedure, which can be easily reproduced. Blood loss is minimal, and the operative time short. There is no need pre-bend the wires in a C or S curve. Stainless steel Kirschner wires are cheap, universally available, and can be manufactured locally. The cost of Image intensifiers is affordable in most of the cities of the developing countries. The hospital does not have to maintain a costly inventory. Provides early mobility, return to home and, school. Gives a predictable clinical pathway and reduces occupancy of hospital beds. The technique was successfully applied for internal fixation of other diaphyseal fractures in children and some selected diaphyseal fractures in adults. Based on my experience and a review of the literature, I recommend this technique as a modality for treatment of femoral shaft fractures in children aged 2 to 14 years.