Internal fixation of femoral shaft fractures in children and adolescents: a ten- to twenty-one-year follow-up of 52 fractures

Rigid intramedullary nail fixation of traumatic femoral fractures in the skeletally immature

Objective

To determine the rate of femoral head osteonecrosis, and other complications following rigid intramedullary (IM) nail fixation of traumatic diaphyseal femur fractures through the greater trochanter in the skeletally immature.

Design

Retrospective review, case series.

Setting

Level I academic trauma center.

Patients/Participants

One hundred forty-eight traumatic pediatric diaphyseal femur fractures in 145 patients treated with rigid IM nail fixation from November 1, 2004 to December 31, 2018.

Intervention

Rigid intramedullary nail fixation of traumatic diaphyseal femur fractures through a trochanteric start point in the skeletally immature.

Main outcome measurement

Rate of osteonecrosis of the femoral head.

Results

Sixty-five fractures in 64 skeletally immature patients met inclusion criteria. Motor vehicle collisions were implicated in 32 fractures. Of the 65 fractures, 5 were open. All rigid IM nails were anterograde with a trochanteric start point. Mean radiographic follow-up was 27.4 ± 8.1 months. Twenty-two patients experienced postoperative pain and/or hardware irritation, with 24 patients (36.9%) undergoing reoperation for hardware removal. No occurrences of infection, malunion, nonunion, refracture, venous thromboembolism, fat embolism, significant leg length discrepancy, or femoral head osteonecrosis were documented. Two cases of heterotopic ossification were observed, 1 requiring surgical excision, yielding a complication rate of 3.1%.

Conclusions

No cases of femoral head osteonecrosis were observed following treatment of 65 traumatic diaphyseal femur fractures with rigid IM nailing through the greater trochanter with a mean radiographic follow-up of 27 months. Rigid IM nail fixation with a trochanteric start point is both safe and efficacious for management of diaphyseal femur fractures in the skeletally immature.

Retrospective, multicenter evaluation of complications in the treatment of diaphyseal femur fractures in pediatric patients

INTRODUCTION

Femoral shaft fractures are the commonest major pediatric fractures. For generations, traction and casting were the standard method of treatment for children. However, over the past two decades there has been growing recognition of the advantages of fixation and rapid mobilization.

METHODS

A prospective multicenter study was conducted at four Italian centers of reference for pediatric fractures (January 2005 to December 2014). The study involved 62 patients of both sexes, between 6 and 14 years of age, with closed femoral shaft fractures. The aim was to find out more about the short-term complications of titanium elastic nailing in diaphyseal femur fractures in children in order to reduce them.

RESULTS

The commonest complication observed in our study was pain at the nail entry point (24.19%) due to a local inflammatory reaction. After 1 year, 3.22% had limbs of different lengths. Proximal migration occurred in 1.61% of cases.

DISCUSSION

Over the last two decades, the treatment of femoral shaft fractures in pediatric patients has developed to include internal fixation using Titanium Elastic Nails (TEN). We only observed a few complications in our study, most of which were minor and associated with the surgical technique employed, particularly during the initial phase of the surgeon's learning curve.

CONCLUSIONS

TEN are an excellent internal fixation system if used by an expert surgeon and have a very low rate of complications. None of them produced permanent damage in the patients. In older children weighing more than 50 kg, alternative techniques such as subtrochanteric nailing, plates, or external fixation are advisable.

Pediatric Diaphyseal Femur Fractures: Submuscular Plating Compared With Intramedullary Nailing

This study compared the radiographic and clinical outcomes of pediatric diaphyseal femur fractures treated by submuscular plating, flexible retrograde intramedullary nailing, or rigid antegrade intramedullary nailing with a trochanteric entry point in skeletally immature patients who were 8 years and older. A retrospective review was conducted of skeletally immature patients 8 years and older who were treated for femur fracture with submuscular plating, flexible intramedullary nailing, or rigid intramedullary nailing from 2001 to 2014 with a minimum 12-week follow-up. Treatment outcomes were compared for statistical significance, including time to union, malunion, nonunion, heterotopic ossification, avascular necrosis, time to full weight bearing, limb length discrepancy, residual limp, painful hardware, and infection. The study identified 198 femur fractures in 196 patients (mean age, 11.9 years). Each femur fracture was treated with submuscular plating (35), flexible intramedullary nailing (61), or rigid intramedullary nailing (102). Mean follow-up across the cohort was 48 weeks, ranging from 12 to 225 weeks. Flexible nailing was associated with an increased incidence of malunion (P<.0001) and hardware irritation (P=.0204) and longer time to full weight bearing (P=.0018). Rigid nailing was associated with an increased incidence of limp at 12-week followup (P=.0412). Additionally, 23.5% of patients who were treated with rigid nailing had heterotopic ossification. Of all surgical methods, submuscular plating allowed for the most rapid return to full weight bearing (mean, 7 weeks) and offered the fastest healing rate (mean, 6 weeks). Submuscular plating resulted in faster times to union and full weight bearing, with minimal complication rates. Rigid intramedullary nailing with trochanteric entry resulted in a lower incidence of malunion and hardware-related complications; however, these patients had an increased incidence of heterotopic ossification and residual limp postoperatively. Flexible retrograde intramedullary nailing resulted in the highest rates of malunion and hardware irritation and the longest time to full weight bearing. [Orthopedics. 2016; 39(6):353-358.].

Comparison between external fixation and elastic stable intramedullary nailing for the treatment of femoral shaft fractures in children younger than 8 years of age

The main objective of this study was to compare external fixation (EF) with elastic stable intramedullary nailing (ESIN) for the treatment of femoral shaft fractures in children aged 8 or younger. Fifteen children with femoral shaft fractures treated by EF and 23 children with femoral shaft fractures treated by ESIN were retrospectively reviewed. All patients were pain free at the last follow-up, with good ranges of motion in the hip and knee. Partial and full weight bearing occurred sooner in patients treated with EF than with ESIN, although more polytrauma patients were present in the ESIN group. In conclusion, EF and ESIN can be considered as safe and effective methods for femoral shaft fracture treatment in children younger than 8 years of age.

Rigid Intramedullary Nailing of Femoral Shaft Fractures for Patients Age 12 and Younger: Indications and Technique

Femoral shaft fractures are common injuries in the pediatric and adolescent age groups. Rigid intramedullary nailing is an excellent treatment option for older children and adolescents, particularly for length-unstable fractures and larger patients (>49 kg). Appropriate indications, contraindications, and preoperative assessment are described. The rigid nailing surgical technique is detailed including positioning, operative steps, pearls, and pitfalls. Complications and the reported outcomes of lateral trochanteric entry nailing are reviewed from the published series.

Titanium elastic nailing in pediatric femoral diaphyseal fractures in the age group of 5-16 years - A short term study

BACKGROUND

Management of femoral diaphyseal fracture in the age group of 5-16 years is controversial. The purpose of this study is to demonstrate the effectiveness of intramedullary fixation of femoral shaft fractures by using titanium elastic nailing system (TENS).

MATERIALS AND METHODS

Between April 2011 and April 2014, 40 pediatric patients (31 boys, 9 girls) aged 5-16 years with diaphyseal femoral fractures were treated by retrograde TENS fixation. Fractures were classified according to system of Winquest and Hansen as Grade-I (n = 18), Grade-II (n = 10), Grade-III (n = 7) and compound fractures according to the Gustilo and Anderson's classification Grade-I (n = 3), Grade-II (n = 2). The final results were evaluated by using Flynn's criteria.

RESULTS

The mean duration of follow-up was 21 months (range 3-39 months). All fractures were radiologically united with grade 3 callus formation at 8-10 weeks period (mean 9 weeks) and full weight bearing was possible in a mean time of 9.5 weeks. According to Flynn's criteria, excellent result was found in 33 patients (82.5%) and satisfactory in 7 patients (17.5%). Limb lengthening was noticed in 6 cases, varus mal-alignment was in 4 cases and rotational mal-alignment was seen in 3 cases. Peri-operative difficulties encountered were failure of closed reduction in 4 cases and cork screwing of nails in 2 cases.

CONCLUSION

TENS is a safe and effective method for the treatment of pediatric femoral shaft fractures, because it is minimally invasive, relatively easy to use and shows very good functional and cosmetic results.

Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients Using a Lateral Trochanteric Entry Portal

Introduction

We describe rigid intramedullary nailing using a trochanteric entry for internal fixation of femoral shaft fractures in older children and adolescents.

Step 1 Preparation Prior to Incision

Appropriate preparation prior to the operation is key to minimizing intraoperative and postoperative complications.

Step 2 Perform Incision and Exposure

A well-positioned incision will facilitate and reduce difficulty with ideal guidewire placement.

Step 3 Place and Overream the Guide Pin

Ensure that the guide pin is properly positioned on the greater trochanter, while avoiding the piriformis fossa.

Step 4 Place the Guidewire and Reduce the Fracture

Prepare the definitive guidewire. Insert the guidewire into the proximal fragment via the trochanteric portal. While maintaining the fracture reduction, advance the guidewire into the distal fragment.

Step 5 Measure Nail Length and Begin Overreaming

Pay careful attention to the amount of reaming as well as distraction across the fracture site to provide the best fit for the nail.

Step 6 Insert the Nail

Be sure to maintain the reduction while advancing the nail across the fracture site. Reconfirm that traction has been reduced to avoid distraction at the fracture site.

Step 7 Insert Proximal and Distal Interlocks

Use the interlocking screws to secure the proper rotational alignment.

Step 8 Make Final Images and Close the Wound

Confirm the reduction and adequate fixation before closure.

Results

In our original study, a cohort of 246 femoral shaft fractures among 241 skeletally immature patients treated with trochanteric entry rigid intramedullary nailing was retrospectively reviewed.IndicationsContraindicationsPitfalls & Challenges.

Twenty-Year Experience with Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients

BACKGROUND

Debate exists over the safety of rigid intramedullary nailing of femoral shaft fractures in skeletally immature patients. The goal of this study was to describe functional outcomes and complication rates of rigid intramedullary nailing in pediatric patients.

METHODS

A retrospective review was performed of femoral shaft fractures in skeletally immature patients treated with trochanteric rigid intramedullary nailing from 1987 to 2009. Radiographs made at initial injury, immediately postoperatively, and at the latest follow-up were reviewed. Patients were administered the Nonarthritic Hip Score and a survey.

RESULTS

The study population of 241 patients with 246 fractures was primarily male (75%) with a mean age of 12.9 years (range, eight to seventeen years). The majority of fractures were closed (92%) and associated injuries were common (45%). The mean operative time was 119 minutes, and the mean estimated blood loss was 202 mL. The mean clinical follow-up time was 16.2 months (range, three to seventy-nine months), and there were ninety-three patients with a minimum two-year clinical and radiographic follow-up. An increase of articulotrochanteric distance of >5 mm was noted in 15.1% (fourteen of ninety-three patients) at a minimum two-year follow-up; however, clinically relevant growth disturbance was only observed in two patients (2.2%) with the development of asymptomatic coxa valga. There was no femoral head osteonecrosis. Among the 246 fractures, twenty-four complications (9.8%) occurred. At the time of the latest follow-up, 1.7% (four of 241 patients) reported pain. The average Nonarthritic Hip Score was 92.4 points (range, 51 to 100 points), and 100% of patients reported satisfaction with their treatment.

CONCLUSIONS

Rigid intramedullary nailing is an effective technique for treatment of femoral shaft fractures in pediatric patients with an acceptable rate of complications.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Rigid intramedullary nail fixation of femoral fractures in adolescents: what evidence is available?

Background

Femoral fracture in adolescents is a significant injury. It is generally agreed that operative fixation is the treatment of choice, and rigid intramedullary nail fixation is a treatment option. However, numerous types of rigid nails to fix adolescent femoral fractures have been described. Hence, the aim of this paper was to collate and evaluate the available evidence for managing diaphyseal femoral fractures in adolescents using rigid intramedullary nails.

Materials and methods

A literature search was undertaken using the healthcare database website (http://www.library.nhs.uk/hdas). Medline, CINAHL, Embase, and the Cochrane Library databases were searched to identify prospective and retrospective studies of rigid intramedullary nail fixation in the adolescent population.

Results

The literature search returned 1,849 articles, among which 51 relevant articles were identified. Of these 51 articles, 23 duplicates were excluded, so a total of 28 articles were reviewed. First-generation nails had a high incidence of limb length discrepancy (Küntscher 5.8 %, Grosse–Kempf 9 %), whilst second-generation nails had a lower incidence (Russell–Taylor 1.7 %, AO 2.6 %). Avascular necrosis was noted with solid Ti nails (2.6 %), AO femoral nails (1.3 %) and Russell–Taylor nails (0.85 %). These complications have not been reported with the current generation of nails.

Conclusions

Rigid intramedullary nail fixation of femoral fractures in adolescents is a useful procedure with good clinical results. A multiplanar design and lateral trochanteric entry are key to a successful outcome of titanium alloy nail fixation.

Intramedullary nailing of femoral fractures in children through the lateral aspect of the greater trochanter using a modified rigid humeral intramedullary nail: preliminary results of a new technique in 15 children

OBJECTIVES

To evaluate the clinical results of intramedullary nailing of femoral shaft fractures using a rigid intramedullary nail placed through the lateral aspect of the greater trochanter in older children and adolescents.

DESIGN

A retrospective study was carried out evaluating all skeletally immature patients with femoral shaft fractures treated using a modified rigid humeral intramedullary nail.

PATIENTS/PARTICIPANTS

Fifteen children and adolescents with displaced femoral diaphyseal fractures and open physes.

INTERVENTION

Femoral shaft fractures in children and adolescents were stabilized using a modified humeral intramedullary nail placed through the lateral aspect of the greater trochanter.

MAIN OUTCOME MEASUREMENTS

Patients were evaluated to determine time to union, final fracture alignment, hospital stay, complications, clinical outcome, and proximal femoral changes including avascular necrosis or proximal femoral valgus with femoral neck narrowing.

RESULTS

Fifteen patients were followed for a minimum of 1 year (range 70-157 weeks). The average age of the patients was 12 years and 5 months (range 8 years and 2 months-17 years and 1 month). All fractures healed at a mean of 7 weeks (range 5-14 weeks) after fracture. The average hospital stay for patients with isolated femur fractures (8/15) was 2.8 days (range 1-5 days). At an average follow-up of 141 weeks (range 70-326 weeks), no patient had developed avascular necrosis, femoral neck valgus, femoral neck narrowing, or other complications.

CONCLUSIONS

The technique of intramedullary nailing in children through the lateral aspect of the greater trochanter seems to be safe, effective, and well tolerated by patients.