Adverse sequelae due to plate retention following submuscular plating for pediatric femur fractures

Distal Femur Valgus Deformity After Rigid Intramedullary Nailing of Adolescent Femoral Shaft Fracture

A 12-year-old girl developed a distal femoral shaft fracture treated with lateral trochanteric entry intramedullary nail fixation. The nail was retained after union because of a persistent nonossifying fibroma at the previous fracture site. At 16 months after surgery, marked valgus deformity was noted at the distal femur, with signs of implant haloing and loosening, suggesting repetitive motion and stress concentration of forces at the distal femur. Owing to recognition before skeletal maturity, the valgus was corrected with hemiepiphysiodesis. This finding illustrates the importance of follow-up up to skeletal maturity for pediatric femoral shaft fractures and consideration of routine removal of implants after fracture union to avoid this previously unreported complication.

Submuscular Plating Versus Elastic Intramedullary Nailing in Children with Femoral Shaft Fracture; a systematic review and meta-analysis

Introduction

Elastic stable intramedullary nailing (ESIN) is currently the technique of choice for pediatric femoral fractures. Submuscular plating (SMP) allows reliable healing associated with an early range of motion. The following systematic review and meta-analysis was carried out to reveal the functional and surgical outcomes of SMP and ESIN for fixation of pediatric femoral fractures and to aid in the decision-making processes for those who perform these procedures.

Methods

An extensive systematic literature review was implemented from inception to 23 February 2022. All clinical studies included had patients that were younger than 18 years old with femoral shaft fractures that compared outcomes between SMP and ESIN. Studies including patients with pathological fractures, closed femoral physis, multiple fractures, or refractures were excluded.

Results

This meta-analysis included six articles encompassing 568 patients. Of them, 206 patients were treated with SMP, while 362 were subjected to ESIN procedure. There was significantly more blood loss among patients treated with SMP (MD -45.45; 95% -61.62, -29.27; p < 0.001). The risk of postoperative adverse surgical events was significantly higher among patients subjected to the ESIN (RR 2.97 19.5; 95% 1.27, 6.98; p = 0.01). The mean hospital stay was significantly shorter among patients subjected to ESIN (SMD -1.47; 95% -2.43, -0.51; p = 0.003). Patients subjected to SMP showed significantly more EFOs when comparing Flynn Scores (OR 0.24; 95% 0.09, 0.64; p = 0.004). There was no significant difference between SMP and ESIN regarding the mean operation time, limb length discrepancy, and mean time to union.

Conclusions

Children with femoral shaft fractures can be managed effectively and safely with SMP. There was a similar surgical outcome between SMP and ESIN, but SMP had more EFOs. While SMP was associated with a low risk of postoperative adverse surgical events, it was associated with a more significant blood loss and prolonged hospital stays.

PROXIMAL HUMERAL LOCKING PLATE: A VIABLE ALTERNATIVE FOR FIXATION OF DISTAL FEMORAL FRACTURES IN CHILDREN

Distal femoral metaphyseal fractures are rare in children, and the proximity of the fracture to the growth plate makes their approach challenging.

Objective

Evaluate outcomes and complications of treatment of distal femoral metaphyseal fractures in children with proximal humeral locking plates.

Method

Retrospective study between 2018 and 2021, including seven patients. The analysis included general characteristics, trauma mechanism, classification, clinical and radiographic outcomes, and complications.

Results

The mean follow-up was 20 months, the average age was nine years, five patients were boys, and six fractured on the right side. Five fractures were caused by car accidents, one by falling from their own height and one by playing soccer. Five fractures were classified as 33-M/3.2 and two as 33-M/3.1. Three fractures were open, Gustilo IIIA. All seven patients recovered mobility and resumed their pre-trauma activities. All seven healed, and one fracture was reduced to 5 degrees valgus, without any other complications. Six patients had the implant removed and did not present refracture.

Conclusion

Treatment of distal femoral metaphyseal fractures with proximal humeral locking plates is a viable option that offers good results and fewer complications, saving the epiphyseal cartilage. Level of Evidence II; Controlled study without randomization.

Load-bearing composite fracture-fixation devices with tailored fibre placement for toy-breed dogs

Fibre reinforced composites are attractive materials for hard tissue reconstructions, due to the high strength and low flexural modulus. However, lack of contourability in the operation theatre inhibits their clinical applications. The study presents a novel in situ contourable composite implant system for load-bearing conditions. The implant system consists of a thin bioresorbable shell with several cavities, much like bubble-wrap. The central cavity contains a semi-flexible glass fibre preform prepared using Tailored Fibre Placement method. The preform is either pre-impregnated with a light curable resin, or the resin is injected into the cavity during the surgical procedure, followed by light curing. The semi-flexible glass fibre preforms were also examined as separate devices, "miniplates". Two types of miniplates were scrutinized, a simplified pilot design and a spatially refined, "optimized" design. The optimized miniplates were implemented as biostable and bioresorbable versions. The feasibility of the in situ contourable composite implant system was demonstrated. The potential of Tailored Fibre Placement for the semi-flexible glass fibre preforms and miniplates was confirmed in a series of biomechanical tests. However, structural optimization is required. Antebrachial fractures in toy-breeds of dogs are exemplar veterinary applications of the devices; further applications in veterinary and human patients are foreseen.

Pediatric fractures following implant removal: A systematic review

OBJECTIVES

To evaluate the available literature for postoperative fracture rates following implant removal in the pediatric population.

METHODS

A systematic review of articles in the PubMed and Embase computerized literature databases from January 2000 to June 2022 was performed using PRISMA guidelines. Randomized controlled trials, case-control studies, cohort studies (retrospective and prospective), and case series involving pediatric patients that included data on fracture rate following removal of orthopedic implants were eligible for review. Two authors independently extracted data from selected studies for predefined data fields for implant type, anatomic location of the implant, indication for implantation, fracture or refracture rate following implant removal, mean time to implant removal, and mean follow-up time.

RESULTS

Fifteen studies were included for qualitative synthesis. Reported fracture rates following implant removal vary based on several factors, with an overall reported incidence of 0%-14.9%. The available literature did not offer sufficient data for conduction of a meta-analysis.

CONCLUSION

Our systematic review demonstrates that fracture following implant removal in pediatric patients is a relatively frequent complication. In children, the forearm and femur are the most commonly reported sites of fracture following removal of implants. Traumatic fractures treated definitively with external fixation have the highest reported aggregate rate of refracture. Knowledge of the incidence of this risk is important for orthopedic surgeons. There remains a need for well-designed studies and trials to further clarify the roles of the variables that contribute to this complication.

Effect of Length Stability on Complications in the Treatment of Preadolescent Diaphyseal Femur Fractures Treated With Elastic Stable Intramedullary Nailing

OBJECTIVES

To examine the effectiveness and complication rates in age- and size-appropriate patients with either stable or unstable fracture patterns treated with elastic stable intramedullary nailing (ESIN).

DESIGN

Retrospective case series.

SETTING

Academic tertiary care children's hospital.

PATIENTS/PARTICIPANTS

This was a consecutive series of 106 preadolescent children with femoral shaft fractures. The mean age of the patients was 8.0 years (range, 4.0-16.0 years).

INTERVENTION

All children were treated by retrograde ESIN.

MAIN OUTCOME MEASURES

Fractures were categorized as either length stable or unstable. Length stability and complications were assessed. A subset of patients with final full-length, standing x-rays was also evaluated.

RESULTS

We analyzed 63 stable and 43 length unstable fractures. The mean age and weight of the patients with stable and unstable fractures were similar. There was no difference in complication rates between groups (χ2(1) = 0.00, P = 0.99). There was no difference (t(96.93) = 0.53, P = 0.59) in femoral shaft length change. Leg length discrepancies as assessed by full-length standing radiographs at follow-up were similar (χ2(2) = 1.52, P = 0.47).

CONCLUSIONS

Preadolescent children younger than 10 years do not experience increased complications after ESIN of length unstable femur fractures [odds ratio (OR) = 1.68 (0.18-16.87), P = 0.65]. Length unstable femur fractures are not at increased risk of more complications [OR = 0.90 (0.26-2.92), P = 0.87], early femoral shortening [OR = (0.42-2.02), P = 0.85], or leg length discrepancy [OR = (0.13-1.56), P = 0.21] when treated with ESIN.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for complete description of levels of evidence.

Indications for and Risks Associated With Implant Removal After Pediatric Trauma

A wide range of implants are used in the treatment of pediatric fractures, including wires, plates, screws, flexible rods, rigid rods, and external fixation devices. Pediatric bones differ from adult bones both mechanically and biologically, including the potential for remodeling. Implants used in pediatric trauma patients present a unique set of circumstances regarding indications, risks, timing of implant removal, weight-bearing restrictions, and long-term sequelae. Indications for implant removal include wire/pin fixation, when substantial growth remains, and infection. When considering implant removal, the risks and benefits must be assessed. The primary risk of implant removal is refracture. The timing of implant removal varies widely from several weeks to a year or more with the option of retention depending on the fracture, type of implant, and skeletal maturity of the patient.

Outcomes of Hardware Removal Surgery for Children

Hardware removal is among the most common orthopedic procedures performed in the United States. The goal of this study was to report the outcomes of deep hardware removal for children. This study received institutional review board approval. Patients younger than 18 years who underwent deep hardware removal between 2007 and 2017 were studied. We reviewed 227 procedures involving 132 boys and 95 girls. Mean follow-up was 25 months (range, 14-36 months). Mean age at the time of surgery was 12.8 years (range, 2-17 years). Mean time from initial surgery to hardware removal was 8.4 months (range, 1-72 months). Of the 227 cases, 75 used a tourniquet. Mean tourniquet time was 30.1 minutes (range, 1-118 minutes). Mean length of surgery was 44.0 minutes (range, 4-173 minutes). Mean resident level performing the surgery was postgraduate year 3 (range, postgraduate year 2 to fellow). There were 3 complications. Locations of the implanted hardware included: femur, 85; humerus, 49; tibia, 46; hip/pelvis, 17; ulna, 11; miscellaneous foot, 10; radius, 6; and fibula, 3. Indications for surgery included surgeon recommendations in 122 cases; symptomatic hardware in 68 cases, and parent wishes in 37 cases. Hardware removal for children was safe, and the outcomes were excellent. Complications of hardware removal at a teaching hospital can be minimized when a more senior resident is the primary surgeon. Despite the challenging and historically troublesome nature of deep hardware removal, the current study shows that hardware removal for children is safe and effective. [Orthopedics. 2022;45(2):e91-e95.].

Health-Related Quality of Life after Adolescent Fractures of the Femoral Shaft Stabilized by a Lateral Entry Femoral Nail

(1) Background: In adolescents, fractures of the femoral shaft that are not suitable for elastic-stable-intramedullary-nailing (ESIN), are challenging. We aimed to evaluate the health-related quality of life (HRQoL) and complications in adolescents treated with intramedullary rodding using the adolescent lateral trochanteric entry femoral nail (ALFN), and to assess if HRQoL was associated with additional injuries. (2) Methods: We followed-up on 15 adolescents with a diaphyseal femoral fracture who were treated with an ALFN from 2004 to 2017. Patients were asked to fill in a questionnaire that includes the iHOT, Peds-QL, and the Pedi-IKDC. (3) Results: The ALFN was used as a primary method of fixation in 13 patients, and as a fixation for failed ESIN in two cases. All 15 fractures healed radiographically. One distal locking screw broke. After a mean follow-up of 2.8 years, the mean iHOT-12 was 14.0 (SD 15.4), PedsQL-function was 85.7 (SD 19.3), PedsQL-social-score was 86.2 (SD 12.5), and the mean Pedi-IKDC was 77.2 (SD 11.3). In patients where the femoral fracture was an isolated injury, the HRQoL-scores were consistently higher compared with patients who sustained additional injures. (4) Conclusions: Treating diaphyseal fractures in adolescents with an ALFN resulted in good radiographic outcomes in all our cases. HRQoL, as measured by the iHOT, PedsQL, and Pedi-IKDC, was good to excellent; but it was consistently inferior in patients with additional injuries. These results suggest that the ALFN is a good alternative when patients are not suitable for ESIN, and that the HRQoL of adolescents who were treated with an ALFN is mainly influenced by the presence of additional injures, and less by the fracture of the femur itself.

Expert Consensus for a Principle-based Classification for Treatment of Diaphyseal Pediatric Femur Fractures

INTRODUCTION

Recent studies demonstrate considerable deviation from the American Academy of Orthopaedic Surgeons (AAOS) evidence-based guidelines for the treatment of pediatric diaphyseal femur fractures (PDFFs). This study aimed to determine if expert-consensus can be reached on a principle-based classification to be applied broadly to a wide variety of PDFF scenarios and if outcomes correspond to adherence to the classification.

METHODS

A 2-stage study was performed. First, a survey of experts using a principle-based approach to PDFF. We conducted a survey of 17 thought-leaders (criteria≥20 y' experience+authors of the seminal pediatric femur fracture studies) who were asked to classify 15 cases of PDFF using the principle-based classification for agreement. Next, we conducted a retrospective review of 289 consecutive PDFF treated (2011-2015) at a level 1 pediatric trauma center. For each case, we compared the actual treatment and proposed "ideal" principle-based classification. We then compared clinical results and outcome data points including the length of stay, physician visits, and hospital charge data.

RESULTS

A substantial (κ=0.7) expert-agreement was noted for assigning treatment principles with near-perfect (κ=0.93) agreement on conservative versus surgical management. We obtained agreement on employing a flexible implant (κ=0.84) rigid fixation (κ=0.75) and damage control philosophy (κ=0.64). Suboptimal clinical results were noted in 43% of the undertreated patients (24/56), 18.8% of the adequately treated, and 14.3% of overtreated (P<0.01) patients. An increasing trend for the length of hospital stay and a number of clinic visits was noted as the treatment class increased (P<0.01). Charges were 4.2 times higher for an episode of operative versus nonoperative care (P<0.01). Rigid fixation (class 4) had significantly (P=0.01) higher total and material charges than flexible fixation (class 3).

DISCUSSION

The proposed classification has a substantial agreement among thought-leaders. Clinical results demonstrated significantly more suboptimal results in undertreated fractures, compared with ideally treated or more invasively treated fractures. More invasive treatments led to increased burden to families and the system in terms of length of stay and hospital charges.

LEVEL OF EVIDENCE

Level III.

Overgrowth of the Femur After Internal Fixation in Children With Femoral Shaft Fracture-A Multicenter Study

OBJECTIVES

To evaluate overgrowth after internal fixation for pediatric femur fracture and to identify any factors related with overgrowth in terms of fracture type and fixation method.

DESIGN

Retrospective comparative study.

SETTING

Multicenter, children's hospital and general hospital.

PATIENTS/PARTICIPANTS

Eighty-seven children between 4 and 10 years of age were included. Length-stable fracture was noted in 49 children, and length-unstable fracture was found in 38 children.

INTERVENTION

Thirty-six children were treated by minimal invasive plate osteosynthesis (MIPO), and elastic stable intramedullary nail fixation (ESIN) was used in 51 children.

MAIN OUTCOME MEASUREMENTS

The degree of overgrowth after internal fixation compared to fracture type, fracture site, and surgical method. Multivariable logistic regression analysis was conducted to identify factors related with overgrowth.

RESULTS

The average overgrowth of the femur was 10.5 ± 7.3 mm. There was no patient who required correction for final leg length discrepancy (>2 cm). There was no significant difference in overgrowth between ESIN (9.9 ± 7.2 mm) and MIPO (11.2 ± 7.6 mm) (P = 0.417). Overgrowth was similar among length-unstable fractures (12.3 ± 7.4 mm) and length-stable fractures (9.2 ± 7.0 mm), although it was statistically greater in length-unstable fractures (P = 0.048). In the MIPO group, length-unstable fractures were associated with an increased log odds of 6.873 for overgrowth of the femur (P = 0.042).

CONCLUSIONS

Femur overgrowth after internal fixation seems to not be a clinically significant problem, regardless of whether that be for length-stable or length-unstable fractures and whether they were treated by MIPO or ESIN. Length-unstable fracture may be a risk factor for overgrowth in children. However, the difference is very small, and the postoperative overgrowth would likely not be a significant factor in deciding the surgical plan.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for authors for a complete description of levels of evidence.

Complications in a Young Adult Attributable to a Retained Pediatric Dynamic Hip Screw

Introduction

Orthopedic implants are used for many different conditions in the pediatric population. The literature on hardware removal is controversial and vague.

Case Report

We highlight a young adult male who underwent a dynamic hip screw (DHS) due to a motor vehicle accident at 11 years old. He healed the fracture and did well for years. He was lost to follow-up and the hardware was never removed. The patient presented to our facility with a periprosthetic subtrochanteric proximal femur fracture just distal to the retained hardware. The DHS was removed and the fracture fixed with an intramedullary nail. The patient healed the fracture and did well.

Discussion

A literature review was performed to highlight the benefits and complications of hardware removal vs. retention. We hope to equip the orthopedic surgeon with the reasons for or against hardware removal to optimize treatment to each patient. In this instance, we recommend hardware removal due to the serious consequences of retained hardware in the adolescent/young adult population.

The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Femoral Shaft Fracture Pearls and Pitfalls

Pediatric femoral shaft fractures present many challenging patient care decisions. Nonoperative treatment approaches still dominate care of the youngest age groups while surgical intervention is commonplace in virtually all older children. Treatment is determined primarily by patient age as modified by clinical factors including mechanism of injury, weight, and skeletal maturity. Infants can be successfully treated by placement into a Pavlik harness, whereas children younger than 5 years are most commonly treated by early reduction and spica cast immobilization. Children aged up to 11 years are most commonly treated by flexible intramedullary nailing, whereas older children and adolescents, particularly with length unstable fractures should be treated with more rigid fixation such as lateral entry locked nails or submuscular plating.

Early results using a biodegradable magnesium screw for modified chevron osteotomies

This is the first larger study analyzing the use of magnesium-based screws for fixation of modified Chevron osteotomies in hallux valgus surgery. Forty-four patients (45 feet) were included in this prospective study. A modified Chevron osteotomy was performed on every patient and a magnesium screw used for fixation. The mean clinical follow up was 21.4 weeks. The mean age of the patients was 45.5 years. Forty patients could be provided with the implant, in four patients the surgeon decided to change to a standard metallic implant. The AOFAS, FAAM and pain NRS-scale improved markedly. The hallux valgus angle, intermetatarsal angle and sesamoid position improved significantly. Seven patients showed dorsal subluxation, rotation or medial shifting of the metatarsal heads within the first 3 months. One of these patients was revised, in all others the findings were considered clinically not significant or the patients refused revision. This study shows the feasibility of using magnesium screws in hallux valgus-surgery. Surgeons starting with the use of these implants should be aware of the proper handling of these implants and should know about corrosion effects during healing and its radiographic appearance. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:2207-2214, 2016.

[Femoral shaft fractures in children under 3 years old. Current treatment standard]

INTRODUCTION

Femoral shaft fractures in children are a common injury. Operative treatment is recommended for children above 3 years of age. The question of this investigation was the current clinical standard for the treatment of femoral shaft fractures in children under 3 years old.

MATERIAL AND METHODS

An e-mail questionnaire was sent to all clinics and hospital departments of the members of the German Society for Trauma Surgery and the German Society of Pediatric Surgery.

RESULTS

Out of 775 clinics and departments, 121 participated in the survey (16 %). From 2011 to 2012 overall 756 femoral shaft fractures of children 3 years and younger were treated of which 375 (50 %) were stabilized with elastic stable intramedullary nailing (ESIN), 183 (24 %) with an overhead extension, 178 (23 %) with a plaster cast and 9 (1 %) with external fixation. Finally, operative treatment was used in 51 % compared to 49 % with conservative treatment.

DISCUSSION

Obviously, operative treatment of femoral shaft fractures in children younger than 3 years is routinely used despite the fact that there is no evidential basis for this approach. There are good arguments for and against operative and conservative forms of treatment. Indications for operative treatment include multiple trauma, open fractures, body weight over 20 kg, child already free walking and lack of stable fixation with conservative treatment. To achieve more evidence for the existing recommendation of the American Academy of Orthopaedic Surgeons (AAOS) and the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF, Working Group of the Scientific Medical Specialist Societies), further investigations are needed.

The Targon PH(®) nail for distal femoral fracture fixation in disabled children. A report of three cases

Recommendations for distal femoral fracture treatment in children with neuromuscular disease are various, including conservative, plating, nailing, and ESIN. All methods have disadvantages. Retrograde femoral intramedullary nailing using a statically interlocked Targon PH nail was performed in three cases. A right nail was used for a right femur (and vice versa). A short nail was used for supracondylar fractures, a long nail for distal femoral shaft fractures. Closed reduction was performed in all cases. Despite osteopenia, small bone dimensions and muscle dystrophy, no intraoperative or postoperative complications occurred. All cases achieved primary stability, allowing immediate rehabilitation. Bone healing occurred uneventfully within four months. No deterioration of functional status or range of motion was seen. There were no peri-implant fractures or hardware removal need over a two-year-period. Retrograde femoral nailing with the Targon PH nail seems to be a reasonable treatment concept for these rare and demanding cases.

LEVEL OF EVIDENCE

IV.