Complications of titanium and stainless steel elastic nail fixation of pediatric femoral fractures

TREATMENT OF PEDIATRIC FEMUR FRACTURES WITH FLEXIBLE STAINLESS STEEL INTRAMEDULLARY NAIL

OBJECTIVES

To identify the characteristics of patients and femur fractures treated with a stainless steel intramedullary nail (ESIN) in children under 15 years of age. Know the results of using the ESIN of related steel in the service.

METHODS

Retrospective study with review of hospital records and organization of data in spreadsheets.

RESULT

24 cases were identified, 17 male cases and 7 female cases. A minimum age of 4 years and a maximum of 11 years were observed (average of 7 years). The 3 most common trauma mechanisms were being run over (n:8, 33%) and falling from a height (n:8, 3%). The most common location of the fractures was in the mid-diaphyseal region (n: 20, 88%), only one case presented a bilateral femur fracture. The most common associated trauma was traumatic brain injury. The observation period observed several months between 2 and 5. With regard to complications, 3 cases were observed (12.5%) being bursitis, vicious construction and loss of reduction.

CONCLUSION

Steel HIF shows similar good results. As the study includes the retrospective profile, the absence of a group and the small sample size. Level of Evidence IV, Case series.

Maintenance of acetabular correction following PAO: a multicenter study comparing stainless-steel and titanium screws

Stainless-steel screws are commonly used for fragment fixation during periacetabular osteotomy (PAO) at our institutions. Titanium is reserved for patients with documented nickel allergies. Titanium screws possess a significantly lower Young's modulus than stainless steel and, therefore, potentially less resistance to physiologic loading. Thus, we hypothesized that the use of titanium screws might be associated with changes in acetabular correction prior to healing. The aim of this study was to compare the maintenance of acetabular correction following PAO using stainless-steel or titanium screws. A documented nickel allergy was confirmed with an allergy specialist. Patients' age at surgery, gender and BMI were collected. The lateral center-edge angle of Wiberg (LCEA), medial center-edge angle (MCEA), anterior wall index (AWI), posterior wall index (PWI) and Tönnis angle were measured. The delta value for radiographic parameters was calculated as the difference between values immediately post-operation and at 6 months post-operation. Only age at surgery (P < 0.001) and the pre-operative LCEA (P = 0.013) were significantly different between groups (Tables I and II). The remaining pre- and post-operative radiological measurements were similar (Table II). Comparison of delta values at 6 months follow-up indicated no significant differences between screw types (Table III). No patients in the titanium group had a trans-iliac retrograde screw included in their construct (P = 0.003). All patients healed from their osteotomies. The use of titanium screws in patients with an allergy to nickel was not associated with differences in acetabular correction or the rate of osseous union rates despite its lower inherent mechanical properties.

Comparing the Outcomes of Titanium and Stainless Steel Flexible Nails in Repairing Pediatric Long Bone Fractures

Background

Traditionally, pediatric femoral fracture treatment favored conservative methods, relying on casting and the inherent bone remodeling ability in immature bones. Surgical intervention was deferred until age 6, as nonoperative approaches often resulted in complications. Titanium elastic nailing (TENS) emerged as an effective treatment for diaphyseal femoral fractures in ages 6 to 16. However, the choice between TENS and stainless steel elastic nailing (SSENS) remains debated due to inconsistent findings.

Objective

This study aimed to evaluate the effectiveness of both nailing systems in pediatric long bone fractures.

Methods

A retrospective chart review at William Beaumont Hospital Royal Oak included 83 patients aged 6 to 16 treated with TENS or SSENS between January 2011 and January 2021. Data collected encompassed nail related issues, time to fracture union, full weight bearing, and nail removal.

Results

In the TENS group (n=29), the average age was 8.8±2.4 years, and the average BMI was 17.2±3.4. The SSENS group (n=54) had an average age of 9.3±2.7 and an average BMI of 19.7±8.4. Time to fracture union for TENS was 93.8±60.5 days, while SSENS was 82.2±40.0 days.

Conclusion

This study found no statistically significant differences in nail-related complications, time to fracture union, full weight bearing, or nail removal between TENS and SSENS in pediatric long bone fractures. The choice between these systems should be based on individual circumstances. Limitations include a small sample size and the study's retrospective nature.

Treatment of Length-Unstable Pediatric Femur Fractures in Children Aged 5 to 11 years: A Focused Review

Pediatric femur fractures in children aged 5 to 11 years are typically classified as length-stable versus length-unstable. For length-stable fracture patterns, there is frequent consensus among pediatric orthopaedic specialists regarding the appropriateness of flexible intramedullary nails, submuscular plates (SMP), or lateral-entry rigid intramedullary nails (LE-RIMN). With length-unstable fracture patterns, however, the decision is more complex. Age, weight, fracture pattern, fracture location, surgical technique, surgeon experience, several implant-specific details, and additional factors are all important when choosing between flexible intramedullary nail, SMP, and LE-RIMN. These familiar methods of fixation may all be supported by conflicting and sometimes heterogeneous data. When planning to treat length-unstable fractures in young children, surgeons should understand evidence-based details associated with each implant and how each patient-specific scenario affects perioperative decisions.

Closed reduction and intramedullary nails for acute completely displaced femoral diaphysis fracture in children aged 2-6

Background

The management of femoral fractures in children aged two to six years is still controversial. The purpose of this study was to assess the results of closed reduction and elastic stable intramedullary nail (ESIN) fixation in completely displaced fractures of the femoral diaphysis in children in this age group.

Methods

A retrospective review of all children with acute completely displaced fractures of the femoral diaphysis in children aged 2-6 years treated from 2013 to 2020 was performed. A total of 34 patients were treated who met the inclusion criteria: Group 1: 21 fractures (transverse and short oblique); Group 2: 13 fractures (long oblique and spiral) that underwent closed reduction and elastic stable intramedullary nail (ESIN) fixation. No differences existed between the 2 groups with respect to age, extremity, sex, time to treatment, mechanism of injury, or fracture displacement. Demographic characteristics and radiographs were reviewed, and the following parameters were documented: surgery time, time to union, return to activities, range of motion of knee joints, and complications. Major complications were defined as those with presumptive long-term side effects or those requiring a reoperation. No major complications were observed in the two groups. All included fractures were treated by a single senior paediatric surgeon. The mean follow-up period was 28.4 months (range 24-45 months). The level of significance was set at p < 0.05.

Results

Thirty-four children with acute completely displaced fractures of the femoral diaphysis were included: Group 1: 21 fractures; Group 2: 13 fractures. The patients included 15 girls (44.1%) and 19 boys (55.9%), with an average age of 4.4 years (range 2.8 to 6.5 years). The mean follow-up period was 28.4 months (range 24.2-45.0 months). The demographic characteristics did not differ between the two groups of patients. Overall, successful closed reduction and elastic stable intramedullary nail (ESIN) fixation could be achieved in all 34 patients. The mean surgical time was 40.4 and 43.0 min in Group 1 and Group 2, respectively (p = 0.857). Fluoroscopy time was not significantly different between the two groups (37.0 vs. 36.1 s, respectively; p = 0.247). Cosmetic results were described as good and satisfactory by all patients. There were no refractures and no incidences of nonunion or growth arrest in the proximal epiphysis. Only two patients suffered from a superficial infection, which was resolved after the pins were shortened and oral antibiotics were administered.

Conclusion

Closed reduction and elastic stable intramedullary nail (ESIN) fixation can be successfully used to treat completely displaced fractures of the femoral diaphysis in children aged two to six years. This technique is efficient and minimally invasive, and the results are satisfactory.

Mechanical behaviors of titanium, nickel-titanium, and stainless elastic intramedullary nail in fixation of tibial diaphyseal fractures

INTRODUCTION

Elastic nails have been widely used in the diaphyseal fracture fixation of long bones in adolescents. However, high complication rates have been reported in cases involving weights exceeding 55 kg. The existing nails are fabricated with different metals in clinical settings; however, the effect of the materials on the mechanical responses of the fractured bone remains unclear. Hence, the present study is conducted to compare the mechanical responses of typically used metals, namely titanium, stainless, and nickel-titanium, for elastic nails in the fixation of tibial diaphyseal fractures.

MATERIAL AND METHODS

A sawbone tube is used to determine the contact force, which is developed after constraining the nail inside the narrow canal using different nail materials. Furthermore, a finite element (FE) model of the tibial diaphyseal fracture is developed to predict the fracture gap deformation based on different nail materials under axial compression and bending loads. The push-out force in the FE simulation is compared with that of a case without an end cap.

RESULTS

In the sawbone tube, the results indicate that the contact force developed by the titanium nail is significantly higher than those developed by stainless and nickel-titanium nails. The contact forces developed by the titanium, stainless steel, and nickel- titanium nails are 385 (SD 34), 358 (SD 49), and 258 (SD 42) N, respectively. In the FE simulation, the titanium nail yields the highest push-out force when an end cap is not used, and the push-out forces in axial compression are 201, 183, and 87 N in the titanium, stainless, and nickel-titanium nails under axial compression, respectively. By contrast, the stainless nail yields the smallest gap deformation when an end cap is used.

CONCLUSION

Results of the present study show that the end cap is an important factor affecting the mechanical responses of nails fabricated using different materials. Titanium nails are preferred when an end cap is not used, whereas stainless nails are preferred when an end cap is used.

Reduced Cell Adhesion on LightPLAS-Coated Implant Surfaces in a Three-Dimensional Bioreactor System

Most implants used in trauma surgery are made of steel and remain inside the body only temporarily. The strong tissue interaction of such implants sometimes creates problems with their explantation. Modified implant surfaces, which decrease tissue attachment, might allow an easier removal and therefore a better outcome. Such a modification must retain the implant function, and needs to be biocompatible and cost-effective. Here, we used a novel VUV-light (Vacuum-Ultraviolett)-based coating technology (LightPLAS) to generate coated stainless-steel plates. The tested LightPLAS coating only had an average thickness of around 335 nm, making it unlikely to interfere with implant function. The coated plates showed good biocompatibility according to ISO 10993-5 and ISO 10993-12, and reduced cell adhesion after four different time points in a 2D cell culture system with osteoblast-like MG-63 cells. Furthermore, we could show decreased cell adhesion in our 3D cell culture system, which mimics the fluid flow above the implant materials as commonly present in the in vivo environment. This new method of surface coating could offer extended options to design implant surfaces for trauma surgery to reduce cell adhesion and implant ingrowth. This may allow for a faster removal time, resulting in shorter overall operation times, thereby reducing costs and complication rates and increasing patient wellbeing.

The Clinical Use of Osteobiologic and Metallic Biomaterials in Orthopedic Surgery: The Present and the Future

As the area and range of surgical treatments in the orthopedic field have expanded, the development of biomaterials used for these treatments has also advanced. Biomaterials have osteobiologic properties, including osteogenicity, osteoconduction, and osteoinduction. Natural polymers, synthetic polymers, ceramics, and allograft-based substitutes can all be classified as biomaterials. Metallic implants are first-generation biomaterials that continue to be used and are constantly evolving. Metallic implants can be made from pure metals, such as cobalt, nickel, iron, or titanium, or from alloys, such as stainless steel, cobalt-based alloys, or titanium-based alloys. This review describes the fundamental characteristics of metals and biomaterials used in the orthopedic field and new developments in nanotechnology and 3D-printing technology. This overview discusses the biomaterials that clinicians commonly use. A complementary relationship between doctors and biomaterial scientists is likely to be necessary in the future.

Titanium elastic nails vs locking plate in pediatric subtrochanteric femur fractures: A systematic review and meta-analysis

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.

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.

Unplanned Return to the Operating Room (UpROR) After Pediatric Diaphyseal Femoral Fractures

BACKGROUND

Femoral fractures are the most common cause of fracture-related admissions. Unplanned return to the operating room (UpROR) is a major event and imposes a substantial burden on the family and health care system. The purpose of this study was to determine the incidence of complications and early UpROR during the first 6 months following treatment of femoral fractures and their risk factors.

METHODS

In an institutional review board-approved study, a retrospective review of all patients who were treated for a femoral fracture during a 10-year period at a pediatric tertiary care center was performed. Patients less than 18 years old with a diaphyseal fracture and complete records were included, and nondiaphyseal or pathologic fractures, as well as underlying metabolic or genetic disorders, were excluded. All clinic visits in the first 6 months after treatment were reviewed, and all complications and UpRORs were extracted. Patients were grouped based on their age (below 5, 5 to 11, above 11 y old) at initial treatment, and statistical tests were used to infer differences between groups.

RESULTS

Overall, 841 fractures in 832 patients were included, with a mean age of 5.5±4.8 years fracture, of which 72% were male. A total of 106 complications (12.6%) and 45 UpRORs (5.3%) were encountered during the study period. Patients with and without UpROR had similar demographics and injury and treatment characteristics. Loss of reduction was the most common reason for UpROR (58%), followed by implant-related complications. Flexible nails had the highest risk of UpROR among patients who were initially treated surgically (P=0.03).

CONCLUSIONS

Our findings indicate that children under the age of 5 years have a 5% risk of UpROR in the first 6 months after the fracture, mainly for repeat spica casting due to loss of reduction. Patients aged 5 years or older have an ∼6% risk of UpROR, mainly related to complications of flexible nails. The findings of this study are important when consulting families on different treatments of diaphyseal femoral fractures.

LEVEL OF EVIDENCE

Therapeutic level III-retrospective cohort study.

Modification of polyetheretherketone implants: From enhancing bone integration to enabling multi-modal therapeutics

Polyetheretherketone (PEEK) is a popular thermoplastic material widely used in engineering applications due to its favorable mechanical properties and stability at high temperatures. With the first implantable grade PEEK being commercialized in 1990s, the use of PEEK has since grown exponentially in the biomedical field and has rapidly transformed a large section of the medical devices landscape. Nowadays, PEEK is a standard biomaterial used across a wide range of implant applications, however, its bioinertness remains a limitation for bone repair applications. The increasing demand for enhanced treatment efficacy/improved patient quality of life, calls for next-generation implants that can offer fast bone integration as well as other desirable therapeutic functions. As such, modification of PEEK implants has progressively shifted from offering desirable mechanical properties, enhancing bioactivity/fast osteointegration, to more recently, tackling post-surgery bacterial infection/biofilm formation, modulation of inflammation and management of bone cancers. Such progress is also accompanied by the evolution of the PEEK manufacturing technologies, to meet the ever increasing demand for more patient specific devices. However, no review has comprehensively covered the recently engaged application areas to date. This paper provides an up-to-date review on the development of PEEK-based biomedical devices in the past 10 years, with particularly focus on modifying PEEK for multi-modal therapeutics. The aim is to provide the peers with a timely update, which may guide and inspire the research and development of next generation PEEK-based healthcare products. STATEMENT OF SIGNIFICANCE: Significant progress has been made in PEEK processing and modification techniques in the past decades, which greatly contributed to its wide applications in the biomedical field. Despite the high volume of published literature on PEEK implant related research, there is a lack of review on its emerging applications in multi-modal therapeutics, which involve bone regeneration, anti-bacteria/anti-inflammation, and cancer inhibition, etc. This timely review covers the state-of-the-art in these exciting areas and provides the important guidance for next generation PEEK based biomedical device research and development.

Ender's nailing of displaced tibia shaft fractures in children - A nine-year experience

BACKGROUND

Displaced fractures of the tibial shaft in children can be effectively treated with minimal complications with flexible nails. Our aim is to evaluate the outcome of displaced paediatric tibia shaft fractures treated with Ender's nails.

MATERIALS

We retrospectively reviewed the records of all unstable tibial fractures treated between 2010 and 2018, in our institution. Only children with a minimum of six months follow-up and complete clinical data were considered for the study.

RESULTS

Of the 72 patients who fulfilled the inclusion-exclusion criteria, 8 were lost for follow-up and hence we had 64 patients included for the study. There were 54 boys and 10 girls, with an average age of 10.9 years(4 to 17 years). The average follow-up was 16.9 months (6 to 47 months). There were nine open fractures. Two nails were used in 52(81.25%) patients while a single nail was used in 6(9.37%) patients and three nails were used in 6(9.37%) patients. The union rate was 100% with an average union time of 10.6 weeks. There were 17 (26.5%) patients with delayed union but none required intervention. One (1.56%) child had a malunion >10° (recurvatum of 11.9° and varus of 8.1°). Radiographs at the final review demonstrated >5° of coronal plane malalignment in eight patients (12.5%) and >5° sagittal plane malalignment (recurvatum) in six patients (9.37%). There was an associated fibular fracture in 50 children and there was no significant association between the presence of fibular fracture and malalignment (p>0.05). All children who presented for implant removal had full range of movement at the knee and ankle joint and no limb length discrepancy.

CONCLUSION

We report the largest series of paediatric tibial shaft fractures treated with Ender's nails. Ender's nail is a simple and cost-effective option for treating these fractures with excellent union rates and minimal complications.

Flexible Intramedullary Nailing of Femoral Shaft Fractures in Children Weighing ≥40 kg: A Systematic Review and Meta-analysis

BACKGROUND

Pediatric femur fractures are commonly treated with flexible intramedullary nails (FIN). However, there is controversy regarding the effect of patient weight on outcomes and complications. The purpose of this meta-analysis was to review the literature and describe implant choice, analyze complication, and reoperation rates; as well as the report clinical and radiographic outcomes of FIN in pediatric patients weighing ≥40 kg with femoral shaft fractures.

METHODS

A systematic review was performed of all retrospective and prospective studies focusing on the use of FIN in heavy children in Medline, Cochrane, and Web of Science databases. Data extraction was performed and summarized using descriptive statistics. Quality assessment was performed using the Newcastle-Ottawa Scale. Meta-analysis was performed for complications using pooled data from included studies.

RESULTS

The initial search strategy yielded 177 references, and after exclusions, 5 studies were included. The majority of studies were retrospective, and the most commonly used implants in heavier patients were titanium FIN and stainless steel Enders FIN. There were higher rates of radiographic nonunion and malunion, complications, and reoperations for refracture; and nonunion in heavier children treated with FIN. Meta-analysis performed on 4 applicable studies showed the overall complication rate was higher in the heavier patients compared with lighter patients (30.6% vs. 11.1%) with a relative risk of 1.20 [95% confidence interval (CI), 1.02-1.41]. Heavier patients also had higher rates of major complications (relative risk, 1.32; 95% CI, 1.03-1.69) but similar minor complications (relative risk, 1.13; 95% CI, 0.90-1.41).

CONCLUSIONS

Heavier children have worse radiographic outcomes and higher complication rates with the use of FIN for femoral shaft fractures. Additional research is needed to determine the effect of FIN material on clinical outcomes in heavier children, and the relationship between weight and other known risk factors for poor outcome in FIN, such as length stability.

LEVEL OF EVIDENCE

Level III-systematic review of level-III studies.

Flexible Intramedullary Nailing of Pediatric Femoral Fractures

Background

Flexible intramedullary nailing is performed for femoral fractures in pediatric patients who may be too large for spica cast immobilization but who have substantial growth remaining and who are not a candidate for rigid intramedullary nailing. Flexible nailing allows the surgeon to obtain correct alignment of the femur fracture so as to allow for healing without a lower extremity deformity.

Description

The patient is positioned on a radiolucent table, flexible nails are chosen according to the diameter of the medullary canal, medial and lateral incisions are made along the distal aspect of the thigh, and access to the canal is obtained with use of a drill-bit of the appropriate size. Flexible nails are contoured to place the apex at the location of the fracture site and then passed 1 at a time up to the fracture through the medial and lateral corticotomies. Fracture reduction is obtained, and the nails are passed across the fracture 1 at a time. Leave a small amount of nail prominent at the entry site; the nails are then cut and advanced with a tamp.

Alternatives

Spica cast immobilization, rigid intramedullary nailing, external fixation, and submuscular plating.

Rationale

Flexible nailing provides relative stability of a femoral fracture similar to external fixation, submuscular plating, and rigid nailing; however, external fixators come with pin-track complications and infections, as well as a bulky device external to the thigh. Submuscular plating is beneficial for length-unstable fractures but is a longer procedure and implant removal is more difficult. In an older child with growth remaining, a rigid femoral nail is an option with similar outcomes to flexible nailing; however, the implant is harder to remove. Flexible nailing provides a cosmetic incision with reliable relative fixation in length-stable fractures, and easy removal of implants with equal or even improved outcomes compared with other surgical techniques.

Expected Outcomes

The outcomes of this procedure are excellent. Most pediatric femoral fractures treated with flexible nailing heal well with few complications. Angulation at the fracture site is the most common complication and is more common in fractures of the proximal or distal third of the femur¹. Worse outcomes occur in older children and children who are heavier¹. Outcomes are improved when flexible nailing is done in length-stable fractures; however, postoperative immobilization in a single-leg spica cast or knee immobilizer can augment fixation in fractures that are not stable. Implant irritation can occur at the insertion site; however, the implants are easy to remove once the fracture has healed. There is a substantially lower rate of malunion when stainless-steel nails (6%) are utilized compared with titanium nails (23%). Consideration should therefore be given to the use of stainless-steel nails for pediatric femoral fractures².

Important Tips

Use a radiolucent table with either a post or a sheet for counter-traction aids during reductionUse stainless-steel nailsPass the easier nail firstAdvance into the femoral neck or trochanteric apophysisDo not wrap rods around each otherCut off the machined tip of the nail and custom-contour the nail in patients with poor bone quality.

The history of intramedullary nailing

PURPOSE

To summarize the evolution of intramedullary nailing, highlight important milestones, introduce the atmosphere of the era concerning the first uses and development of intramedullary nailing, and present the status of nailing in modern international orthopaedics and traumatology.

METHOD

A thorough literature search was undertaken in PubMed and Google Scholar as well as in physical books in libraries to summarize the literature on the history and evolution of intramedullary nailing.

RESULTS

The first use of an intramedullary device was attested in ancient Egypt; however, the first use of intramedullary nailing was reported in 1524 in Mexico, and the first medical journals reported on intramedullary nailing around the mid-1800s. The evolutions of intramedullary nailing including approach, material, cross-section and shape, and reaming technique occurred in the twentieth century. During the 1960s, intramedullary nailing was abandoned in favour of plate and screws osteosynthesis; however, in the 1970s, 1980s, and 1990s, a surge of novelties including flexible reaming, interlocking, and use of image intensification and titanium nails led to the advent of the second-generation intramedullary nailing. Today, intramedullary nailing has become the standard treatment of long bone fractures with low infection rates, small scars, excellent stabilization of the fractures, and immediate mobilization of the patients.

CONCLUSION

Intramedullary nailing has revolutionized the treatment of long bone fractures. However, with numerous nail designs, a lot of information on their efficacy is lacking. Considerably more work will need to be done to determine the optimal nail specifications.

Flexible nails have a significantly increased risk of complications compared with plating techniques when treating diaphyseal femoral fractures in children aged 5-12: A systematic review

BACKGROUND

One third of paediatric femoral fractures occur between the ages of 5 and 12. The American Academy of Orthopaedic Surgeons (AAOS) provide evidence-based guidance for treating such fractures that occur in children under 5 and over 12 but not for this age cohort. We aimed to synthesise the available evidence comparing flexible nailing versus plating techniques for diaphyseal femoral fractures in children between the ages of 5 and 12.

METHODOLOGY

A systematic review of interventional and observational studies was performed using MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science, WHO Global Index Medicus and LILACS. The search strategy combined keywords for: children, diaphyseal femoral fractures, plates and nails. Two independent reviewers screened, selected, assessed quality and extracted data from identified studies. The primary outcome was overall complication rates. Secondary outcomes assessed rates of individual complications, and operative variables (e.g. operative time, blood loss).

RESULTS

Five studies fulfilled the eligibility criteria. No RCTs were identified. The studies included 308 femoral fractures in 306 patients: 174 fractures were treated with flexible nailing and 134 with plating. The post-operative complication rate was 27.0% (n = 47) after flexible nails and 12.7% (n = 17) after plating, relative risk 2.13 (95% CI 1.28, 3.53; p = 0.0035). The relative risk of malunion was 3.59 (95% CI 1.05, 12.25; p = 0.0409) with flexible nails and of prominent metalwork was 5.39 (95% CI 1.25, 23.31; p = 0.0241) with flexible nails.

CONCLUSIONS

Data on this topic for this age group is limited despite accounting for one third of paediatric femoral fractures. This review identified a significantly increased relative risk of all complications, and in particular with respect to malunion and prominent metalwork when fractures in this cohort are treated with flexible nails compared to plates. A multi-centre randomised trial to determine if either treatment is superior would be justified.

Distal third femoral shaft fractures in school-aged children: A comparative study of elastic stable intramedullary nail and external fixator

Internal fixation such as elastic stable intramedullary(ESIN) nail and submuscular plate (SMP) is gaining popularity for femoral shaft fractures in school-aged children. However, external fixation (ExFix) might be a valuable option for the distal third femoral shaft fractures, where the fracture heals rapidly, but it is crucial to avoid angular malunion. This study aims to compare the clinical outcomes, postoperative complications of distal third femoral shaft fractures in school-aged children treated by ESIN versus ExFix.Patients aged 5 to 11 years with distal third femoral shaft fractures treated at our institute from January 2014 to January 2016 were included and categorized into ESIN (n = 33) and ExFix (n = 38) group. The preoperative data, including baseline information of the patients, radiographic parameters, and type of surgical procedure, were collected from the hospital database, and postoperative data, including complications, were collected during the follow-up visit.In all, 33 patients (average, 8.0 ± 2.1 years, male 20, female 13) in the ESIN group and 38 patients (average, 8.3 ± 2.3 years, male 23, female 15) in the ExFix group were included in this study. There was significantly less operative time for the ExFix group (45.4 ± 7.8 min) as compared to the ESIN group (57.8 ± 11.3 min) (P < .01), reduced estimated blood loss (EBL) in the ExFix group (9.9 ± 3.5) as compared to the ESIN group (16.4 ± 6.5) (P < .01). As for the frequency of fluoroscopy, there was a significant difference between the ExFix group (13.9 ± 2.4) and the ESIN group (15.5 ± 3.2) (P = .02). The rate of major complications was not significantly different between the 2 groups (P = .19). The rate of implant irritation was significantly higher in the ExFix group (28/38, 73.7%) than the ESIN group (12/33, 36.4%) (P < .01). The rate of surgical site infection (SSI) is significantly higher in the ExFix group (18/38, 47.4%)) than the ESIN group (1/33, 3%) (P < .01). The rate of scar concern was significantly higher in the ExFix (9/38, 23.7%) than the ESIN (2/33, 6.1%), (P = .04). According to the Flynn scoring system, 30(90.9%) patients in the ESIN group and 24(89.5%) patients in the ExFix group were rated as excellent. None of the patients had poor outcomes.Both ESIN and ExFix produced satisfactory outcomes in distal third femoral shaft fractures. ExFix remains a viable choice for selected cases, especially in resource-challenged and austere settings.

The optimal choice for length unstable femoral shaft fracture in school-aged children: A comparative study of elastic stable intramedullary nail and submuscular plate

The utilization of elastic stable intramedullary nail (ESIN) in length unstable femoral shaft fractures in children remains controversial, and the results in different studies vary a lot. This study aims to investigate the clinical outcomes of ESINs versus submuscular plate (SMP) in length unstable femoral shaft fractures.Patients aged 5 to 11 years old with length unstable femoral shaft fractures treated at our institute from January 2008 to January 2018 were included and categorized into ESIN and SMP group. The preoperative data and operative variables were collected from the hospital database, and postoperative data including complications were collected at follow-up visits.In all, 77 patients (8.1 ± 1.9 years old, male 45, female 32) in ESIN group and 45 patients (8.0 ± 2.2 years old, male 26, female 19) in SMP group were included in this study. Comparing operative variables, there was significantly less operative time, reduced estimated blood loss (EBL) and shortened hospital stay for ESINs as compared with SMP (P < .001). However, the fluoroscopy frequency was not significantly different between these 2 fixation methods (P = .42). As for elective removal surgery, there was significantly reduced operative time, EBL and shortened hospital stay for ESINs as compared with SMP (P < .001).Both ESIN and SMP are safe and effective choices for length unstable femoral shaft fractures in children aged 5 to 11 years. In ESIN, extra care is required to provide additional immobilization using spica cast or brace. Compared with SMP, ESIN is able to deliver comparable clinical outcomes with less EBL, operative time and shorter hospital stay.

Elastic Stable Intramedullary Nailing for Treatment of Pediatric Femoral Fractures; A 15-Year Single Centre Experience

Objective:

To analyze outcomes of treatment and complications in children treated with elastic stable intramedullary nailing (ESIN) due to femoral fracture.

Methods:

From May 2002 until May 2018 case records of 103 patients (76 male and 27 female), with median age of 9 (range, 3-17) and follow-up of 92 months, who underwent ESIN because of displaced femoral fracture were retrospectively reviewed. The patient’s information including age, sex, side involved, trauma mechanism, type of fracture, associated injuries, neurovascular status, complications, operation time, duration of hospital stay, time to implant removal were analyzed. The surgical procedure implied a reposition of bone fragments and osteosynthesis with titanium elastic nails introduced through an incision over the lateral and medial border of the distal femoral metaphysis.

Results:

All patients achieved complete radiographic healing at a mean of 8.5 (range, 5-15) weeks. Nine (8.49%) postoperative complications were recorded: three entry site skin irritation, two cases of valgus angulation and one case of nail protrusion, re-fracture, Varus angulation and delayed union. All complications, except case of re-fracture and one valgus angulation, were treated conservatively, with no long term consequences for the patients. Two patients were re-operated. After removal of nails all patients recovered complete function of the extremity, without long term consequences.

Conclusion:

The ESIN for treatment of femoral fractures shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction. Because of the excellent objective and subjective results, the operative stabilization of femoral fractures with ESIN should be recommended to all pediatrics patients

Can flexible intramedullary nails provide proper fixation of long bone fractures in patients weighing over 100 pounds?

Purpose:

Length stable diaphyseal femur and tibial shaft fractures in paediatric patients may be fixed with flexible intramedullary nails (FINs) in selected paediatric patients. Previous studies based on biomechanical models have suggested that the forces of gait may overcome the stability of this construct in patients weighing more than 45 kg. Surgeons occasionally use FINs for fixation in patients outside this limit. The purpose of this study was to evaluate whether FINs could be used in paediatric patients weighing over 45 kg without increasing the rate of complications.

Methods:

A retrospective cohort review was performed for 12 patients weighing over 45 kg with femoral or tibial fractures treated with FINs, matched 1:2 for gender and bone type with 24 patients weighing less than 45 kg; also with femoral or tibial fractures treated with FINs over the same period.

Results:

There was no significant differences in rate of major complication or increases in angulation between the study and control group. The study group had major complication (8.3%) of hypertrophic nonunion in the tibia, and the control group had one major complication (4.2%) of increased anterior bowing in the femur. The odds ratio of developing a major complication in the study group was 2:1 which was not significant (p = 0.06).

Conclusions:

FINs can be considered as a treatment option for fixation of femoral and tibial fractures in a select group of paediatric patients weighing more than 45 kg. Clinical and functional outcomes measurements in larger sample sizes are needed before making any definitive conclusions.

Atypical use of pediatric flexible nails in the treatment of diaphyseal fractures in adults

Background and aim of the work:

Elastic intramedullary nails are commonly used for the treatment of diaphyseal fractures in adolescents and children. The major advantages are the minimally invasive nature of the technique, the short operation time, and the preservation of the growth plate and periosteum thus allowing bone healing within a closed and intact biological environment. Elastic nails are rarely applied to the adult fractures.

Methods:

Five selected adult patients affected by diaphyseal fractures were treated using paediatric flexible nails T2 Kids (Stryker®, Mahwah, NJ, USA) as consequence of their poor clinical conditions, high risk of neurovascular injuries and skin/soft tissues problems. All patients were monthly clinically and radiographically evaluated after surgery until fracture healing.

Results:

Radiological and clinical outcomes were satisfying. All fractures healed after a mean period of 3 months. No losses of reduction as well as mobilization/breakage of implant were observed. Conclusions: Use of pediatric elastic nails is a valid surgical option in treatment of diaphyseal fractures in selected adult patients who request fast and minimally invasive surgery as consequence of precarious clinical or soft tissues conditions. (www.actabiomedica.it)

Retrograde Stainless Steel Flexible Nails Have Superior Resistance to Bending in Distal Third Femoral Shaft Fractures

BACKGROUND

It has been shown that retrograde titanium flexible intramedullary nails (Ti FIN) provide superior resistance to bending compared to antegrade Ti FIN in distal femur fractures. The purpose of this study was to compare resistance to torsional and bending forces of stainless steel (SS) FIN, with or without a locking screw, and Ti FIN in distal third femoral shaft fractures. We hypothesize that locked retrograde SS FIN will demonstrate greater resistance to both bending and torsional forces.

METHODS

Thirty adolescent synthetic femur models were used to simulate transverse distal femoral fractures at either 60 mm or 90 mm proximal to the distal femoral physis. The femurs were instrumented with antegrade Ti FIN, antegrade SS FIN, retrograde Ti FIN, retrograde SS FIN, or retrograde locked SS FIN. Three models for each construct at both osteotomy levels were tested. Models were analyzed to determine maximum resistance to bending and torsion.

RESULTS

In fractures 60 mm from the physis, retrograde SS FIN demonstrated statistically superior resistance to bending when compared with both antegrade and retrograde Ti FIN (P=0.001 and 0.008, respectively) and antegrade SS FIN (P=0.0001). Locked SS constructs showed a trend towards greater resistance to bending forces when compared with unlocked constructs (P>0.05). No significant difference was seen in resistance to bending when fractures were 90 mm proximal to the distal femoral physis between the five groups. No significant differences were observed in resistance to torsion in either the proximal or distal fracture models, regardless of construct type.

CONCLUSIONS

Retrograde SS FIN confer significantly greater resistance to bending forces for fractures 60 mm proximal to the distal femoral physis compared with Ti FIN or antegrade entry SS FIN. In fractures 90 mm from the physis, no differences were noted in our model. Our results support the use of retrograde SS nails in the pediatric patient with distal femoral shaft fractures.

LEVEL OF EVIDENCE

Level II-comparative biomechanical study.

Biomechanical Analysis of Retrograde Flexible Intramedullary Nail Constructs in a Simulated Pediatric Femur Fracture Model

BACKGROUND

Various flexible intramedullary nail (FIMN) constructs for pediatric femur fractures are described; however, no biomechanical study has compared stability of medial-lateral entry versus all-lateral entry retrograde nailing. Our purpose is to compare the rotational and bending stiffness of 2 different FIMN constructs and 2 different materials in a simulated pediatric femur fracture model.

METHODS

Eighty adolescent-sized composite femurs were used to simulate transverse (40 femurs) and oblique (40 femurs) mid-diaphyseal fractures. Retrograde FIMN of the femurs was performed using either 3.5 mm titanium (Ti) or 3.5 mm stainless-steel (SS) flexible nails in 2 configurations: 2 "C"-shaped nails (CC) placed through medial and lateral entry sites or 1 "C"-shaped nail and 1 "S"-shaped nail (CS) placed through a single lateral entry site. Models were first tested in 10 cycles of axial rotation to ±1 N m of torque at a rate of 0.5 degrees/s under 36 kg of compression. Axial compression was performed and bending stiffness defined as the force required to achieve 10 degrees varus at the fracture site.

RESULTS

No differences were noted in rotational stiffness comparing Ti and SS nails regardless of nail configuration or fracture pattern. Comparable rotational stability was found for CC and CS configurations with SS implants for both fracture patterns. The CS construct (0.60 N m/degree) was stiffer in rotation than the CC construct (0.41 N m/degree) with Ti implants in the transverse fracture model (P<0.005). SS nails provided greater bending stiffness than Ti nails in both oblique and transverse fracture patterns, regardless of nail construct. The all-lateral entry (CS) construct demonstrated statistically significant greater bending stiffness regardless of implant material or fracture pattern (P<0.03).

CONCLUSIONS

An all-lateral entry (CS) FIMN construct demonstrated greater bending stiffness in both fracture patterns and materials. Ti and SS implants have comparable rotational stiffness in all fracture patterns and materials; however, SS nails were superior at resisting bending forces in both fracture patterns. CS nail configuration and SS implants demonstrated superior bending stiffness and rotational stiffness when compared with the more commonly used CC construct and Ti implants.

LEVEL OF EVIDENCE

NA (biomechanical study).

A Quartet of Elastic Stable Intramedullary Nails for More Challenging Pediatric Femur Fractures

INTRODUCTION

The insertion of 2 elastic stable intramedullary nails (ESINs) is a common treatment for pediatric femur fractures. However, the use of this technique in length-unstable or metadiaphyseal fractures has historically been associated with higher complication rates. To improve stability, the addition of a third ESIN has been assessed biomechanically and clinically, but the addition of a fourth nail has only been evaluated biomechanically. The purpose of this study is to report our surgical technique and radiographic outcomes using a quartet of ESINs in pediatric femur fractures.

METHODS

A retrospective review was performed of pediatric patients with length-unstable or metadiaphyseal femur fractures who were treated with 4 ESINs by a single surgeon from 2008 to 2013. Nails were inserted in a retrograde manner, 2 each from medial and lateral starting points. Patients were followed clinically and radiographically until the union and routine removal of hardware. Primary outcomes included fracture union, sagittal, and coronal plane alignment, and complications.

RESULTS

Fourteen patients underwent quartet ESIN placement. Two patients were excluded: one for early loss to follow-up and another with a diagnosis of osteogenesis imperfecta. The average patient age was 9.3 years (range, 4 to 14 y) and weight was 47 kg (range, 21 to 95 kg). All fractures achieved radiographic union at mean 5.5 months (range, 2 to 9 mo). Hardware was removed at a mean of 9.4 months (range, 2 to 22 mo) following implantation. At final mean follow-up of 18 months, patients and families reported no functional limitations. There were no hardware failures or revision surgeries. There were no limb length discrepancies or malalignment at the time of final radiographic follow-up. There were 2 minor complications-1 patient with pain secondary to nail migration resulting in prominence at the knee and another with refracture following a fall. The stable refracture occurred before complete fracture union and hardware removal and went on to the union without the need for any additional treatment.

CONCLUSIONS

Treatment with a quartet of ESINs should be considered for skeletally immature children with length-unstable or metadiaphyseal femur fractures. In this series, all fractures achieved union without major complications or hardware failure. This modification to traditional elastic nailing techniques is an option for the surgeon to consider as an alternative to rigid intramedullary nailing, submuscular plating, or external fixation.

LEVEL OF EVIDENCE

Level IV.

Comparison of Mechanical Stability of Elastic Titanium, Nickel-Titanium, and Stainless Steel Nails Used in the Fixation of Diaphyseal Long Bone Fractures

Elastic nails made of the nickel-titanium shape memory alloy (Nitinol) have been reported to control bone modeling in animal studies. However, the mechanical stability of the Nitinol nail in the fixation of long bone fractures remains unclear. This study compared mechanical stability among nails made of three materials, namely Nitinol, titanium, and stainless steel, in the fixation of long bone fractures. These three materials had identical shapes (arc length: π/2 and radius: 260 mm). A cylindrical sawbone with a 10-mm gap and fixed with two C-shaped elastic nails was used to examine the stability of the nails. A finite element (FE) model was developed based on the sawbone model. The end cap for elastic nails was not used in the sawbone test but was considered based on a constraint equation in FE simulation. The results of stability tests appeared to depend on the presence or absence of the end cap. In the sawbone test, the titanium nail yielded a higher ultimate force against the applied load than did the stainless steel and Nitinol nails before the gap completely closed; the difference in linear stiffness between the nails was nonsignificant. In FE simulation, the titanium nail produced smaller gap shortening than did stainless steel and Nitinol nails without the end cap; the difference in gap shortening between the nails was minor with the end cap. The titanium elastic nail should be a better choice in managing diaphyseal long bone fractures when the end cap is not used. For Nitinol and stainless steel nails, the end cap should be used to stop the nail from dropping out and to stabilize the fractured bone.

Elastic stable intramedullary nailing (ESIN) in paediatric femur and tibia shaft fractures: Comparison between titanium and stainless steel nails

INTRODUCTION

Elastic stable intramedullary nailing (ESIN) is currently considered the gold standard in surgical treatment of femur and tibial shaft fractures in school age paediatric patients. Although elastic intramedullary nails are available in both titanium (Ti) and stainless steel (SS) alloy, titanium nails are most commonly used. Nevertheless, there is still contrasting evidence as to whether the use of Ti nails can offer better outcomes in terms of fracture healing and stability over SS nails. The aim of this study was to compare outcomes and complications of Ti and SS ESIN for femur and tibia shaft fractures in a population of school age paediatric patients.

MATERIALS AND METHODS

All consecutive patients who underwent ESIN for femoral or tibial shaft fracture from June 2012 to May 2015 at our centre were retrospectively reviewed. Standard demographic data were collected. Pre-operative and post-operative X-rays were reviewed, complications were collected from patients charts. Patients were divided in two groups, titanium nails (Ti group) and stainless steel nails (SS group) and outcomes compared between the two.

RESULTS

A total of 34 patients were included (17 patients Ti group, 17 patients SS group) with a total of 14 femur and 21 tibia fractures. Average age at surgery was 9.4 ± 2.5 years in Ti group and 10.4 ± 2.4 years in SS group (p = 0.21). The average time to bone healing was 3 months in Ti group, and 2.8 months in SS group (p = 0.63). At final follow-up (12 months), no patient showed a coronal plane or sagittal plane deformity >10° and >15°, respectively. Complication rate was similar between the two groups (24% Ti group, 22% SS group).

CONCLUSIONS

We did not observe any significant difference in terms of bone healing, fracture mechanical stability, return to full activity, and complication rate between Ti and SS ESIN for paediatric femoral and tibial shaft fractures. While Ti nails remain a better choice for patients with metal allergy, SS nails may offer safe, effective, and cheaper alternative to Ti nails in school age femur and tibial shaft fractures.

Pediatric Orthopedic Trauma: An Evidence-Based Approach

The management of pediatric fractures has evolved over the past several decades, and many injuries that were previously being managed nonoperatively are now being treated surgically. The American Academy of Orthopaedic Surgeons has developed clinical guidelines to help guide decision making and streamline patient care for certain injuries, but many topics remain controversial. This article analyzes the evidence regarding management of 5 of the most common and controversial injuries in pediatric orthopedics today.

Flexible Intramedullary Nails for Femur Fractures in Pediatric Patients Heavier Than 100 Pounds

BACKGROUND

Flexible intramedullary nailing (FIMN) of femoral shaft fractures in children >100 pounds remains controversial. The purpose of this study is to assess the relationship between patient weight and alignment at radiographic union following Ender's FIMN of pediatric femoral shaft fractures.

METHODS

An IRB approved, retrospective review of all patients who sustained a femoral shaft fracture treated by retrograde, stainless-steel Ender's FIMN was performed at a level 1 pediatric trauma center from 2005 to 2012. Preoperative radiographs were analyzed to determine fracture pattern, location, and isthmic canal diameter. Patient weight was measured on presentation to the emergency room. Radiographs at bony union were reviewed to measure shortening, coronal angulation, and sagittal angulation.

RESULTS

A total of 261 children underwent Ender's FIMN for femoral shaft fractures during the study period. There were 24 patients who weighed ≥100 lbs and 237 patients who weighed <100 lbs. There were no significant differences in sex (75% vs. 73% male), fracture stability (42.6% vs. 41.7% length unstable), or fracture patterns between the 2 groups. The ≥100 lbs group was significantly older (10.6 vs. 8.0 y, P<0.001). There were no significant differences in final coronal angulation (1.5 vs. 3.0 degrees), sagittal angulation (2.8 vs. 3.1 degrees), or shortening (3.4 vs. 3.5 mm) between the 2 groups. There were significantly more nail removals in the <100 lbs group (81.4% vs. 66.7%, P<0.01). Four percent of the population (10 patients) weighed ≥120 lbs and aside from age (11.4 vs. 8.1 y, P<0.01), there were no significant demographic or fracture pattern differences between this group and the remaining population. This heaviest group demonstrated no significant difference in shortening (3.3 vs. 3.5 mm), coronal angulation (0.8 vs. 3.0 degrees), or sagittal angulation (0.7 vs. 3.2 degrees) at radiographic union when compared with the lighter patients.

CONCLUSIONS

Stainless-steel Ender's FIMN is an effective treatment for pediatric femoral shaft fractures in patients ≥100 pounds with excellent radiographic outcomes and no increased risk for malunion.

LEVEL OF EVIDENCE

Therapeutic Level III.

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.

Two Techniques for Retrograde Flexible Intramedullary Fixation of Pediatric Femur Fractures: All-Lateral Entry Versus Medial and Lateral Entry Point

BACKGROUND

Multiple techniques for flexible intramedullary nailing (FIMN) of pediatric femur fractures have been described. To our knowledge, no study has compared combined medial-lateral (ML) entry versus all-lateral (AL) entry retrograde nailing. This study compares surgical outcomes, radiographic outcomes, and complication rates between these 2 techniques.

METHODS

A retrospective review of a consecutive series of patients treated by retrograde, dual FIMN of femur fractures was performed from 2005 to 2012. Demographics and operative data were recorded. Radiographs were analyzed for fracture pattern, fracture location, percent canal fill by the nails, as well as shortening and angulation at the time of osseous union. Rates of symptomatic implants and their removal were noted. Data were compared between patients treated with medial and lateral entry (ML group) nailing and those treated with all-lateral entry (AL group) nailing using the Student t test and correlation statistics.

RESULTS

Of the 244 children with femoral shaft fractures treated with retrograde FIMN using Ender stainless steel nails, 156 were in the ML group and 88 were in the AL group. There were no statistical differences in sex (74% vs. 82% males), age (8.0 vs. 8.6 y), weight (29.4 vs. 31.1 kg), or fracture pattern between the 2 groups. The average total anesthesia time was less in the AL group (133 vs. 103 min) (P<0.0001). There was no difference between the techniques in shortening (3.9 vs. 3.0 mm), coronal angulation (2.9 vs. 2.6 degrees), or sagittal angulation (3.3 vs. 2.7 degrees) at union. In the AL group, there was a correlation between canal fill and reduced shortening at union. No differences were found in the presence or degree of varus alignment, procurvatum deformity, or recurvatum angulation between the constructs. There were 5 malunions in the AL group and 9 malunions in the ML group (5.7% vs. 5.8%, P=1). The incidence of having a healed femur fracture with >10 degrees of valgus was higher in the AL group (0% vs. 3.4%) (P=0.04). There were no differences between the groups in the rate of symptomatic implant removal or surgical complications.

CONCLUSIONS

The AL entry technique for FIMN of pediatric femur fractures is 30 minutes faster without worse final fracture alignment, additional complications, or increased rates of symptomatic implants. When using the AL technique, specific attention should be paid to percentage of canal fill and ensuring that the fracture is not reduced in a valgus position.

LEVEL OF EVIDENCE

Level III-therapeutic.

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.

Intramedullary Implant Choice and Cost in the Treatment of Pediatric Diaphyseal Forearm Fractures

OBJECTIVES

To compare outcomes and costs between titanium elastic nails (TENs), stainless steel elastic nails (SENs), and Kirschner wires (K-wires) in the treatment of pediatric diaphyseal forearm fractures with intramedullary fixation.

DESIGN

Retrospective cohort study.

SETTING

Level 1 Pediatric Trauma Center.

PATIENTS/PARTICIPANTS

A total of 100 patients (65 male and 35 female) younger than 18 years with diaphyseal forearm fractures treated with intramedullary fixation were included in the study.

INTERVENTION

Patients received single or both bone intramedullary fixation with either TENs, SENs, or K-wires.

MAIN OUTCOME MEASUREMENTS

Time to radiographic union, complication rate, surgical time, and average cost per implant.

RESULTS

One hundred patients were included in the study. Thirty-one patients were treated with TENs, 30 with SENs, and 39 with K-wires. No significant difference in time to radiographic union, complication rate, or surgical time was found between the 3 types of fixation. Average time to union was 9.4 ± 5.4 weeks, and complication rate was 12.9% for TENs, 10.0% for SENs, and 12.8% for K-wires. There was a significant difference in cost per implant, with an average cost of $639, $172, and $24 for TENs, SENs, and K-wires, respectively (P < 0.001).

CONCLUSIONS

This study demonstrates no difference between TENs, SENs, and K-wires in the treatment of pediatric diaphyseal forearm fractures with regards to outcome, time to union, surgical time, or complication rates. Given the significant cost difference between these implants, we recommend that surgeons consider modifying their implant selection to help mitigate cost.

LEVEL OF EVIDENCE

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

Analysis of a paediatric orthopaedic network: a six-year experience in the South West of the United Kingdom

PURPOSE

We report our experience of a paediatric orthopaedic network, based on a 'hub and spoke' model, covering the South West of the United Kingdom. We identify the areas of most clinical concern, the effect of the network on stream-lining patient management and the benefits of the network to the clinician.

METHODS

Prospective data were collected from the minutes of the bi-annual meetings of the South West Paediatric Network (UK) between November 2006 and May 2012. Data collected included details of the condition, previous treatment, problems, complications and advice given. Cases continue to be followed up in subsequent meetings.

RESULTS

In total 131 cases were included and hip conditions were discussed most frequently (35.1%). The most common indication for discussion was to support and confirm the local management plan. In total, a mean average of 8.75 cases in total were presented per consultant during the study period, with those within ten to 12 years of starting independent practice presenting the majority. The clinical outcome for patients discussed in this forum was local provision of care in 74%, with transfer to the regional centre in 15.7%. Following advice, 14% of direct referrals were given appropriate advice and avoided a journey to the tertiary centre.

CONCLUSION

The network has enabled local provision of care, reduced the burden of travel on patients and prevented unnecessary referrals to the tertiary centre. Additionally, it provides a mechanism to reassure and educate clinicians.

V, RHH A, Khurana A. Current Concepts in Paediatric Femoral Shaft Fractures

Pediatric femoral shaft fractures account for less than 2% of all fractures in children. However, these are the most common pediatric fractures necessitating hospitalization and are associated with prolonged hospital stay, prolonged immobilization and impose a significant burden on the healthcare system as well as caregivers. In this paper, the authors present a comprehensive review of epidemiology, aetiology, classification and managemement options of pediatric femoral shaft fractures.

The outcomes of pediatric femoral shaft fractures treated surgically by different types of orthopedists

BACKGROUND

The objective of this study was to compare the outcomes of pediatric femoral shaft fractures treated with titanium elastic nail (TEN) by pediatric orthopedists and non-pediatric orthopedists.

METHODS

From May 2006 to June 2014, 88 children with femoral shaft fractures were randomized to operative stabilization either by pediatric orthopedists (Group A, 44 cases) or by non-pediatric orthopedists (Group B, 44 cases). Demographic data and clinical characteristics (age, sex, weight, fracture side and type, cause of injury, associated injuries and interval from injury to surgery) were comparable between the two groups before surgery. Peri-operative data, clinical and functional outcomes between the two groups were recorded.

RESULTS

The mean follow-up period was 20.9±4.5months for Group A and 20.0±3.6months for Group B (P=0.356). There was no significant difference in the time to union, length of hospitalization, full weight-bearing time and TEN scores between the two groups (P=0.785, P=0.835, P=0.803, P=0.940, respectively). However, the mean operating time and radiation time was longer in Group B than in Group A (P=0.001 and P=0.047, respectively). Also, there was a trend for patients of Group B to have a higher rate of open reduction (P=0.047). When comparing the total complications, no significant difference existed between the groups (P=0.978).

CONCLUSIONS

This study indicated that both pediatric and non-pediatric orthopedists provided satisfactory clinical and functional results in treating these common injuries.

Biomechanical investigation of titanium elastic nail prebending for treating diaphyseal long bone fractures

This study numerically investigated the deformation of titanium elastic nails prebent at various degrees during implantation into the intramedullary canal of fractured bones and the mechanism by which this prebending influenced the stability of the fractured bone. Three degrees of prebending the implanted portions of the nails were used: equal to, two times, and three times the diameter of the intramedullary canal. Furthermore, a simulated diaphyseal fracture with a 5-mm gap was created in the middle shaft portion of the bone fixed with two elastic nails in a double C-type configuration. End caps were simulated using a constraint equation. To confirm that the simulation process is able to present the mechanical response of the nail inside the intramedullary, an experiment was conducted by using sawbone for validation. The results indicated that increasing the degrees of nail prebending facilitated straightening the nails against the inner aspect of canal after implantation, with increase in stability under torsion. Furthermore, reducing nail prebending caused a larger portion of the nails to move closer to the loading site and center of bone after implantation; the use of end caps prevented the nail tips from collapsing and increased axial stability. End cap use was critical for preventing the nail tips from collapsing and for increasing the stability of the nails prebent at a degree equal to the diameter of the canal with insufficient frictional force between the nail and canal. Therefore, titanium elastic nail prebending in a double C-type configuration with a degree three times the diameter of the canal represents a superior solution for treating transverse fractures without a gap, whereas that with a degree equal to the diameter of the intramedullary canal and combined with end cap use represents an advanced solution for treating comminuted fractures in a diaphyseal long bone fracture.

Clinical outcomes and complications of titanium versus stainless steel elastic nail in management of paediatric femoral fractures-a systematic review

Femoral shaft fractures in children account for approximately 1.6% of all fractures. These fractures can be treated both operatively and non-operatively. Surgical fixation is more common in the age group above 6 years. Elastic intramedullary nails have become the most popular surgical modality of treatment over the last few decades. However, there is continuous debate about which type of elastic nails (titanium and stainless steel) provides better clinical outcomes with less complication. The main purpose of this study was to systematically search for and critically appraise articles comparing clinical outcomes and complications of titanium elastic nail system (TENS) and stainless steel elastic nail system (SSENS) in management of femoral fractures in the paediatric age group. A comprehensive search of MEDLINE, EMBASE, and Cochrane library databases was performed using specific search terms and limits. Applying strict eligibility criteria, the identified studies were screened. Five studies were identified and reviewed. All of the identified studies were non-randomised comparative studies apart from one randomised controlled study. Studies provide contradictory evidence with regard to time to fracture union and time to full weight bearing. Only one study commented on time to nail removal and found that it is shorter in the TENS group. Two studies showed significantly higher rate of malunion in the TENS group, whereas the rest showed no difference. There was no difference in the rates of delayed union or infection between the two groups and no consistent difference in the rates of skin irritation. Three studies compared Flynn's outcome score and found no difference apart from one study which found better scores in the SSENS group. There is no consistent evidence to indicate the advantage of one type of elastic nails over the other in management of paediatric femoral shaft fractures; however, the overall trend is in favour of SSENS especially being cheaper than TENS. Critical appraisal of the studies identified significant methodological deficiencies, and further prospective randomised trials are recommended for more potent evidence.

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.].

Computational comparison of tibial diaphyseal fractures fixed with various degrees of prebending of titanium elastic nails and with and without end caps

INTRODUCTION

Elastic stable intramedullary nailing (ESIN) is a treatment strategy for the management of diaphyseal long-bone fractures in adolescents and children, but few studies have investigated the mechanical stability of tibial diaphyseal fractures treated with various degrees of prebending of the elastic nails. Therefore, the aim of this study was to compare the mechanical stability, including the gap deformation and nail dropping, of a tibia fracture with various fracture sites and fixed with various degrees of prebending of the elastic nails by the finite element method. Furthermore, the contribution of end caps to stability was taken into consideration in the simulation.

METHODS

A tibia model was developed with a transverse fracture at the proximal, middle and distal parts of the diaphysis, and fixed with three degrees of prebending of elastic nails, including those equal to, two times and three times the diameter of the intramedullary canal. The outer diameter of the nail used in the computation was 3.5mm, and the fractured tibia was fixed with two elastic double C-type nails. Furthermore, the proximal end of each nail was set to free or being tied to the surrounding bone by a constraint equation to simulate with or without using end caps.

RESULTS

The results indicated that using end caps can prevent the fracture gap from collapsing by stopping the ends of the nails from dropping back in all prebending conditions and fracture patterns, and increasing the prebending of the nails to a degree three times the diameter of the canal reduced the gap shortening and the dropping distance of the nail end in those without using end caps under axial compression and bending. Insufficient prebending of the nails and not using end caps caused the gap to collapse and the nail to drop back at the entry point under loading.

CONCLUSIONS

Using end caps or increasing the prebending of the nails to three times the diameter of the canal is suggested to stop the nail from dropping back and thus produce a more stable structure, with less gap deformation, in the management of a simulated tibial diapyhseal fracture by using titanium elastic nails with a double C-shape.

Treatment of pediatric femoral shaft fractures by stainless steel and titanium elastic nail system: A randomized comparative trial

PURPOSE

Literature suggests that the lower modulus of elasticity of titanium makes it ideal for use in children compared with stainless steel. Better fracture stability was observed in association with titanium nails on torsional and axial compression testing. However, stainless steel nails are stiffer than titanium counterparts, which may provide a rigid construct when fixing paediatric femoral shaft fractures. Complications have been observed more frequently by various researchers when titanium nails are used for fracture fixation in patients with increasing age or weight. The concept of this study was to compare the functional outcome after internal fixation with titanium elastic nail system and stainless steel elastic nail system in paediatric femoral shaft fractures.

METHODS

The study was conducted on 34 patients admitted in the department of orthopaedics, LLRM Medical College & SVBP Hospital, Meerut, India from January 2013 to August 2014. We included patients aged 5-12 years with fracture of the femoral shaft, excluding compound fractures, pathological fractures and other lower limb fractures. Patients were treated by titanium (n=17) or stainless steel (n=17) elastic nail system and followed up for one year. The clinical parameters like range of motion at hip and knee joints, time to full weight bearing on the operated limb and radiological parameters like time to union were compared between two groups. A special note was made of intra- and post-operative complications. Functional outcomes were analysed according to Flynn criteria.

RESULTS

Based on the Flynn criteria, 59% of patients had excellent results, 41% had satisfactory results, and no one showed poor results. There was no clinically significant difference between the two groups with respect to time to union and full weight bearing. But the incidence of puncture of the opposite cortex while inserting the nail and trying to advance it through the diaphysis during operation is greatly different. Only one such case was observed in titanium group but five in stainless steel group.

CONCLUSION

Majority of paediatric femoral shaft fractures are now treated operatively by elastic stable intramedullary nails. Operative intervention results in a shorter hospital stay and has economic and social benefits over conservative treatment. The cost of stainless steel nail is one third the cost of titanium nail. However, the clinico-radiological results are not significantly different between titanium and stainless steel nails at one year follow-up as observed by our study.

Bridge Plating Length-Unstable Pediatric Femoral Shaft Fractures

The treatment of pediatric diaphyseal femur fractures, particularly length-unstable fractures, continues to be an area of controversy in patients from age 6 to skeletal maturity. Submuscular bridge plating is an alternative that allows for stable internal fixation while minimizing soft tissue disruption. We describe a surgical technique that has simplified both implantation and removal. This technique provides a stable construct in comminuted and unstable fracture patterns allowing for early mobilization with minimal complications.

UNSTABLE FEMORAL FRACTURES TREATED WITH TITANIUM ELASTIC INTRAMEDULLARY NAILS, IN CHILDREN

Objective: To evaluate the indications, epidemiology, associated lesions, complications and prognosis among children with unstable femoral diaphysis fractures who were treated with titanium elastic intramedullary nails. Method: This was a retrospective analysis on 24 patients aged 5-12 years with unstable femoral diaphysis fractures who underwent surgical treatment with elastic titanium intramedullary nails at the Cajuru University Hospital, Curitiba-PR, between April 2002 and March 2008, with a minimum follow-up of 36 months. The epidemiological data, angular deviations, leg shortening and bone consolidation were evaluated. Results: The medical files of 113 cases operated between April 2002 and March 2008 were reassessed. From these, 24 cases of unstable femoral diaphysis fractures treated with elastic titanium intramedullary nails with retrograde insertion were included in the study. There were two bilateral fractures and two exposed fractures. Seven patients were female and 17 were male, and the mean age was 8.3 years. The following were presented at the end of the study: shortening, varus or valgus displacement, final retrocurvatum or antecurvatum of zero, and absence of delayed consolidation or pseudarthrosis. Conclusions: The elastic titanium intramedullary nails were easily placed and removed. We believe that using elastic titanium intramedullary nails is a good option for fixation of unstable femoral fractures in children.