Extra-articular proximal femur fractures in children and adolescents treated by elastic stable intramedullary nailing

Flexible nailing: Pushing the indications for diametaphyseal lower-extremity fractures

Elastic stable intramedullary nailing (ESIN) has been shown to be an effective form of surgical management for lower-extremity diametaphyseal fractures in pediatric patients, but studies are limited because ESIN treatment for these fractures is relatively uncommon. We sought to determine whether ESIN can be used effectively in the most distal or proximal short-segment forms of these fractures. We queried the electronic medical record system at Johns Hopkins Hospital using Current Procedural Terminology codes for femur and tibia fractures treated with ESIN in patients under 18 years old between January 2015 and October 2022. Preoperative and postoperative radiographs were subsequently reviewed to identify patients with a proximal or distal third femoral or tibial shaft fracture treated with ESIN and to define criteria for short-segment diametaphyseal fractures. We used Beaty radiological criteria to evaluate radiographic outcomes and Flynn titanium elastic nails (TENs) outcome scale to assess clinical recovery after radiographic evidence of union. There were 43 children who met the inclusion criteria. Among them, 10 patients had short-segment diametaphyseal fractures. There were 22 (51.2%) who sustained femur fractures and 21 (48.8%) who sustained tibia fractures. Using Beaty radiologic criteria, ESIN was associated with more satisfactory outcomes in patients with distal or proximal third shaft fractures (32/33) than in patients with short-segment diametaphyseal fractures (7/10) (P = .03). Using the TENs outcome scale, 21 (63.4%) patients with distal or proximal third shaft fractures had excellent results, 11 (33.3%) had satisfactory results, and 1 (3%) had a poor result. Among patients with short-segment diametaphyseal fractures, 4 (40%) had excellent results, 5 (50%) had satisfactory results, and 1 (10%) had a poor result. There were no differences in TENs outcomes between the groups (P = .24). Patients with short-segment lower-extremity diametaphyseal fractures treated with ESIN had worse radiographic outcomes but did no worse clinically than patients with distal or proximal third shaft fractures. Consequently, ESIN should be considered a safe and effective surgical management option for pediatric patients with even the most distal or proximal forms of these fractures.

Submuscular nonlocking plates: an effective option for pediatric extra-articular proximal femur fractures

The aim of this study is to evaluate the results of submuscular plating using nonlocking plates for extra-articular proximal femur fractures (EPFF) in children. From our hospital records, we retrieved data of 15 children treated with submuscular plating with nonlocking dynamic compression plates (DCP) for EPFF between January 2010 and September 2021. EPFF was defined as a proximal femur fracture within 10% of the femoral length below the lesser trochanter. Patients' demographics, as well as details of the duration of operation, type of DCP used, time to union, complications, and outcomes using Flynn criteria were noted. There were nine males and six females. Mean age of the patients was 10.8 ± 1.9 years (range 7-14 years). All the patients had fracture union and two patients had union with an angulation less than 10°. All fractures healed uneventfully with a mean time to union of 11.8 ± 1.2 weeks (range 10-15 weeks). No patient required surgery for complications or malunion. Using Flynn criteria, excellent outcomes were seen in 13 out of 15 patients. There were no poor outcomes. Our study shows that submuscular plating using nonlocking plates is an effective option for treating pediatric EPFF. Treatment of these tricky fractures with submuscular plating using nonlocking plates shows excellent outcomes with minimal complications.

FLEXIBLE INTRAMEDULLARY NAILS IN PEDIATRIC SUBTROCHANTERIC FEMUR FRACTURE: BIOMECHANICAL STUDY

Objective

Evaluate the stability provided by two flexible intramedullary nails (FINs) in a simulation of fractures at the proximal levels in pediatric femur models.

Methods

Two FINs were inserted in 18 synthetic models of pediatric femurs. Fractures were simulated at one of three levels, and the models were divided into the following groups (n=6): diaphysis (control), subtrochanteric and trochanteric. Flex-compression tests were performed with force up to 85 N. Relative stiffness and the average deformation was obtained. Torsion tests were performed by rotating the proximal fragment until 20°, to obtain the average torque.

Results

At flex-compression, the set's average relative stiffness and average deformations were: 54.360x10³ N/m and 1.645 mm in the control group, respectively. In the subtrochanteric group, the relative stiffness was 31.415x10³ N/m (-42.2%) and the deformation was 2.424 mm (+47.3%) (p<0.05). For the trochanteric group, the relative stiffness was 30.912x10³ N/m (+43.1%) and the deformation was 2.508 mm (+52.4%) (p<0.05). In torsion, the average torque was 1.410 Nm in the control group; 1.116 Nm in the subtrochanteric group (-20.8%), and 2.194 Nm in the trochanteric group (+55.6%) (p<0.05).

Conclusion

FINs do not seem to be biomechanically competent for the treatment of proximal femoral fractures. Level of Evidence I; Therapeutic Studies - Investigating the results of treatment.

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.

Operative choice for subtrochanteric femoral fracture in school-aged children: Triple elastic stable intramedullary nail versus locking plate

BACKGROUND

The management strategy of subtrochanteric fractures remains controversial, and triple elastic stable intramedullary nail (ESIN) has not been reported for pediatric subtrochanteric fractures. This study aimed to compare the clinical effects of treating school-aged children with subtrochanteric fractures with triple ESINs versus locking plates.

METHODS

We conducted a retrospective review of pediatric patients with subtrochanteric femoral fracture receiving either triple ESINs (TE) or locking plates (LPs) between January 2010 and January 2018. Sixteen patients in each group with matched age, sex, and fracture characteristics were included in the study. The preoperative data, including baseline information of the patients, fracture pattern, and types of surgical procedure, were collected from the hospital database. Patients were followed-up at the outpatient clinic in the 3rd month, 6th month, 12th month, and annually afterward. Hardware removal was performed at 9 - 18 months after the primary surgery.

RESULTS

In all, 16 patients (8.4 ± 1.5-year-old, 7 boys, 9 girls) in the TE group and 16 patients (8.4 ± 1.4-year-old, 7 boys, 9 girls) in the LP group were included. There was significantly less operative time, reduced estimated blood loss, and shortened hospital stay for the TE as compared with the LP (P < 0.001). However, higher fluoroscopy frequency was observed in the TE group than in the LP group (P < 0.001). The time to union was faster in the TE group than in the LP group (P = 0.031). However, the angulation was higher in the TE group (3.2 ± 0.6) than the LP group (1.8 ± 0.5), and the incidence of implant prominence was higher in the TE group (7/16, 43.8%) than the LP group (1/16, 6.3%).

CONCLUSION

Compared with the locking plates, triple ESINs demonstrated significantly less operative time, reduced estimated blood loss, and shortened hospital stay. Besides, both TE and LP groups produced satisfactory outcomes in school-aged children with subtrochanteric fractures. Therefore, TE remains a feasible choice for subtrochanteric fractures in school-aged children.

Titanium elastic nailing can be used in 6 to 10 years old pediatric with Delbet IV femoral neck fractures

The purpose of this study was to analyze the outcomes of titanium elastic nail (TEN) for the children in 6 to 10 years old who sustained a Delbet IV femoral neck fracture.A total of 56 children aged 6 to 10 years old with Delbet IV femoral neck fracture treated with TEN or cannulated screw (SC) were identified at our hospital from January 2009 to December 2019. Of which 24 were treated with TEN, and 32 with SC. All of them were followed up for 1 year after operation, and the differences in operation time, intraoperative blood loss, hospitalization time, hip joint function, and complication between the 2 groups were compared. Harris and Ratliff hip score were used to evaluate the hip function.All 56 fractures united properly. No major complications were noted in both groups. The intraoperative blood loss and operation time in TEN group and SC group were (11.42 ± 3.41) mL, (19.66 ± 4.05) mL (P = .000) and (33.58 ± 7.89) min, (40.22 ± 7.48) min (P = .002), respectively. There was no significant statistical difference between hip regarding range of motion and femoral neck-shaft angle in both groups, as well as Harris and Ratliff hip score between the 2 groups.TEN represent safe and effective methods in the treatment of Delbet IV femoral neck fracture in 6 to 10 years old children. TEN internal fixation is a minimal invasive and simpler technique and suitable for young children of Delbet IV femoral neck fracture.

Clinical Efficacy of Minimally Invasive Elastic Stable Intramedullary Nailing for Limb Long Bone Fractures in Children

Objective

The aim of the present paper was to investigate the clinical efficacy of minimally invasive elastic stable intramedullary nailing (ESIN) for long bone fractures in children.

Methods

A total of 350 children with limb fractures from June 2012 to June 2018 were recruited and randomized into two groups: an ESIN group (n = 175) treated with elastic stable intramedullary nailing, and an MPIF group (n = 175), treated with metal plate internal fixation. Both groups received the same physical examination and routine medication. Operation related indexes, clinical efficacy, complications, and postoperative quality of life scores were analyzed and compared.

Results

The operation time, intraoperative blood loss, hospitalization time, and fracture healing time in the ESIN group were 43.74 ± 4.96 min, 8.14 ± 1.34 mL, 5.97 ± 1.88 days, and 55.89 ± 5.61 days, respectively, which were all significantly less than those in the MPIF group (all P < 0.001). In terms of common complications after limb fracture treatment, there were 6 cases of osteomyelitis, 5 cases of skin irritation response, and 7 cases of inflammatory granuloma in the MPIF group. There were 2 cases of skin irritation response and 5 cases of inflammatory granuloma in the ESIN group. The incidence of postoperative complications in the ESIN group was 4.00%, which was significantly lower than that in MPIF group (10.29%) (P < 0.05). The effective rate for recovery condition in the ESIN group (93.71%) was significantly higher than that in the MPIF group (P < 0.001). The quality of life scores after treatment in both groups were improved, while the score in the ESIN group was significantly higher than that in the MPIF group (79.43%) (P < 0.001). The postoperative satisfaction rate in the ESIN group (94.29%) was significantly higher than that in the MPIF group (86.29%) (P < 0.05). The quality of life scores after treatment in both groups were improved, while the score in the ESIN group was significantly higher than that in the MPIF group (P < 0.001). The postoperative satisfaction rate and the acceptance rate for adjacent joint function in the ESIN group (100%) were significantly higher than those in the MPIF group (92.00%) (P < 0.0001).

Conclusion

Elastic stable intramedullary nailing is a minimally invasive procedure for long bone fractures in children. It can effectively improve the operation‐related indicators and postoperative quality of life and reduce the incidence of complications.

Can titanium elastic nail be safely used for paediatric subtrochanteric femur fractures?

In this study, we aimed to show that subtrochanteric femur fractures, an uncommon type of fracture in the paediatric age group, can be treated with titanium elastic nailing (TEN). We reviewed the patients treated with TEN in the paediatric age group with subtrochanteric femur fractures who had been treated at the Orthopaedics and Traumatology Clinic of Izmir Tepecik Research and Training Hospital between January 2011 and December 2016 retrospectively. All fractures were fixed by retrograde nailing with supracondylar entry following reduction. Patients' demographics as well as data such as fracture type, fracture level, time of operation, reduction type, time to union, shortness, additional fixation, duration of additional fixation, Flynn scores and reduction loss were evaluated. The 20 patients included in our study were followed up for at least 1 year, had an age range of 54-173 months (mean, 104 ± 31.82 months) and were operated within 2-11 days after fracture. All patients had fracture union and only three patients had union with an angulation of less than 5°. None of the patients had limb length inequality. Fourteen patients underwent reoperation, all of these were routine operations for implant removal and no patients required reoperation for complications. We think that paediatric subtrochanteric femur fractures can be treated by TEN fixation using the proper technique, with a limited invasive intervention.