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Wen Y, Wang Q, Song B, Feng W, Zhu D. External fixator versus elastic stable intramedullary nail for treatment of metaphyseal-diaphyseal junction fractures of the pediatric distal femur: a case-control study. BMC Musculoskelet Disord 2024; 25:389. [PMID: 38762453 PMCID: PMC11102165 DOI: 10.1186/s12891-024-07469-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 04/22/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Several methods have been used for the treatment of pediatric distal femoral fractures, such as elastic stable intramedullary nail (ESIN), external fixator (EF) and plate osteosynthesis, but there has been no consensus about the optimal method. The purpose of this study was to compare the clinical outcome between EF and ESIN techniques used in metaphyseal-diaphyseal junction (MDJ) fractures of the pediatric distal femur. METHODS We retrospectively analyzed operatively treated MDJ fractures of pediatric distal femur between January 2015 and January 2022. Patient charts were reviewed for demographics, injury and data of radiography. All of the patients were divided into EF and ESIN groups according to the operation techniques. Malalignment was defined as more than 5 degrees of angular deformity in either plane. Clinical outcomes were measured by Flynn scoring system. RESULTS Thirty-eight patients were included in this study, among which, 23 were treated with EF, and 15 with ESIN. The mean follow-up time was 18 months (12-24 months). At the final follow-up, all of the fractures were healed. Although there were no statistical differences between the two groups in demographic data, length of stay, estimated blood loss (EBL), rate of open reduction, time to fracture healing and Flynn score, the EF was superior to ESIN in operative time, fluoroscopic exposure and time to partial weight-bearing. The EF group had a significantly higher rate of skin irritation, while the ESIN had a significantly higher rate of malalignment. CONCLUSION EF and ESIN are both effective methods in the treatment of MDJ fractures of the pediatric distal femur. ESIN is associated with lower rates of skin irritation. However, EF technique has the advantages of shorter operative time, reduced fluoroscopic exposure, and shorter time to partial weight-bearing, as well as lower incidence of malalignment. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Yuwei Wen
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nalishi Road, Beijing, 100045, China
| | - Qiang Wang
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nalishi Road, Beijing, 100045, China.
| | - Baojian Song
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nalishi Road, Beijing, 100045, China
| | - Wei Feng
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nalishi Road, Beijing, 100045, China
| | - Danjiang Zhu
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nalishi Road, Beijing, 100045, China
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Valenza WR, Soni JF, Bodanese BHS, Rossetto DM, Kosovits FGDEP, Cordeiro PIP. PROXIMAL HUMERAL LOCKING PLATE: A VIABLE ALTERNATIVE FOR FIXATION OF DISTAL FEMORAL FRACTURES IN CHILDREN. ACTA ORTOPEDICA BRASILEIRA 2023; 31:e262167. [PMID: 37323152 PMCID: PMC10263410 DOI: 10.1590/1413-785220233102e262167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/09/2022] [Indexed: 06/17/2023]
Abstract
Distal femoral metaphyseal fractures are rare in children, and the proximity of the fracture to the growth plate makes their approach challenging. Objective Evaluate outcomes and complications of treatment of distal femoral metaphyseal fractures in children with proximal humeral locking plates. Method Retrospective study between 2018 and 2021, including seven patients. The analysis included general characteristics, trauma mechanism, classification, clinical and radiographic outcomes, and complications. Results The mean follow-up was 20 months, the average age was nine years, five patients were boys, and six fractured on the right side. Five fractures were caused by car accidents, one by falling from their own height and one by playing soccer. Five fractures were classified as 33-M/3.2 and two as 33-M/3.1. Three fractures were open, Gustilo IIIA. All seven patients recovered mobility and resumed their pre-trauma activities. All seven healed, and one fracture was reduced to 5 degrees valgus, without any other complications. Six patients had the implant removed and did not present refracture. Conclusion Treatment of distal femoral metaphyseal fractures with proximal humeral locking plates is a viable option that offers good results and fewer complications, saving the epiphyseal cartilage. Level of Evidence II; Controlled study without randomization.
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Affiliation(s)
- Weverley Rubele Valenza
- . Hospital do Trabalhador de Curitiba, Curitiba, PR, Brazil
- . Hospital Universitário Evangélico Mackenzie, Curitiba, PR, Brazil
| | - Jamil Faissal Soni
- . Hospital do Trabalhador de Curitiba, Curitiba, PR, Brazil
- . Hospital Universitário Evangélico Mackenzie, Curitiba, PR, Brazil
| | | | | | | | - Pedro Ivo Pedroni Cordeiro
- . Hospital do Trabalhador de Curitiba, Curitiba, PR, Brazil
- . Hospital Universitário Evangélico Mackenzie, Curitiba, PR, Brazil
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Edwards TA, Daly C, Donovan RL, Whitehouse MR. Risk of complications following surgical fixation of femoral diaphyseal fractures in children aged 4 to 12 years: A systematic review and meta-analysis. Injury 2022; 53:1020-1028. [PMID: 34782115 DOI: 10.1016/j.injury.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There is debate regarding the optimal surgical technique for fixing femoral diaphyseal fractures in children aged 4 to 12 years. The National Institute for Health and Care Excellence (NICE) and the American Academy of Orthopaedic Surgeons (AAOS) have issued relevant guidelines, however, there is limited evidence to support these. The aim of this study was to conduct a systematic review and meta-analysis to compare the complication rate following flexible intramedullary nailing (FIN), plate fixation and external fixation (EF) for traumatic femoral diaphyseal fractures in children aged 4 to 12. METHODS We searched MEDLINE, EMBASE and CENTRAL databases for interventional and observational studies. Two independent reviewers screened, assessed quality and extracted data from the identified studies. The primary outcome was the risk of any complication. Secondary outcomes assessed the risk of pre-specified individual complications. RESULTS Nine randomised controlled trials (RCTs) and 19 observational studies fulfilled the eligibility criteria. Within the RCTs, five analysed FIN (n = 161), two analysed plates (n = 51) and five analysed EF (n = 168). Within the observational studies, 13 analysed FIN (n = 610), seven analysed plates (n = 214) and six analysed EF (n = 153). The overall risk of complications was lower following plate fixation when compared to FIN fixation (RR 0.45, 95% CI 0.28 to 0.73, p = 0.001) in the observational studies. The overall risk of complications was higher following EF when compared to FIN fixation in both RCTs (RR 1.94, 95% CI 1.25 to 3.01, p = 0.003) and observational studies (RR 1.97, 95% CI 1.50 to 2.58, p<0.001). The overall risk of complications was higher following EF when compared to plate fixation in both RCTs (RR 7.42, 95% CI 1.84 to 29.98, p = 0.005) and observational studies (RR 4.39, 95% CI 2.64 to 7.30, p<0.001). CONCLUSION Although NICE and the AAOS recommend FIN for femoral diaphyseal fractures in children aged 4 to 12, this study reports a significantly decreased relative risk of complications when these injuries are managed with plates. The overall quality of evidence is low, highlighting the need for a rigorous prospective multicentre randomised trial at low risk of bias due to randomisation and outcome measurement to identify if any fixation technique is superior.
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Affiliation(s)
- Tomos A Edwards
- Trauma and Orthopaedic Department, North Bristol NHS Trust, Brunel Building, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, United Kingdom.
| | - Catriona Daly
- Trauma and Orthopaedic Department, Somerset NHS Foundation Trust, Musgrove Park Hospital, Parkfield Drive, Taunton, TA1 5DA, United Kingdom
| | - Richard L Donovan
- Trauma and Orthopaedic Department, North Bristol NHS Trust, Brunel Building, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, United Kingdom; Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - Michael R Whitehouse
- Trauma and Orthopaedic Department, North Bristol NHS Trust, Brunel Building, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, United Kingdom; Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, United Kingdom; National Institute for Health Research, Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol
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Guo M, Su Y. Risk factors for refracture of the femoral shaft in children after removal of external fixation. J Orthop Traumatol 2021; 22:4. [PMID: 33625585 PMCID: PMC7905006 DOI: 10.1186/s10195-021-00569-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 02/15/2021] [Indexed: 12/17/2022] Open
Abstract
Background External fixation is the primary treatment option in children for femoral shaft fractures, such as open femoral or multiple fractures. One complication is refracture, which is the biggest limitation of fixation devices. This study aims to investigate the risk factors associated with refracture after the removal of external fixation devices and decrease the frequency of refracture. Materials and methods Retrospectively reviewed clinical data of 165 patients treated at our hospital for fresh femoral shaft fractures with external fixation between May 2009 and February 2018 were included in this study. Patients with pathological fractures, fractures of the femoral neck, fractures that were fixed using plates or elastic stable intramedullary nailing, and old fractures, as well as those who underwent postoperative femoral surgery were excluded. Potential risk factors included: patient age, gender, and weight, fracture sides, open or closed fracture, fracture sites, reduction methods, operation time, perioperative bleeding, number and diameter of the screws, and immobilization time. These factors were identified by univariate and logistic regression analyses. Results Femoral shaft refracture developed in 24 patients. Univariate analysis revealed that refracture was not statistically significantly associated with any of the above factors, except AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) classification type 32-D/4.2 and L2/L3 ratio (L2, length of femur fixed by the two screws farthest from the fracture line; L3, the total length from the greater trochanter to the distal end of femur; P < 0.001 and P = 0.0141, respectively). Multivariate analysis showed that PCCF classification type 32-D/4.2 and L2/L3 ratio were also independent risk factors for femoral refracture. Conclusions Femoral shaft refracture is relatively common in children treated with external fixation. Because of the limited number of cases in this study, we cautiously concluded that the PCCF classification type 32-D/4.2 and L2/L3 ratio were independent risk factors for femoral shaft refracture in these patients. Level of evidence IV
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Affiliation(s)
- Meizhen Guo
- Department II of Orthopedics, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, The Children's Hospital of Chongqing Medical University, 136# Zhongshan 2road Yuzhong District, Chongqing, 400014, China
| | - Yuxi Su
- Department II of Orthopedics, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, The Children's Hospital of Chongqing Medical University, 136# Zhongshan 2road Yuzhong District, Chongqing, 400014, China.
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