Pitfalls of femoral titanium elastic nailing

Diaphyseal Femur Fractures in Children and Adolescents-Opportunities and Limitations of the ESIN Technique

Background: Elastic stable intramedullary nailing (ESIN) is the gold standard for non-overweight children aged 6−12 years. However, the complication rate using elastic stable intramedullary nailing is considerably high. Nevertheless, the question arises of whether the indication for elastic stable intramedullary nailing therapy can be extended and which factors must be taken into account when determining the indication. Methods: A retrospective chart review of patients <18 years admitted with diaphyseal femur fracture at a Level I Trauma Center in Germany between 2005 and 2017 was performed. In total, 118 patients were included. For the classification of femur fractures in children, the AO Pediatric Comprehensive Classification of Long-Bone Fractures (AO-PCCF) was applied. Results: Simple oblique fractures (32-D/5.1) occurred in most of the patients. Patients with simple oblique fractures were significantly younger compared to patients with simple transverse (32-D/4.1) or multifragmentary (32-D/5.2) fracture type according to the AO Pediatric Comprehensive Classification of Long-Bone Fractures. Most patients were treated with elastic stable intramedullary nailing (68 patients, 58%). Although children treated with elastic stable intramedullary nailing were older than those treated conservatively (25%, n = 29, mean age 1.5, median age 1.0), the children in the elastic stable intramedullary nailing group were comparatively young (range 1−12 years, mean age 5.4, median age 5). A total of 32 children below the age of 6 years were treated with elastic stable intramedullary nailing. Complications were more frequent in patients with overhead extension (50%) compared to conservative treatment with a spica cast (17%) or elastic stable intramedullary nailing (15%). Conclusions: Elastic stable intramedullary nailing therapy was associated with a low complication rate and was, therefore, a safe and frequently used treatment strategy in diaphyseal femur fractures with satisfactory results, even though the age groups were expanded in favor of younger patients.

TREATMENT OF PEDIATRIC FEMORAL FRACTURES IN THE CITY OF ZAGREB

Femur fractures in children can be treated with a number of operative and conservative methods. Numerous factors determine which method is optimal for a specific fracture. The aim of this research was to analyze distribution of femur fractures in children living in the urban communities of Zagreb and Zagreb County by localization, type and frequency of treatment methods used according to age and fracture mechanism. The research included 103 children aged up to 18 years, treated for femur fractures at the Zagreb University Hospital Centre and Zagreb Children’s Hospital. Data were collected from these institutions and a retrospective study covered the 2010-2015 period. The cause of fracture and diagnosis were coded with the help of the International Statistical Classification of Diseases and Related Health Problems. Operative treatment was applied in 55% of cases, which is contrary to previous researches. The highest incidence of femur fractures was recorded in the 0- to 4-year age groups, accounting for 49.1% of all fractures. These fractures mostly occurred due to falls and were more often treated with non-operative methods. All other age groups were mostly treated with operative methods. Coxofemoral immobilization and traction were used as non-operative methods, whereas flexible intramedullary nailing was the most frequently used operative method. The treatment depended on age, complexity of the fracture, fracture type, fragment displacement, and associated injuries. The cause was also an important factor on choosing the treatment method. Non-operative treatment was mostly used for fractures caused by falls (64.71% of cases due to falls) and operative treatment was mostly used for fractures caused by traffic accidents (79.4% of cases due to traffic accidents). It is a wide-known opinion that the best treatment for femur fractures in children is non-operative treatment. However, recent studies have shown that the use of operative methods in femur fracture treatment is growing. Our cohort of children treated during a five-year period (2010-2015) also underwent operative treatment more often than non-operative one. Two non-operative and eight operative methods were used. With such a large number of methods, it is clear that there is no unique method for all fractures. However, it is clear that the trend of using operative treatment is connected to the perennial trend of considerable sociodemographic and socioeconomic changes in urban settings such as Zagreb. Lifestyle changes directly affect the prevalence of femur fractures among children, as well as approach to treatment choice. General opinion is that most of fractures that occur at an early age can be treated with non-operative methods. Our research on femur fractures in children confirmed this rule. The youngest age group that had the highest incidence of fractures (49.1% of all fractures) was treated with non-operative methods in 75% of cases. Operative methods prevailed in other age groups. Similar results have been published by other authors. In conclusion, nearly half of all femur fractures (49.1%) occurred at a young age (0-4 years). Diaphysis fractures were most common. Most of the fractures that occurred during the 2010-2015 period were treated with operative methods, mostly in children aged 5-9 years. Out of eight different operative methods, elastic stable intramedullary osteosynthesis was most frequently used (60%). Coxofemoral immobilization and traction were used as non-operative methods.

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.

Femoral shaft fractures in young children (<5 years of age): operative and non-operative treatments in clinical practice

BACKGROUND

Femoral shaft fractures comprise around 4 % of all long-bone fractures in childhood. There is controversy about the treatment of fractures in children below 5 years, between those preferring non-operative methods, such as casting or traction, and those supporting elastic stable intramedullary nailing (ESIN).

METHODS

This retrospective study evaluates the day-by-day treatment of femoral shaft fractures in children aged 6-60 months in four major paediatric surgery trauma centres in Germany from 1 January 2004 to 31 December 2011 by chart review. We analysed all patient-related data, causes of fracture, fracture type, treatment method and potential post-treatment complications.

RESULTS

We identified 225 patients (male to female 2:1) with femoral shaft fractures. Around 2/3 of these resulted from falls of less than 1 m or 1-3 m, the most frequent result (>40 %) being a long spiral fracture. All 19 children below 1 year of age were treated by casting or traction. Between the ages of 12 and 24 months (n = 56), different treatment concepts were preferred (1/5 ESIN, 2/5 traction and 2/5 spica casting). Between 24 and 36 months, operative and non-operative therapies were equally distributed. In children older than 36 months (n = 64), most fractures were treated by ESIN: six children by external fixation and 14 by other treatments like spica casting, plate osteosynthesis or a combination of methods. 42 changes of treatment were performed: traction to spica casting or secondary operative treatment and 21 complications occurred (nails left in place for too long, skin defects or wound infections).

CONCLUSIONS

Spica casting of femoral shaft fractures or, in some cases, traction is still the preferred treatment in the first and second years of life. In the third year, children are treated operatively as well as non-operatively, although now there is no current evidence of better short-term outcomes in operatively treated children. But elastic stable intramedullary nailing is the standard treatment for femoral shaft fractures in children older than 3 years of age.

Risk factors for complications and readmission after operative fixation of pediatric femur fractures

PURPOSE

Operative fixation of pediatric femur fractures with intramedullary implants has grown in popularity in recent decades. However, risk factors for short-term adverse events and readmission have not been well studied.

METHODS

Pediatric patients who underwent intramedullary nailing of a femur fracture between 2012 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Risk factors for any adverse event (AAE) and readmission after intramedullary nailing were evaluated using univariate and multivariate analysis.

RESULTS

A total of 522 pediatric patients who underwent intramedullary nailing of the femur during the study period were identified. The mean age of this patient cohort was 10.2 ± 3.8 years. Review of the cases revealed that 18 (3.4 %) patients had AAE and that 20 (3.8 %) patients were readmitted, of whom 13 (2.5 %) underwent a reoperation. Independent risk factors for AAE were a cardiac comorbidity [odds ratio (OR) 12.7, 95 % confidence interval (CI) 1.5, 103.7], open fracture (OR 10.2, 95 % CI 1.4, 74.4), and prolonged operative time (OR 17.5, 95 % CI 6.1, 50.5). Independent risk factors for readmission were a central nervous system disorder (OR 4.5, 95 % CI 1.3, 16.2) and a seizure disorder (OR 4.9, 95 % CI 1.0, 23.5).

CONCLUSIONS

The results of the multivariate analysis suggest that cardiac comorbidities, open fractures, and prolonged operative time increase the risk for AAE and that central nervous system disorders and seizure disorders may increase the risk for readmission. Surgeons should be aware of these risk factors and counsel the families of pediatric patients who undergo intramedullary nailing of femur fractures.

Elastic Stable Intramedullary Nailing for Fractures in Children - Specific Applications

Elastic stable intramedullary nailing (ESIN) is a new minimally invasive technique for the treatment of pediatric fractures. It approximates the physiological healing process of bone, without opening the fracture site. Also, the operative stress is minimal because of the minimally invasive nature of the procedure, and the volume of implants is small, offering a very good stability without plaster cast immobilization.