Twenty-Year Experience with Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients

Rigid intramedullary nailing of lower limb segments in children and adolescents with metabolic bone disease

Children and adolescents with metabolic bone disease present to the orthopedic surgeon with pain, fractures (which may be impending), and deformity. Different modalities of orthopedic management are available. Scant literature exists on the use of rigid intramedullary nailing in this population. This study sought to evaluate the utilization of this treatment modality in the pediatric cohort, focusing on indications, techniques, and outcomes of the procedures. A retrospective review was performed over an 11-year period at a single tertiary pediatric institution in the UK. Medical records and radiographs were reviewed. Preoperative surgical and medical management, time to bony union, and complications were specifically ascertained. Twenty-seven patients (63 lower limb segments) had rigid intramedullary nailing over the specified period. The majority of patients had an underlying diagnosis of osteogenesis imperfecta or fibrous dysplasia (including McCune Albright Syndrome). Surgical indications included acute fractures, prophylactic stabilization, previous nonunion and malunions, deformity correction, and limb lengthening. All fractures healed and deformity correction was successful. In one patient, delayed union occurred after deformity correction and was successfully treated with dynamization. Fractures healed faster than corrective osteotomies. Complications included implant prominence, cortical penetrance, and screw loosening. Nonunion occurred with limb lengthening in one patient. Rigid intramedullary nailing is a safe and effective method of treatment for lower limb fractures and deformities in children and adolescents. This technique is, therefore, recommended for patients with metabolic bone disease. However, care must be taken in preoperative surgical planning and a multidisciplinary approach should be utilized.

Rate of Osteonecrosis After Femoral Lengthening with Intramedullary Lengthening Nails

BACKGROUND

There has been historical concern that the use of intramedullary nails could present undue risk of osteonecrosis of the femoral head due to compromise of the femoral blood supply. Intramedullary lengthening nails are rapidly becoming commonplace in lengthening procedures. As such, the primary objective of this study was to analyze the rates of osteonecrosis following femoral lengthening. The secondary objective was to characterize general trends in femoral lengthening.

METHODS

This retrospective cohort study evaluated patients who had undergone femoral lengthening at a single institution from 2012 to 2021. Retrospective chart review and radiographic evaluation of osteonecrosis were conducted. The primary end point was radiographic evidence of osteonecrosis. The secondary variables were the starting point of the femoral nail, the total amount of lengthening, and the time to consolidation.

RESULTS

Two hundred and forty-seven patients were included in the analysis, including 111 males and 136 females, with a mean age of 17 years. No patient had radiographic evidence of osteonecrosis (0%) or coxa valga (0%). The average amount of lengthening was 4.88 cm (range, 1.5 to 8.5 cm). No patient had any extensive complications, such as alterations in the proximal femoral anatomy.

CONCLUSIONS

This largest study to date investigating complications following femoral lengthening using intramedullary lengthening nails revealed that femoral lengthening is a well-tolerated procedure, and osteonecrosis is an infrequent complication.

LEVEL OF EVIDENCE

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

An alternative choice for overweight pediatric patient with femoral shaft fracture when rigid nail is contraindicated due to narrow intramedullary canal: Elastic stable intramedullary nail plus temporary external fixator

BACKGROUND

Length unstable femoral shaft fractures in school-aged children usually demand surgical treatment, but the optimal choice remains controversial, especially in overweight adolescents. This study aimed to compare the clinical results of locking compression plates (LCP) and elastic stable intramedullary nails (ESIN) combined with temporary external fixator (TEF) in school-aged children weighing over 50 kg.

METHODS

Between January 2010 and January 2018, children over 50 kg with length unstable femoral shaft fracture treated with ESIN & EF in the authors' institute were included in this study. Adolescent patients with matched age, sex, body weight and fracture type receiving LCP were retrieved from hospital database. The Flynn Score System was used to evaluate the clinical outcomes of treatments at the last follow-up.

RESULTS

A total of 30 young children aged 10-14 years were included. Fifteen patients (9 male and 6 female) received ESIN & EF treatment, while the other fifteen (9 male and 6 female) received LCP treatment. All patients were followed up for more than 12 months post-surgery (14-26 months). In all, less operation time, less estimated blood loss and shortened hospital stay (P < 0.001), faster union time (P = 0.031) were observed in ESIN & EF group, compared with the Plating group. All surgeries in the ESIN & EF group were performed without exposing the fracture site. In contrast, 60 % (9/15) of the surgeries in the Plating group were performed with the fracture site exposed. Every patient scored satisfactory or excellent on the Flynn Score System without major complications demanding revision surgeries.

CONCLUSIONS

ESIN plus EF produces satisfactory clinical outcome for overweight pediatric patients with femoral shaft fracture when rigid nail is contraindicated due to narrow medullary canal.

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.

Paediatric femoral shaft fractures: an instructional review for the FRCS examination

This review presents the principal features of paediatric femoral shaft fractures including the contemporary management strategies and relevant supporting evidence. The article is an overview of information relevant to clinical practice, in addition to preparation for the FRCS (Orth) examination.

Intramedullary Fixation for Pediatric Femoral Nonunion in Low- and Middle-Income Countries

BACKGROUND

Pediatric femoral shaft nonunion after use of a plate or intramedullary nail (IMN) is uncommon in the United States. In low and middle-income countries, as defined by The World Bank, these complications may occur with greater frequency. We assessed the rates of union and painless weight-bearing after IMN fixation of pediatric femoral shaft nonunion in lower-resource settings.

METHODS

We queried the SIGN (Surgical Implant Generation Network) Fracture Care International online database to identify all pediatric femoral shaft nonunions that had occurred since 2003 and had ≥3 months of follow-up after their treatment; our query identified 85 fractures in 83 patients. We defined nonunion as failure of initial instrumentation >90 days following its placement, lack of radiographic progression on radiographs made >3 months apart, or the absence of signs of radiographic healing >6 months after initial instrumentation. We evaluated the most recent follow-up radiograph to determine a Radiographic Union Scale in Tibial fractures (RUST) score. We also recorded rates of painless full weight-bearing as assessed by the treating surgeon.

RESULTS

Fifty-seven patients with pediatric femoral shaft nonunions (including 42 male and 15 female patients from 18 countries) were included. The average age (and standard deviation) at the time of revision surgery was 13.8 ± 3.0 years (range, 6 to 17 years). The median duration of follow-up was 67 weeks (range, 13 weeks to 7.7 years). The initial instrumentation that went on to implant failure included plate constructs (56%), non-SIGN IMNs (40%), and SIGN IMNs (4%). At the time of the latest follow-up, 52 patients (91%) had a RUST score of ≥10 and 51 (89%) had painless full weight-bearing. No patient had radiographic evidence of femoral head osteonecrosis at the time of complete fracture-healing or the latest follow-up.

CONCLUSIONS

Pediatric femoral shaft nonunion can occur after both plate and IMN fixation in low and middle-income countries. IMN fixation is an effective and safe treatment for these injuries.

LEVEL OF EVIDENCE

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

Treatment of Pediatric Femoral Shaft Fractures

Diaphyseal femur fractures are common in pediatric orthopaedic settings. A patient-specific treatment plan incorporates several factors, including age, weight, fracture pattern, associated injuries, and social considerations. Nonaccidental trauma should be considered in children younger than 3 years. In general, young children are treated with noninvasive immobilization (Pavlik harness or early hip spica casting) while school-aged children are treated with internal fixation. Internal fixation options include flexible intramedullary nails, rigid locked intramedullary nails, and plate osteosynthesis. Flexible intramedullary nails have the best outcomes in children of appropriate weight, aged 5 to 11 years, with stable fracture patterns. Lateral-entry rigid intramedullary nails have been designed for use in older children. External fixation is usually reserved for complex scenarios. Regarding all treatment methods, surgeons should be aware of several technical factors necessary to optimize outcomes.

Paediatric Femoral Diaphyseal Fractures in a South Wales Tertiary Centre: An Account of Trend in Management and Complications Over 16 Years

Femoral shaft fractures in children have seen a number of interesting developments over the past 20 years. This is a retrospective cohort study looking into epidemiological and outcomes data of femoral shaft fractures in children treated at a tertiary centre in Wales from 2005-2021. Over a period of 16 years, there has been a significant increase in the number of rigid or elastic nailing and submuscular plating, coinciding with a dramatic reduction of external fixation for definitive treatment of diaphyseal femoral fractures. All patients above five years of age underwent operative fixation, with elastic or rigid intramedullary nailing the treatment of choice. Following multiple linear regression with 16 possible explanatory factors, this study found a statistically significant increase in time to union for open fractures, pre-operative translation, and operation time. Furthermore, there was a significant increase in post-operative leg length discrepancy for right versus left-sided fractures. Overall complication rates were 4% for minor and 8% for major complications. Complication rates were lowest for rigid intramedullary nailing and highest for external fixation. No cases of avascular necrosis were found for 27 rigid intramedullary nails inserted. Overall this study reports treatment choices and outcomes in keeping with current trends in management for paediatric femoral shaft fractures.

Indications for and Risks Associated With Implant Removal After Pediatric Trauma

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

Rigid intramedullary nail fixation of traumatic femoral fractures in the skeletally immature

Objective

To determine the rate of femoral head osteonecrosis, and other complications following rigid intramedullary (IM) nail fixation of traumatic diaphyseal femur fractures through the greater trochanter in the skeletally immature.

Design

Retrospective review, case series.

Setting

Level I academic trauma center.

Patients/Participants

One hundred forty-eight traumatic pediatric diaphyseal femur fractures in 145 patients treated with rigid IM nail fixation from November 1, 2004 to December 31, 2018.

Intervention

Rigid intramedullary nail fixation of traumatic diaphyseal femur fractures through a trochanteric start point in the skeletally immature.

Main outcome measurement

Rate of osteonecrosis of the femoral head.

Results

Sixty-five fractures in 64 skeletally immature patients met inclusion criteria. Motor vehicle collisions were implicated in 32 fractures. Of the 65 fractures, 5 were open. All rigid IM nails were anterograde with a trochanteric start point. Mean radiographic follow-up was 27.4 ± 8.1 months. Twenty-two patients experienced postoperative pain and/or hardware irritation, with 24 patients (36.9%) undergoing reoperation for hardware removal. No occurrences of infection, malunion, nonunion, refracture, venous thromboembolism, fat embolism, significant leg length discrepancy, or femoral head osteonecrosis were documented. Two cases of heterotopic ossification were observed, 1 requiring surgical excision, yielding a complication rate of 3.1%.

Conclusions

No cases of femoral head osteonecrosis were observed following treatment of 65 traumatic diaphyseal femur fractures with rigid IM nailing through the greater trochanter with a mean radiographic follow-up of 27 months. Rigid IM nail fixation with a trochanteric start point is both safe and efficacious for management of diaphyseal femur fractures in the skeletally immature.

The clinical features, management options and complications of paediatric femoral fractures

This article discusses the incidence, applied anatomy and classification of paediatric femoral fractures based on critical appraisal of the available evidence. The aim is to identify techniques that are relevant to contemporary practice whilst excluding the technical details of individual procedures that are beyond the scope of this review. Injuries of the proximal, diaphyseal and distal segments are considered individually as there are considerations that are specific to each anatomical site. Femoral neck fractures are rare injuries and require prompt anatomical reduction and stable fixation to minimise the potentially devastating consequences of avascular necrosis. Diaphyseal fractures are relatively common, and there is a spectrum of management options that depend on patient age and size. Distal femoral fractures often involve the physis, which contributes up to 70% of femoral length. Growth arrest is common consequence of fractures in this region, resulting in angular and length-related deformity. Long-term surveillance is recommended to identify deformity in evolution and provide an opportunity for early intervention. Deliberate injury should be considered in all fractures, particularly distal femoral physeal injuries and fractures in the non-walking child.

Evaluation of Intramedullary Fixation for Pediatric Femoral Shaft Fractures in Developing Countries

OBJECTIVES

To report the clinical results after treatment of pediatric femoral shaft fractures with the SIGN Fracture Care International (SIGN) pediatric and standard fin nails.

DESIGN

Retrospective review of prospectively collected data.

SETTING

Sixteen global SIGN centers from 2003 to 2013.

PATIENTS/PARTICIPANTS

One hundred twelve pediatric patients who sustained a diaphyseal pediatric femoral shaft fracture.

INTERVENTION

Intramedullary fixation with the standard or pediatric SIGN nail.

MAIN OUTCOME MEASUREMENTS

Main outcome measurements include clinical and radiographic healing and postoperative complications.

RESULTS

The mean age of the pediatric fin patients was 9.4 years (4-15) and 11.2 years (4-18) for the standard fin patients. Painless weight bearing was achieved in 94.7% and 94.5% of the patients at the last follow-up. In total, 23 patients had repeat surgery for the removal of implant. Failure of implant with bending of the nail and/or a valgus or varus deformity (>10 degrees) was noted in 7/57 (12.3%) of the patients treated with the pediatric fin nail, of which 6/7 were >10 years old. Five of these 7 patients were classified as technical errors attributed to inadequate nail diameter, length, or initial malreduction. No complications were noted at any age in the standard fin nail group.

CONCLUSIONS

In resource-poor settings, SIGN pediatric fin and standard fin nails seem to be an effective treatment option for femoral shaft fractures. In patients with larger canals, the surgeon should consider using the standard fin nail for improved stability and to minimize potential complications.

LEVEL OF EVIDENCE

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

Complications after operative treatment of femoral shaft fractures in childhood and adolescence

Purpose of the study was to retrospectively analyze the complication rates after operatively treated femoral shaft fractures in childhood and adolescence. Retrospective evaluation of 42 children with operatively treated femoral shaft fractures between 2000 and 2014. Fractures were classified as 27 A type, 12 B type and 3 C type fractures according the OTA/AO classification. 8 (19.05%) fractures were open. Age averaged 10.2 years (3-16). Fracture treatment was recorded as temporary or definitive external fixation, ESIN, plate fixation or IMN. Complications such as wound infection, re-fractures, nonunion and malunion were analyzed. Six (14.29%) fractures were temporarily stabilized using an external fixator. In 22 (52.38%) children the femoral shaft fracture was stabilized using ESINs. 10 (23.81%) children had a plate fixation and 9 (21.43%) adolescents were treated using an IMN. ESIN treated children were significantly younger (P=0.000) and had less weight (P=0.000) than children treated with both other methods. Complications were two (4.76%) superficial and two deep (4.76%) wound infections, one (2.38%) re-fracture with the ESIN in situ, one (2.38%) nonunion and one (2.38%) malunion. Six (14.29%) children required a reoperation for a complication. Risk factors for complications were temporarily applied external fixators, open fractures, C Type fractures (P=0.031) and an increasing age (P=0.048) and weight (P=0.047) of the child. The majority of children in our study population were successfully treated using ESIN presenting a low complication rate. Complications were observed following open fractures and more complex fracture types. Furthermore we observed an increasing complication rate with increasing ages and weights of the children.

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.

Double-plating fixation of comminuted femoral shaft fractures with concomitant thoracic trauma

Objective This study was performed to evaluate the clinical outcomes in adult polytraumatized patients with thoracic injury and femoral shaft fractures treated with double-plating fixation. Methods From November 2010 to October 2014, 15 polytraumatized patients with femoral shaft fractures were enrolled in this retrospective study. Radiographic findings and functional outcomes were assessed at 1, 3, 6, and 12 months postoperatively. Results Fourteen (93%) of the 15 femoral shaft fractures achieved bony union, with a mean time to union of 9.2 months. The mean Nonarthritic Hip Score and Lysholm Knee Score was 89.4 and 87.2 points, respectively. The range of motion of the knee joint was comparable between the injured and uninjured legs (116° and 121°, respectively). Conclusions Our findings suggest that lower limb function returns to normal after orthogonal double-plating fixation, which is an alternative technique to intramedullary nailing for femoral diaphyseal fractures in patients with severe chest injury.

Differential proteomic screening and identification for non-traumatic necrotic femoral osseous tissue

Currently, there is a lack of effective early screening and detection methods for femoral head necrosis. Current research on most orthopedic diseases focuses on proteomics in the preliminary stage. The recent fluorescence differential in gel electrophoresis (DIGE) has advantages such as a high reproducibility, high sensitivity, high throughput, and high dynamic range. It is currently one of the most widely used quantitative proteomic research means. We conducted this study to investigate the pathogenesis of non-traumatic femoral head necrosis using the fluorescence DIGE to screen non-traumatic femoral head necrosis based on proteomics and provide a theoretical basis for screening possible biomarkers and molecular targeted treatment. The DIGE technique was used to separate the protein. An electrophoretogram was established on the basis of scanning and analysis. Identification and a bioinformatics analysis were conducted for the differential protein. The protein with differential expression of over 2-fold was excavated and ionized by means of substrate assisted laser desorption. The flight time was identified with a mass spectrometer (matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, MALDI-TOF/TOF). The formation on sequences, structures and functions of these proteins were obtained through database retrieval. Western blot analysis was used to verify the differential protein expression and the reliability of the DIGE result was verified. DIGE was used to successfully separate 1,500±40 protein spots. There were 252 significant differential protein spots. The Ettan™ Spot Picker automatic work station was used to excavate 49 significant differential protein spots with expression difference over 2-fold. The MALDI-TOF/TOF mass spectrometer was used to identify these differential protein spots. Six proteins were identified in total, which include apolipoprotein A1 (APOA1), fibrous protein original chain, fibrous protein original chain, serum albumin, sulfur-oxygen protein peroxiredoxin 2 (PRDX2) and actin. APOA1 and PRDX2 were subject to western blot analysis detection; results were consistent with the DIGE result. Based on an analysis of the biological information, these proteins may be associated with the incidence and progression of femoral head necrosis.

Percutaneous rotational osteotomy of the femur utilizing an intramedullary rod

The purpose is to describe the technique and report the results and complications of percutaneous femoral rotational osteotomy, secured with a trochanteric-entry, locked intramedullary rod, in adolescents with femoral anteversion. Our series comprised an IRB approved, retrospective, consecutive series of 85 osteotomies (57 patients), followed to implant removal. The average age at surgery was 13.3 years (range 8.8–18.3) with a female-to-male ratio of 2.8:1. The minimum follow-up was 2 years. Eighty-three osteotomies healed primarily. Two patients, subsequently found to have vitamin D deficiency, broke screws and developed nonunions; both healed after repeat reaming and rod exchange and vitamin supplementation. Preoperative symptoms, including in-toeing gait, tripping and anterior knee pain or patellar instability, were resolved consistently. We did not observe significant growth disturbance or osteonecrosis. We noted a 12.5 % incidence of broken interlocking screws; this did not affect the correction or outcome except for the two patients mentioned above. This prompted a switch from a standard screw (core diameter = 3 mm) to a threaded bolt (core diameter = 3.7 mm). These results have led this technique to replace the use of plates or blade plates for rotational osteotomies.

Rigid Intramedullary Nailing of Femoral Shaft Fractures for Patients Age 12 and Younger: Indications and Technique

Femoral shaft fractures are common injuries in the pediatric and adolescent age groups. Rigid intramedullary nailing is an excellent treatment option for older children and adolescents, particularly for length-unstable fractures and larger patients (>49 kg). Appropriate indications, contraindications, and preoperative assessment are described. The rigid nailing surgical technique is detailed including positioning, operative steps, pearls, and pitfalls. Complications and the reported outcomes of lateral trochanteric entry nailing are reviewed from the published series.

Internal fixation after fracture or osteotomy of the femur in young children with polyostotic fibrous dysplasia

Children from 4 to 7 years of age with polyostotic fibrous dysplasia (PFD) may need internal fixation of the femur for either fracture or osteotomy. At that age, the small size of the femur allows only the use of small intramedullary nails. However, titanium elastic nails and rigid intramedullary pediatric interlocking femoral nails - good for fracture or osteotomy fixation in the normal femur - are not indicated in PFD. From 2009 to 2011, we treated eight cases of PFD femoral fracture and deformity by internal fixation with a custom-modified adult humeral nail to which a spiral blade was connected. The 7-mm thick nail fit properly into the small femoral shaft and the spiral blade conferred ideal mechanical support to the femoral neck. Three cases had replacement of the humeral nail with a more appropriate adult femoral nail 3 years after the index procedure when the femur had reached an adequate size. In the maximum follow-up period of 4 years, few complications were observed.

What's new in pediatric orthopaedics

This past year has seen an increase in the quality of studies in pediatric orthopaedics, and the completion of BrAIST demonstrated that high-level studies of important questions can be addressed in pediatric orthopaedics. The current commitment of improving quality of care for children promises a healthy future for pediatric orthopaedics.

Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients Using a Lateral Trochanteric Entry Portal

Introduction

We describe rigid intramedullary nailing using a trochanteric entry for internal fixation of femoral shaft fractures in older children and adolescents.

Step 1 Preparation Prior to Incision

Appropriate preparation prior to the operation is key to minimizing intraoperative and postoperative complications.

Step 2 Perform Incision and Exposure

A well-positioned incision will facilitate and reduce difficulty with ideal guidewire placement.

Step 3 Place and Overream the Guide Pin

Ensure that the guide pin is properly positioned on the greater trochanter, while avoiding the piriformis fossa.

Step 4 Place the Guidewire and Reduce the Fracture

Prepare the definitive guidewire. Insert the guidewire into the proximal fragment via the trochanteric portal. While maintaining the fracture reduction, advance the guidewire into the distal fragment.

Step 5 Measure Nail Length and Begin Overreaming

Pay careful attention to the amount of reaming as well as distraction across the fracture site to provide the best fit for the nail.

Step 6 Insert the Nail

Be sure to maintain the reduction while advancing the nail across the fracture site. Reconfirm that traction has been reduced to avoid distraction at the fracture site.

Step 7 Insert Proximal and Distal Interlocks

Use the interlocking screws to secure the proper rotational alignment.

Step 8 Make Final Images and Close the Wound

Confirm the reduction and adequate fixation before closure.

Results

In our original study, a cohort of 246 femoral shaft fractures among 241 skeletally immature patients treated with trochanteric entry rigid intramedullary nailing was retrospectively reviewed.IndicationsContraindicationsPitfalls & Challenges.