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Titanium elastic nailing versus locking compression plating in school-aged pediatric subtrochanteric femur fractures

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The treatment of children between 5 and 12 years of age suffering from subtrochanteric femoral fracture is challenging. The optimal choice of internal fixation for these patients is controversial. The purpose of this study is to compare the outcomes and complications of titanium elastic nail and open reduction with plate fixation of subtrochanteric femur fractures in school-aged children. A total of 67 children aged 5 to 12 years with subtrochanteric femur fractures treated with titanium elastic nails or open plating were identified at our institution from January 2007 to December 2017. We retrospectively compared 39 children treated with titanium elastic nails with 28 children treated with open reduction and plate fixation. The data included age, sex, body weight, fracture pattern, operation time, blood loss, and length of hospitalization. The follow-up investigations included radiograph of pelvis, bilateral hip range of motion, bilateral femoral neck shaft angle, and length of lower extremity. The outcomes were classified according to Flynn classification as excellent, satisfactory, or poor. All the demographic characteristics were compared with statistical analyses. All 67 fractures united properly. No major postoperative complications were noted in both groups. No significant difference was found between the titanium elastic nail and open plating groups in terms of sex, fracture pattern, and length of hospitalization. We noted a significant difference between 2 groups in terms of age, weight, operation time, and blood loss. In total, we observed 24 excellent and 15 satisfactory results in the titanium elastic nail group, and 19 excellent results and 9 satisfactory results in the open plating group. There was no significant statistical difference between involved and uninvolved side of hip regarding range of motion and femoral neck shaft angle in both groups. Titanium elastic nail and pediatric hip plate fixation represent safe and effective methods in the treatment of subtrochanteric fractures in school-aged children. Titanium elastic nail internal fixation is a minimal invasive and simpler technique and suitable for young children of lower body weight. Open plate fixation is a more rigid fixation associated with a lower complication rate.
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Titanium elastic nailing versus locking
compression plating in school-aged pediatric
subtrochanteric femur fractures
Yunlan Xu, MD
a
, Jingxia Bian, MN
a
, Kaiying Shen, MD
a,
, Bin Xue, MD
b,
Abstract
The treatment of children between 5 and 12 years of age suffering from subtrochanteric femoral fracture is challenging. The optimal
choice of internal xation for these patients is controversial. The purpose of this study is to compare the outcomes and complications
of titanium elastic nail and open reduction with plate xation of subtrochanteric femur fractures in school-aged children.
A total of 67 children aged 5 to 12 years with subtrochanteric femur fractures treated with titanium elastic nails or open plating were
identied at our institution from January 2007 to December 2017. We retrospectively compared 39 children treated with titanium
elastic nails with 28 children treated with open reduction and plate xation. The data included age, sex, body weight, fracture pattern,
operation time, blood loss, and length of hospitalization. The follow-up investigations included radiograph of pelvis, bilateral hip range
of motion, bilateral femoral neck shaft angle, and length of lower extremity. The outcomes were classied according to Flynn
classication as excellent, satisfactory, or poor. All the demographic characteristics were compared with statistical analyses.
All 67 fractures united properly. No major postoperative complications were noted in both groups. No signicant difference was
found between the titanium elastic nail and open plating groups in terms of sex, fracture pattern, and length of hospitalization. We
noted a signicant difference between 2 groups in terms of age, weight, operation time, and blood loss. In total, we observed 24
excellent and 15 satisfactory results in the titanium elastic nail group, and 19 excellent results and 9 satisfactory results in the open
plating group. There was no signicant statistical difference between involved and uninvolved side of hip regarding range of motion
and femoral neck shaft angle in both groups.
Titanium elastic nail and pediatric hip plate xation represent safe and effective methods in the treatment of subtrochanteric
fractures in school-aged children. Titanium elastic nail internal xation is a minimal invasive and simpler technique and suitable for
young children of lower body weight. Open plate xation is a more rigid xation associated with a lower complication rate.
Abbreviations: AP =anteroposterior, LCP =locking compression plate, NSA =neck-shaft angle, OP =open plating, ROM =
ranges of motion, TEN =titanium elastic nails.
Keywords: internal facture xation, locking compression plate, open reduction, pediatric, subtrochanteric fractures, titanium
elastic nail
1. Introduction
Fractures of the proximal third of the femur, particularly in the
subtrochanteric region, are at a higher risk for complications.
Correct fracture reduction is more difcult to obtain or maintain
because of their special anatomical position.
[13]
Rigid intra-
medullary nailing and locking compression plating are the
preferred treatment in adolescents.
[4,5]
Few studies focused on
the treatment of the school-aged children or young adolescents
between 5 and 12 years of age suffering from subtrochanteric
femur fracture.
[6]
The optimal choice of internal xation for these
patients is discussed controversially. The purposes of this study are
to (1) compare radiological/clinical outcomeof titanium elastic nail
(TEN) and plate xation in subtrochanteric femur fractures in
school-age children, (2) and to analyze any possible complications.
2. Materials and methods
A consecutive series of patients aged 5 to 12 years with traumatic
subtrochanteric femur fractures were retrospectively compared.
We compared treatment using TENs; Synthes; Synthes Bio-
materials, Oberdorf, Switzerland) to open plating internal (OPI)
xation using locking compression plate (LCP; Synthes; Synthes
Biomaterials, Oberdorf, Switzerland) between January 2007 and
December 2017 in our institution. Informed consent was
obtained and institutional review board approval was acquired.
A subtrochanteric femur fracture was dened as a fracture that
was located within 10% of the total femur length below the lesser
Editor: Perbinder Grewal.
YX and JB, contributed equally to this work and should be considered corst
authors.
The authors of this work have nothing to disclose.
a
Department of Pediatric Orthopedics,
b
Department of Anesthesiology, Shanghai
Childrens Medical Center, Afliated to Shanghai Jiaotong University School of
Medicine, Shanghai, China.
Correspondence: Kaiying Shen, Department of Pediatric Orthopedics, Shanghai
Childrens Medical Center, Afliated to Shanghai Jiaotong University School of
Medicine, 1678 Dongfang Road, Pudong New Area, Shanghai 200127, P.R.
China (e-mail: skyscmc@163.com); Bin Xue, Department of Anesthesiology,
Shanghai Childrens Medical Center, Afliated to Shanghai Jiaotong University
School of Medicine, 1678 Dongfang Road, Pudong New Area, Shanghai
200127, P.R. China (e-mail: xuebin@scmc.com.cn).
Copyright ©2018 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Medicine (2018) 97:29(e11568)
Received: 1 January 2018 / Accepted: 27 June 2018
http://dx.doi.org/10.1097/MD.0000000000011568
Observational Study Medicine®
OPEN
1
trochanter according to Pombo and Shilt.
[7]
The rst available
postoperative full-length anteroposterior (AP) femur radiograph
was used to determine the total length of the femur, which was
dened as the distance between the top of the femoral head and
the medial femoral condyle. Next, the distance between the
inferior aspect of the lesser trochanter and the fracture site was
measured. If this distance was 10% of the total length of the
femur, the fracture was classied as subtrochanteric. Pathologic
fractures, fractures in patients with osteogenesis imperfecta, or
fractures in patients suffering from neuromuscular disorders were
excluded.
The data collected included age, weight, sex, fracture pattern,
method of xation, postoperative immobilization, length of
hospitalization, time to radiographic union, time of operation,
bleeding during the operation, bilateral hip ranges of motion
(ROM), and femoral neck-shaft angle (NSA) between involved
and uninvolved side after surgery. The radiographic data
included AP view of pelvis, AP and lateral views of femur,
preoperatively and postoperatively. Fracture patterns were
classied as length stable or length unstable. Length-stable
fractures were transverse and short oblique. Length-unstable
fractures were comminuted and long oblique fractures, where the
length of the obliquity was at least twice the diameter of the
femoral shaft at that level.
[3]
Radiographic union was dened as
bridging callus across at least three of the four cortices at the
fracture site seen both on AP and lateral radiographs of the
femur.
The nal functional outcomes evaluated by using Flynn scoring
system
[1]
were classied into excellent, satisfactory, or poor based
on residual leg-length inequality, fracture malalignment, pain,
Table 1
Titanium Elastic Nails Outcome Scoring System by Flynn et al
[1]
.
Excellent
result
Satisfactory
result Poor result
Malalignment, °5610 >10
Leg-length inequality, cm <1.0 1.02.0 >2.0
Pain None None Present
Complication None Minor and resolved Major complication
and/or lasting morbidity
Figure 1. A 7.5-year-old male fell down from a height of 1 m. (A) AP and lateral radiographs of the left femur with long oblique unstable subtrochanteric fracture.(B)
Immediate postoperative radiographs after closed reduction and xation with TENs. (C) Six months after surgery, the fracture had good healing radiographically. (D)
AP view of pelvis showed a symmetric normal NSA between involved and uninvolved limb after 38 months.
Xu et al. Medicine (2018) 97:29 Medicine
2
complications, and unplanned surgery for the treatment of
complications (Table 1).
3. Postoperative care
Spica casting was used in patients of the TEN group for 6 weeks
and long-leg casting was used in patients of the OPI group for 2
weeks after surgery. All patients started motion exercises after
cast removal. In the TEN group, patients were allowed to bear
toe-touch weight when the radiographic union occurred and
permitted to gradually bear more weight based on clinical and
radiographic evidence of healing. Patients in the OPI group
started toe-touch weight bearing with crutches at approximately
4 weeks postoperatively. These patients were allowed to bear no
limited weight only when radiographic evidence of healing had
been achieved.
4. Statistical methods
SPSS 13.0 (SPSS Inc., Chicago, IL) was used for all statistical
analyses. We compared the demographic characteristics between
the 2 treatment groups using the x
2
tests for categorical variables
and analyses of the MannWhitney Utests for continuous
variables. The Wilcoxon rank test was used to compare the
bilateral ROM and NSA, and Pvalues <.05 were considered
signicant.
5. Results
A total of 67 patients (40 boys and 27 girls) met the inclusion
criteria. Thirty-nine patients were treated with TEN method
(Figs. 1 and 2) and 28 patients were treated with OPI method
(Figs. 3 and 4). The average age of the patients was 8.3 ±2.0 years
(range, 511.9 years) and the average weight was 35.5 ±5.9 kg
(range, 25.349.6 kg). There were 28 cases of length stable
fracture and 11 cases of length unstable fracture in the TEN
group. Correspondingly, 20 cases of stable fracture and 8
unstable fractures were in the OPI group. The average operation
time of group TEN was 41.2 minutes; the average blood loss of
surgery was 8.2mL; and the average operation time of OPI group
was 98minutes and the average blood loss was 70mL. The TEN
group was hospitalized on an average of 5.7 days, while the OPI
group was hospitalized on an average of 6.5 days. The average
follow-up time was 28.5 months (range, 1642 months).
We noted no statistically signicant difference between the 2
groups in terms of sex, fracture pattern, and length of
hospitalization. However, there was a signicant difference in
age, weight, time of operation, and bleeding during the operation
(Table 2).
At the nal follow-up, all patients were able to walk without
limping and had full symmetric range of motion in the hip joint
with no difference to the uninvolved side in both groups (P>.05)
(Table 3). According to the Flynn outcome scores, excellent
results were demonstrated in 62% of patients in the TEN group
Figure 2. A 7.6-year-old female suffered trafc accident. (A) Preoperative radiographs of the right femur with short oblique stable subtrochanteric fracture. (B)
Immediate postoperative radiographs after closed reduction and xation with 2 nails. (C) The bone healed well 6 months after surgery. (D) The patient showed a
normal NSA (as on the uninvolved side) and a 1.5 cm limb length discrepancy with overgrowth of involved side.
Xu et al. Medicine (2018) 97:29 www.md-journal.com
3
and in 68% of patients in the OPI group. Thirty-eight percent of
patients in the TEN group and 32% of patients in the OPI group
had results as satisfactory. No poor results were observed in both
groups (Table 4).
The complication rates in both groups were low and similar
(18% vs 14%, P=.073). The most common complication in the
TEN group was pain from prominent nail end (3 patients), which
was relieved after using a knee immobilizer. Two patients with 6°
to 10 °of fracture malalignment at the time of radiographic union
were found and the malalignment had remodeled at the time of
nal follow-up. Two patients, who were treated with TEN,
demonstrated leg-length inequality where the affected limb was
1.5 cm longer (Fig. 2) or 1 cm shorter (Fig. 3). Among the patients
who had undergone open plating, 1 had 6 °of varus at the time of
fracture union and 3 had leg length inequality where the involved
limb was longer (ranged from 1 to 2.5 cm) than the other side. No
patient underwent unplanned surgery for complications in both
groups.
6. Discussion
The treatment of pediatric subtrochanteric femur fractures is
discussed controversially. Especially, the method of xation with
different implants is still an open question. We retrospectively
compared TENs with open plating for the treatment of
subtrochanteric femur fractures in school-aged children. The
results showed that both TEN and OPI method can obtain good
functional outcomes according to Flynn score. The rate of
excellentand goodresults was similar in both groups. Sixty-
two percent of patients in the TEN group had excellent results
when compared with 68% of patients in the open plating group.
We found that TENs had a similar complication rate when
compared with plating (18% in TEN group vs 14% in OPI
group). Comparison of demographic data suggested that the
TEN group had younger age, lower body weight, experienced less
blood loss, and showed shorter operation time. On the contrary,
patients with older age and heavier weight were found in the OPI
group.
There is no consensus in the literature on the denition of a
pediatric subtrochanteric femur fracture.
[2,7,8]
Ireland and Fisher
[2]
proposed a denition of subtrochanteric fractures: The
fracture line is located within the proximal one-fourth of the
interval between the intertrochanteric region and the adductor
tubercle. However, according to this denition, the accuracy of
measurement is less satisfactory. Pombo and Shilt
[7]
recently
dened the pediatric subtrochanteric femur fracture as a fracture
Figure 3. A 6.8-year-old boy sustained an injury when falling from height. (A) Anteroposterior and lateral views of the left femur showed a short oblique stable
subtrochanteric fracture. (B) The fracture was xed with pediatric hip plate by open reduction. (C) Eight months after surgery, the fracture healed well and plate and
screws were removed. (D) The patient showed a symmetric NSA. We noted a limb length inequality of -1 cm.
Xu et al. Medicine (2018) 97:29 Medicine
4
located within 10% of the total femur length below the lesser
trochanter. They created their formula on the basis of the
denition of an adults subtrochanteric femur fracture, which is a
fracture that occurs within 5 cm below the lesser trochanter, and
the average length of the adult femur. The difference in femur
lengths at various ages was taken into account in the denition by
Pombo, along with the difference in femur lengths among
children at the same age. We believe that the denition of Pombo
is not only accurate and practical but also easily utilized.
Therefore, we used classication by Pombo in this study.
The incidence of subtrochanteric fractures in children is about
4% to 10% of all childrens femoral fractures.
[8]
In general,
children who are under 5 years of age may be either treated with
closed reduction and spica casting with or without traction.
Children who are over 12 years of age and adolescents were
preferentially treated with interlocking intramedullary nailing.
[6]
Fractures in this region particularly are difcult to manage as a
subset of femur fractures. It is challenging to obtain and maintain
the reduction of the proximal fracture fragment due to the
exion, abduction, and external rotation secondary to forces
from the iliopsoas, hip abductors, and external rotator muscles in
the subtrochanteric region of the femur.
[6]
Jarvis et al
[4]
retrospectively reported that about one-fourth skeletally imma-
ture adolescents with subtrochanteric fracture had poor clinical
and radiologic outcomes by nonoperative management, includ-
ing fracture malalignment with more than 16°of angulation, and
lower limb length shortening of the affected limb by an average of
2.6 cm. Therefore, surgical intervention with internal xation
became more popular. We hypothesize that a solid internal
xation is a rewarding option for reducing complications.
There is a large variation in the individual development of
children 5 to 11 years of age, and the choice of internal xation
implants for subtrochanteric fractures is controversial. TENs are
currently the most popular treatment option for femoral shaft
fractures in school-age children and young adolescents.
[1,9,10]
With the development of surgical technology, the operative
indication of TEN has gradually extended to the proximal femur
Figure 4. A 5.5-year-old boy suffered trafc accident. (A) AP and lateral radiographs of the right femur with comminuted unstable fracture of thesubtrochanteric
region to shaft. (B) The patient was treated by open reduction with locking compression plate xation. (C) Ten months after surgery, the fracture showed good
healing radiographically and internal xation was removed. (D) AP view of pelvis showed a symmetric NSA and no limb length inequality.
Table 2
Demographic data.
TEN group OPI group Total
P(N =39) (N =28) (N =67)
Age
, y 6.8 9.4 8.3 .041
Sex (male/female) 22/15 18 /12 40/27 .11
Weight
, kg 29.2 38.6 35.5 .025
Fracture pattern .19
Length stable 28 20 48
Length unstable 11 8 19
Operation time
, min 41.2 98 .021
Blood loss
, mL 8.2 70 .0001
Length of hospitalization, d 5.7 6.5 .21
Statistically signicant difference between the 2 groups (P<.05).
Xu et al. Medicine (2018) 97:29 www.md-journal.com
5
1/3 and subtrochanteric fractures.
[3,11]
However, several studies
have demonstrated suboptimal results with fractures in the
proximal third of the femur
[1,9]
and length-unstable fracture
patterns.
[3,12]
In the series by Flynn et al,
[1]
the only patient with a
poor Titanium Elastic Nails Outcome Score was an 11-year-old
child with a proximal, oblique comminuted fracture that healed
with 15mm of shortening and 20°of varus angulation. Ho et al
[9]
reported a 22% complication rate with proximal third femur
fractures managed with TENs. Both Narayanan et al
[12]
and Sink
et al
[3]
reported a higher complication rate and risk of unplanned
revision surgery with length-unstable femur fractures treated with
TENs. Therefore, other internal xation methods are recom-
mended to replace TEN in the treatment of subtrochanteric
fractures of the femur in children. Ellis et al
[13]
reported that the
distal femoral interlocking intramedullary nail represents a
successful treatment of length unstable fractures in older children,
which can effectively maintain fracture reduction and prevent
occurrence of shortening. Kanlic et al
[14]
reported a 4%
complication rate in 51 pediatric femoral shaft fractures treated
with submuscular plating. Twenty-four percent of the fractures
were in the subtrochanteric region and 55% of the fractures were
unstable. It was believed that interlocking intramedullary nail or
compression plate technology had biomechanical advantages in
maintaining the length and stabilization of the reduction of
fractures, although they were more demanding to apply and
carried a potential risk of injury to the epiphysis. A multicenter
retrospective study by Ying et al
[6]
showed that the outcome of
subtrochanteric fractures treated with plating in school-age was
better when compared with TEN xation. But according to their
study, open plating and submuscular plating were not analyzed
separately, which may amplify the excellent results. Parikh etal
[11]
recently demonstrated that the outcomes of 33 patients with
subtrochanteric fractures in school-age treated by TEN were
satisfactory. Major complications such as nonunion, malunion, or
limb length discrepancy and other serious complications after
operation were low. The long-term follow-up showed a good
prognosis, so the authors believed that considering TEN represents
asafeandefcient option to treat subtrochanteric femur fractures
in children.
[11]
Closed reduction combined with TEN xation is
less invasivewhen compared with open reductionand locking plate
xation. TEN xation is our preferred method of stabilization for
subtrochanteric femur fractures in younger children and children
of lower body weight. Locking plate xation provides better
stability and thus results in a lower rate of complications.
The application of cast immobilization in pediatric femoral
fractures especially in the proximal third of the femur is discussed
controversially. Some authors believe proximal third femur
fractures or length-unstable fractures treated with TEN may
benet from additional postoperative immobilization.
[1,10,12]
However, Sink et al
[3]
did not nd that routine use of a single-leg
spica cast decreased the complication rate. We usually immo-
bilized pediatric femoral fractures by spica cast for 6 weeks until
radiographic union was noted at follow-up (bridging callus
across at least 3 of the 4 cortices on AP and lateral radiographs).
For the OPI patients, the long cast ends just proximal above the
knee and distal far from the subtrochanteric region. The function
of using a long leg cast in OPI patients is to immobilize the
involved limb and delay the time to weightbearing.
Limitations of this retrospective study are that the patients
were not randomized to the treatment groups. Selection bias did
exist in this retrospective study. Some of the surgeons who
managed the patients in this study may have preferentially chosen
other treatment options. The selection bias of patients is not
eliminated. A prospective study design might be the best way to
reduce selection bias in a further study. A second limitation is our
use of the outcome score by Flynn to classify outcomes of
subtrochanteric femur fractures treated with open plating. The
outcome score was designed to assess the results of TEN but may
not be suitable for the assessment of plating outcomes.
7. Conclusion
We directly compared TENs with open plating for the treatment
of subtrochanteric femur fractures in school-aged children. We
found that both TEN and OPI stabilization can result in good
functional outcomes according to the score by Flynn. The rate of
excellentand goodresults is similar in both groups. The
ROM of hip and NSA of the affected limb were almost the same
as those of the unaffected side. Demographic data suggested that
TEN was more suitable for children with younger age and lower
body weight, and TEN had more advantages with less blood loss
and operation time. On the contrary, patients with older age and
heavier weight may benet from open plate xation.
Author contributions
Conceptualization: Kaiying Shen.
Data curation: Jingxia Bian, Kaiying Shen.
Formal analysis: Yunlan Xu, Bin Xue.
Table 3
Comparison of hips ROM and NSA between involved and uninvolved side after operation.
TEN group OP group
ROM of hip, °
NSA, °
ROM of hip, °
NSA, °
Flexion-extension Abduction-adduction External -internal Flexion-extension Abduction-adduction External -internal
Involved side 135 ±4
13 ±3
35 ±5
23 ±4
36 ±5
42 ±4
130 ±5 132 ±3
12 ±2
31 ±4
22 ±3
34 ±5
41 ±3
125 ±7
Uninvolved side 132 ±3
11 ±2
41 ±5
26 ±4
38 ±3
45 ±4
126 ±9 137 ±4
14 ±2
42 ±5
27 ±4
39 ±2
45 ±3
128 ±8
P.553 .423 .417 .301 .420 .399 .424 .661 .392 .476 .373 .460 .345 .401
NSA =neck-shaft angle, OPI =open plate internal xation, ROM =ranges of motion, TEN =titanium elastic nails.
Table 4
Flynn outcome scores.
N (%)
Excellent Satisfactory Poor
TEN group
24 (62) 15 (38) 0
OPI group
19 (68) 9 (32) 0
OPI =open plate internal xation, TEN =titanium elastic nails.
A patients overall outcome was determined by the category with the worst res ult.
Xu et al. Medicine (2018) 97:29 Medicine
6
Investigation: Jingxia Bian, Bin Xue.
Methodology: Yunlan Xu, Kaiying Shen, Bin Xue.
Software: Kaiying Shen.
Writing original draft: Yunlan Xu, Jingxia Bian.
Writing review & editing: Kaiying Shen.
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pediatric femur fractures: a multicenter study of early results with
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Clin Orthop Relat Res 1975;15766.
[3] Sink EL, Gralla J, Repine M. Complications of pediatric femur fractures
treated with titanium elastic nails: a comparison of fracture types. J
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[4] Jarvis J, Davidson D, Letts M. Management of subtrochanteric fractures
in skeletally immature adolescents. J Trauma 2006;60:6139.
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[8] Jeng C, Sponseller PD, Yates A, et al. Subtrochanteric femoral fractures
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[11] Parikh S, Nathan S, Priola M, et al. Elastic nailing for pediatric
subtrochanteric and supracondylar femur fractures. Clin Orthop Relat
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... Maximum biomechanical stability can be obtained longer plates and fewer screws which increases the working length of the plate. One of our patients with comminuted fracture extending into subtrochanteric was managed with this technique had excellent result [12,13]. [14,15]. ...
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Abstract Background: Femur fractures are one of the most prevalent injuries in children. Femoral shaft fractures are the most common orthopedic injury that requires hospitalization, accounting for around 1.6 percent of all bone injuries in children. Treatment for femoral shaft fractures in children is determined by the patient's age and weight, as well as the type of fracture. Traction and hip Spica were the usual treatments for all femoral shaft fractures that needed a lengthy stay in the hospital until recently. However, in recent decades there has been a shift toward increased use of surgery such as intramedullary nailing and plate fixation because of decrease impairment, increase convenience and decrease cost of care. There are increasing reports in literature that operative treatment more satisfactory results than non-operative but the treatment of choice in children are still controversial. Aims and Objective: To compare the functional outcome in patients who underwent surgery for the femoral shaft fracture using the titanium elastic nail and the plate fixation. Methods: This is prospective and comparative study was carried out in the department of orthopedic surgery, unit IV and V Taihe Hospital affiliated to Hubei University of Medicine, Shiyan, Hubei, China from April 2018 to February 2019. A total of 20 patients were enrolled in this study and divided equally into 2 groups TENS and plate 10 patients on each group. Results: Out of 20 patients10 (50%) patients treated with TENS and 10 (50%) were treated with plates. Mean age of total patients was 6.65 ± 2.110 years. road traffic accident is the main cause of injury in both group which comprises 5 (50%) patients in TENS group and 4 (40%) patients in plate group. Majority of the factures were in the middle third of the femoral shaft. The mean blood loss in TENS group was 16 ± 6.146 ml while in plates group 160 ± 45.947 ml. which shows significant between two groups with (p = 0.00 < 0.005). The average operating time in TENS group was found to be 54 ± 14.298 minute while in case of plaiting group was 127 ± 22.998 minute with (p = 0.000 < 0.05). Average time of union in TENS group was 8.10 ± 2.846 weeks and in plate group was 9.80 ± 1.989 weeks. Which is insignificant with (p = 0.139 > 0.05). among total 17 (85%) patients had no complications, Superficial infection found in 2 (10%) patients with plates group. and delayed union was found in 1 (5%) patient in with TENS group with (p = 0.217 > 0.05). There is no significance difference found with respect to complication between both groups. The final outcome assessed by Flynn’s criteria, showed that 14 {7 (70%) were from TENS group and 7 (70%) from plate group} had excellent results. 6{3 (30%) from TENS group 3 (30%) from plate group} had satisfactory and None of them have poor result in both group. These differences were not found to be statistically significant (p = 1.000 > 0.05). Keywords: Titanium Elastic Nail; Plate Fixation; Pediatric Femur Fracture; Femoral Shaft Fracture
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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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Objectives: To determine the clinical and radiological outcome of proximal femur shaft fractures in school going children treated with locking compression plates (LCP). Methods: This descriptive study was conducted in Orthopaedic Division Lady Ready Reading Hospital Peshawar from 25th June 2018 to 25th September 2020. Children of either gender and age 6 to 12 years old with subtrochanteric and proximal one third femur factures fulfilling the inclusion criteria were enrolled in this study. Open reduction and internal fixation with 4.5 mm narrow locking compression plates (LCP) were done in all. Post operative clinical outcome was evaluated by using Flynn scoring system and graded as excellent, satisfactory and poo results. Radiological assessment of fracture union was done through anteroposterior (AP) and lateral X-ray radiographs. Results: A total of 60 children with mean age 9.01±1.61 SD (range 6 to 12 years) were included in our study. Oblique fractures were present in 23(38.3%) children, spiral in 20(33.3%), transverse in 11(18.3%) and comminuted in 6 (10%) children. The radiological union time was 13.3±1.2 weeks (range 9.4 to 18 weeks). Majority (88.3%, n=53) of children had excellent clinical outcome according to Flynn's scoring system while satisfactory outcome was noted in 7(11.6%) children. No cases of delayed union, mal union, nonunion and implant failure was reported. Conclusion: The results of our study indicated that proximal femoral shaft fractures in school going children treated with locking compression plates had excellent clinical and radiological outcome. We therefore recommend locking compression plate as the implant of choice to fix proximal femoral shaft fractures in school going children.
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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.
Article
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.
Article
We modified the traditional titanium elastic nail (TEN) technique to increase stability, by involving the apophysis of the greater trochanter (GT) and the femoral neck cortex. We report the clinical/radiological outcomes after at least 5 years of follow-up. We prospectively included 17 children aged 5-12 years diagnosed with subtrochanteric femoral fractures between January 2004 and December 2013. Radiological evaluations of bony union, malunion, and limb-length discrepancies (LLDs) were performed at the final follow-up. Clinical outcomes, as revealed by the Flynn scoring system, and the range of hip motion were also recorded. The mean patient age was 8.4 ± 2.0 years. Twelve patients presented with length-stable fractures and the others with unstable fractures. Bony union was evident at a mean of 4.5 months postoperatively. Radiologically, malunion >5° was evident in three patients, but all angles were <10° at the final follow-up. LLDs >1 cm were evident in five patients, but all were <2 cm at the final follow-up. Thirteen patients showed excellent outcomes and 4 had satisfactory outcomes. Complications were apparent in only two patients; both showed only temporary discomfort caused by prominent nails. The range of hip motion was satisfactory in all cases; no difference compared to the contralateral hip was apparent. Finally, the radiological/clinical outcomes did not differ by the fracture stability or pattern. We penetrated the apophysis of the GT and the femoral neck cortex with TENs to further stabilise subtrochanteric femoral fractures. This was a simple procedure that enhanced patient outcomes. Level of evidence: therapeutic level II.
Article
Purpose Extra-articular proximal femur fractures (EPFF) remain challenging for their intrinsic instability. The aim of this study is to evaluate the results of elastic stable intramedullary nailing (ESIN) of extra-articular proximal femur fractures in children and adolescents. Methods A retrospective monocentric study of children treated by ESIN for EPFF between 2012 and 2018 was conducted. We included all patients sustaining a fracture within 10% of the femur length below the lesser trochanter. Studied data were age, sex, femur length, fracture distance below the lesser trochanter, number of days of hospitalization, time to nail removal, and complications. Beaty’s criteria and the titanium elastic nailing (TEN) outcome measure scale were used to evaluate radiologic outcome and assess clinical recovery, respectively. Results A total of 24 cases were reviewed (18 males, 6 females). Mean age was 8.23 years (range 5–13). Mean duration of hospitalization was 3.7 days (range 2–12). Mean time to nail removal was 28 weeks (range 12–53). Malalignment was observed in five patients, but in all cases, angulation did not exceed 10°. No limb length discrepancy was observed. Twenty out of 24 patients had excellent Beaty’s radiological and TEN clinical outcome scores. No poor results were observed. Conclusions The results of our study show that good outcomes following surgical treatment by ESIN should be expected in children younger than 14 years of age with displaced EPFF. Excellent radiological and clinical outcomes were observed in 83.7% of the cases, with a low rate of complications and short hospital stay.
Article
Subtrochanteric and supracondylar femur fractures are difficult injuries to treat in children. Although elastic stable intramedullary nails are commonly used for pediatric femur shaft fractures, there is little information on their effectiveness for managing pediatric subtrochanteric and supracondylar femur fractures. We (1) evaluated radiographic union rates and fracture alignment after elastic nailing of pediatric subtrochanteric and supracondylar femur fractures, (2) identified complications, and (3) determined risk factors for complications. Between 2005 and 2011, 36 subtrochanteric fractures and eight supracondylar femur fractures were treated with elastic stable intramedullary nails and had complete followup until clinical and radiographic union. Elastic nailing was used for subtrochanteric fractures in children 5 to 12 years of age or after failed spica cast treatment in younger children and for displaced supracondylar fractures in children older than 5 years. Fracture alignment and union were measured on radiographs, and complications were identified from review of patient charts. Patients with and without complications were compared using nonparametric tests to identify risk factors. All fractures healed; 23 of 33 (70%) subtrochanteric femur fractures and five of seven (71%) supracondylar femur fractures healed with anterior angulation of about 5°. For subtrochanteric fractures, complications included repositioning/removal of nails before radiographic union (n = 4), malunion (n = 2), fracture (n = 1), irritation (n = 1) at nail insertion site, and limb length discrepancy (n = 1); despite these complications, there were 22 (61%) excellent, 12 (33%) satisfactory, and only two (6%) poor outcomes. For supracondylar fractures, complications included infection after nail removal (n = 1) and nail site irritation (n = 2); there were three (38%) excellent, five (62%) satisfactory, and no poor outcomes. Complications were more likely after subtrochanteric fracture during motor vehicle accident (p = 0.045). Although complication rates are high with elastic nailing for pediatric subtrochanteric (22%) and supracondylar (38%) femur fractures, elastic nailing represents an important option for difficult-to-manage femur fractures. Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
Article
Background: Studies have demonstrated a higher risk of complications when children with fractures in the proximal third of the femur and length-unstable fractures are treated with titanium elastic nails. Alternative treatment methods include open plating and submuscular plating. We are not aware of any published studies that directly compare titanium elastic nail and plate fixation of pediatric subtrochanteric femur fractures. The purpose of the present study was to retrospectively compare the outcomes and complications of titanium elastic nail and plate fixation of subtrochanteric femur fractures in children and young adolescents. Methods: A total of 54 children aged 5 to 12 years with subtrochanteric femur fractures treated with titanium elastic nails or plating at 2 institutions between 2003 and 2010 were identified. We retrospectively compared 25 children treated with titanium elastic nails to 29 children treated with either open plating or submuscular plating. Similar to previous studies, a fracture that was located within 10% of the total femur length below the lesser trochanter was classified as subtrochanteric. Outcomes were classified as excellent, satisfactory, or poor. A major complication was defined as any complication that led to unplanned surgery. Minor complications were defined as complications that resolved with nonoperative treatment or did not require any treatment. Results: Outcome scores were significantly better in the plating group (P=0.03), but both groups demonstrated high rates of excellent and satisfactory results. The overall complication rate was significantly higher in the titanium elastic nails group (48%; 12 of 25) when compared with the plating group (14%; 4 of 29) (P=0.008). Patients in the titanium elastic nails group were advanced to full weightbearing significantly earlier (6.6 vs. 9.9 wk) (P=0.005). The major complication rate, length of hospitalization, and time to radiographic union were similar for the 2 groups. Conclusions: Our results indicate that plate fixation of pediatric subtrochanteric femur fractures is associated with better outcome scores and a lower overall complication rate when compared with titanium elastic nails. Level of evidence: Therapeutic Level III.
Article
Femoral fractures in adolescents usually need operative treatment, but the optimal method is unclear. The purpose of this study is to compare intramedullary nailing (IN) and submuscular plating (SP) in adolescent femoral fractures. We performed the prospective, comparison study of IN and SP in adolescent femoral shaft fractures at a mean age of 13.9 years (11-17.4). Twenty-two cases of IN and 23 cases of SP were followed for a minimum of 1 year. We compared radiological and clinical results, surgical parameters, and complications of two techniques. Bony union was achieved in all cases except one case of IN. Time to union was similar in both groups. None showed mal-union over 10° or limb length discrepancy over 1 cm. None of SP group and 2 in IN group experienced re-operation; one patient had deep infection with nonunion. The other patient sustained mal-rotation. Both patients healed after revision procedure. All patients showed excellent or satisfactory results of Flynn's criteria. The time to full-weight bearing was shorter in IN (IN: 57.3 days, SP: 89.2 days, p<0.05). In surgical parameters, operative time seemed shorter in IN (IN: 94.7 min, SP: 104 min, p=0.095), and fluoroscopy time was shorter in IN (IN: 58s, SP: 109s, p<0.05) than SP group. Although both IN and SP yield good results and minimal complication in adolescent femoral fractures, IN may be advantageous in less need of fluoroscopy, technical easiness in reduction and early weight bearing.
Article
Stainless steel flexible Enders rods have been used for intramedullary fixation of pediatric femur fractures with good success. Despite intraoperative anatomic alignment, length unstable femur fractures can present postoperatively with fracture shortening. The purpose of this study was to review all length unstable pediatric femoral shaft fractures in which Enders rods were used and compare those that were locked to those that were not locked. A retrospective clinical and radiographic review of all patients at a single institution undergoing flexible intramedullary fixation for length unstable femoral shaft fractures from 2001 to 2008. A length unstable fracture was defined as either a comminuted fracture or a spiral fracture longer than twice the diameter of the femoral shaft. A total of 107 length unstable femoral shaft fractures fixed with Enders rods were identified, of which 37 cases (35%) had both Enders rods "locked" through the eyelet in the distal femur with a 2.7 mm fully threaded cortical screw. Patient demographics, clinical course, complications, fracture characteristics, and radiographic outcomes were compared for the locked and nonlocked groups. There were no statistical differences between the groups in demographic data, operative variables, fracture pattern, fracture location, time to union, femoral alignment, or major complications. Shortening of the femur and nail migration measured at 1 to 6 weeks postoperatively was significantly greater for the nonlocked cases. The medial and lateral locked Enders rods moved 1.3 and 1.9 mm, respectively, and the unlocked Enders each moved 12.1 mm (P < 0.05). At final follow-up there were significantly more (P < 0.05) clinical complaints in nonlocked group, including limp, clinical shortening, and painful palpable rods. Locking Enders rods for length unstable pediatric fractures is an excellent option to prevent shortening and resulted in no additional complications, added surgical time, or increased blood loss. Level III.
Article
Subtrochanteric fractures are relatively rare in children and usually result from severe trauma. The unique biomechnical forces about the hip following fracture tend to complicate treatment. Remodeling and growth stimulation generally ensure good results by nonoperative means in children under 10 years of age. Open reduction should be considered in older children when good alignment cannot be achieved by closed methods.
Article
Fifteen children younger than 10 years of age with subtrochanteric fractures treated by a uniform method were evaluated. These patients had been treated with femoral skeletal traction, with the hip and knee flexed to 90 degrees until radiographic callus appeared, then with a hip spica cast. True neck to shaft and anteversion angles were calculated bilaterally using a biplanar method. Leg lengths were measured radiographically and clinically. Mean age at injury was 4.5 years, and mean followup was 6.5 years. Overgrowth averaged 10 mm after fracture. Anteversion at final followup differed only by a mean of 2 degrees from the contralateral side (range, -3 degrees to +4 degrees), and the mean neck shaft angle differed by only 1 degree. Remodeling of coronal angulation was 50% or more in all cases.
Article
Titanium elastic nailing is used instead of traction and casting in many European centers, but limited availability has prevented widespread use in North America. Before a planned general release in America, titanium elastic nails (TENs) were trialed at several major pediatric trauma centers. This multicenter study is a critical analysis of early results and complications of the initial experience. Overall, TENs allowed rapid mobilization with few complications. The results were excellent or satisfactory in 57 of the 58 cases. No child lost rotational alignment in the postoperative period. Irritation of the soft tissue near the knee by the nail tip occurred in four patients, leading to a deeper infection in two cases. As indications, implantation technique, and aftercare are refined, TENs may prove to be the ideal implant to stabilize many pediatric femur fractures, avoiding the prolonged immobilization and complications of traction and spica casting.
Article
Limited data exist about complications of titanium elastic nails (TNs) for femur fracture management in pediatric patients. Thirty-nine patients with 43 femoral shaft fractures were identified whose average age was 6.0 years. There were 21 complications (1 intraoperative, 20 postoperative) in 43 femur fractures (49%). There were two major postoperative complications: one septic arthritis after nail removal and one hypertrophic nonunion. Minor postoperative complications were pain at the nails in 13 extremities, nail erosion through the skin in 4, and one delayed union. There was an association between the prominence of TNs and nail pain or skin erosion. Fracture angulation and outcome were associated with the patient's weight and size of the nails implanted. Technical pitfalls exist with this implant and can be minimized by leaving less than 2.5 cm of nail out of the femur and by using the largest nail sizes possible.
Article
Flexible intramedullary nailing has become a popular method of fixation of pediatric femoral fractures. The authors analyzed their first 5-year experience with titanium elastic stable intra-medullary nailing, specifically to report the complications associated with this technique and to provide recommendations to avoid these complications. Seventy-eight children with 79 femoral fractures were treated by this method. Complications included pain/irritation at the insertion site (41), radiographic malunion (8), refracture (2), transient neurologic deficit (2), and superficial wound infection (2). Ten patients required reoperation prior to union. Malunion and/or loss of reduction requiring reoperation was strongly associated with the use of nails of mismatched diameters (odds ratio = 19.4) and comminution of more than 25% (odd ratio = 5.5). Pain at the insertion site was significantly associated with bent or prominent nail ends. Most complications are minor, and many are preventable. Surgeons should advance nail ends to lie against the supracondylar flare of the femur to avoid symptoms at the insertion site and should avoid implanting nails of two different diameters. Comminuted fractures should be monitored carefully and might benefit from additional immobilization.
Article
Conventional treatments of pediatric femoral shaft fractures may result in an unacceptable rate of complications, especially in complex fractures. These fractures include high-energy injuries resulting in unstable fracture patterns, fractures in the proximal or distal third, and fractures occurring in large or multiply injured children. Our goal was to evaluate whether a minimally invasive submuscular bridge plating technique provides stability for early functional treatment (without protective casting or bracing) and predictable healing. Fifty-one patients with an average age of 10 years were studied. Sixty-seven percent had high-energy injuries and 55% had unstable fracture patterns. With an average followup of 14.2 months, all fractures united with excellent clinical results. Two (4%) significant complications occurred: fracture of one 3.5-mm LC-DCP Ti plate, and refracture of a pathologic fracture after early plate removal. Four patients (8%) had a leg-length discrepancy ranging from 23-mm short to 10-mm long. The average operative time was 106 minutes, with average fluoroscopy time of 84 seconds. Procedures were done by 15 surgeons in five university medical centers. This technique offers the advantage of adequate stability for early functional treatment and predictable healing with maintenance of length and alignment for all pediatric femoral shaft fractures.