|
1
|
Lu Y, Zhang T, Chen K, Canavese F, Huang C, Yang H, Shi J, He W, Zheng Y, Chen S. Application of biodegradable implants in pediatric orthopedics: shifting from absorbable polymers to biodegradable metals. Bioact Mater 2025; 50:189-214. [PMID: 40256329 PMCID: PMC12008652 DOI: 10.1016/j.bioactmat.2025.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2024] [Revised: 03/05/2025] [Accepted: 04/02/2025] [Indexed: 04/22/2025] Open
Abstract
Over the past two decades, advances in pediatric orthopedics and closed reduction combined with percutaneous internal fixation techniques have led to significant growth in pediatric orthopedics surgery. Implants such as Kirschner-wires, cannulated screws and elastic stabilization intramedullary nails are commonly used in these procedures. However, traditional implants made of metal or inert materials are not absorbable, leading to complications that affect treatment outcomes. To address this issue, absorbable materials with excellent mechanical properties, good biocompatibility, and controlled degradation rates have been developed and applied in clinical practice. These materials include absorbable polymers and biodegradable metals. This article provides a comprehensive summary of these resorbable materials from a clinician's perspective. In addition, an in-depth discussion of the feasibility of their clinical applications and related research in pediatric orthopedics is included. We found that the applications of absorbable implants in pediatric orthopedics are shifting from absorbable polymers to biodegradable metals and emphasize that the functional characteristics of resorbable materials must be coordinated and complementary to the treatment in pediatric orthopedics.
Collapse
Affiliation(s)
- Yunan Lu
- Department of Pediatric Orthopedics, Fuzhou Second General Hospital, The Third Clinical Medicine College of Fujian Medical University, 47th Shangteng Road of Cangshan District, Fuzhou, 350007, Fujian, China
- Department of Emergency Trauma Surgery, Shengli Clinical Medical College of Fujian Medical University, Shengli Hospital affiliated to Fuzhou University, Fuzhou, 350001, China
| | - Ting Zhang
- School of Materials Science and Engineering, Peking University, Beijing, 100871, China
| | - Kai Chen
- School of Materials Science and Engineering, Peking University, Beijing, 100871, China
- Shenzhen Key Laboratory of Spine Surgery, Department of Spine Surgery, Peking University Shenzhen Hospital, Shenzhen Peking University-The Hong Kong University of Science and Technology Medical Center, Shenzhen, 518036, Guangdong, China
| | - Federico Canavese
- Orthopedic and Traumatology Department, IRCCS Istituto Giannina Gaslini, DISC-Dipartimento di scienze chirurgiche e diagnostiche integrate, University of Genova, Genova, Italy
| | - Chenyang Huang
- School of Engineering Medicine, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100191, China
| | - Hongtao Yang
- School of Engineering Medicine, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100191, China
| | - Jiahui Shi
- School of Materials Science and Engineering, Peking University, Beijing, 100871, China
| | - Wubing He
- Department of Emergency Trauma Surgery, Shengli Clinical Medical College of Fujian Medical University, Shengli Hospital affiliated to Fuzhou University, Fuzhou, 350001, China
| | - Yufeng Zheng
- School of Materials Science and Engineering, Peking University, Beijing, 100871, China
| | - Shunyou Chen
- Department of Pediatric Orthopedics, Fuzhou Second General Hospital, The Third Clinical Medicine College of Fujian Medical University, 47th Shangteng Road of Cangshan District, Fuzhou, 350007, Fujian, China
- Fujian Provincial Clinical Medical Research Center for First Aid and Rehabilitation in Orthopedic Trauma (2020Y2014), Fuzhou, 350007, China
- Key Clinical Specialty of Fujian Province and Fuzhou City (20220104), Fuzhou, China
| |
Collapse
|
|
2
|
Miller AM, Clement RC, Leonardi C. Does postoperative immobilization affect final alignment of pediatric femur fractures treated with flexible intramedullary nailing? J Pediatr Orthop B 2025; 34:205-208. [PMID: 39229910 DOI: 10.1097/bpb.0000000000001203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2024]
Abstract
Flexible intramedullary nail (FIN) fixation of pediatric femur fractures is a popular method of fixation in children. Typical immobilization options include spica casting, long leg cast, knee immobilizers, or no immobilization and the decision to use each is usually left to surgeon preference. Our primary aim is to evaluate whether different postoperative immobilization status influences outcomes, namely radiographic alignment at the time of healing. A retrospective chart review was conducted of all patients with femur fractures treated with FIN fixation at a pediatric hospital from April 2018 through July 2022. Postoperative immobilization protocols were recorded and separated into two groups, patients who were immobilized (IMM) and patients who were not immobilized (NoIMM). Radiographs were evaluated for fracture alignment immediately following surgery and at the time of healing. Patients demographic, fracture, and postoperative clinical characteristics were compared between the two groups (NoIMM vs. IMM). A total of 41 patients were treated for diaphyseal femur fractures with FINs at our institution during the study period. No significant difference was observed in alignment at healing. Our results suggest that either immobilization or no immobilization after flexible intramedullary nailing of pediatric femoral shaft fractures are viable options when postoperative immobilization status is left to the surgeon's discretion.
Collapse
Affiliation(s)
- Adam Michael Miller
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center
| | - Rutledge Carter Clement
- Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center
- Department of Pediatric Orthopedic Surgery, Children's Hospital of New Orleans
| | - Claudia Leonardi
- Behavioral and Community Health Sciences, School of Public Health, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| |
Collapse
|
|
3
|
Rinat B, Dujovny E, Bor N, Rozen N, Chezar A, Rubin G. Enhancing Stability of Pediatric Femoral Fractures Treated with Elastic Nail Using an External Fixator. J Clin Med 2025; 14:1060. [PMID: 40004588 PMCID: PMC11856513 DOI: 10.3390/jcm14041060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2024] [Revised: 01/29/2025] [Accepted: 02/05/2025] [Indexed: 02/27/2025] Open
Abstract
Background: Diaphyseal femoral fractures in children older than 5 years and before adolescence are usually treated surgically. The literature describes several surgical techniques; however, we present an additional minimally invasive technique that combines the use of elastic intramedullary nails and a uniplanar external fixator as an optional solution for managing more complex cases. Method: This was a retrospective review of four children aged 9-12 years who suffered from unstable diaphyseal femoral fractures and were admitted to our institution. Results: We treated four children between the years 2021 and 2023. All patients underwent closed reduction of their fractures and fixation with an elastic intramedullary nail and an external fixator. Full radiographic fracture healing with acceptable alignment was achieved in all patients. The minimum clinical follow-up was 1.5 years. No major complications were observed, and all patients achieved full clinical recovery as well as proper limb alignment and length. Conclusions: Fixation of complex diaphyseal femoral fractures using a combination of internal and external fixation is a simple technique that avoids the need for extensive soft tissue exposure while also promoting fracture stability and maintenance of bone length and rotation. This method can be incorporated into the armamentarium of orthopedic surgeons as an additional solution for addressing more challenging cases.
Collapse
Affiliation(s)
- Barak Rinat
- Orthopedic Department, Emek Medical Center, Afula 1834111, Israel; (E.D.); (N.B.); (A.C.); (G.R.)
| | - Eytan Dujovny
- Orthopedic Department, Emek Medical Center, Afula 1834111, Israel; (E.D.); (N.B.); (A.C.); (G.R.)
| | - Noam Bor
- Orthopedic Department, Emek Medical Center, Afula 1834111, Israel; (E.D.); (N.B.); (A.C.); (G.R.)
- Faculty of Medicine, Technion, Haifa 3525433, Israel
| | - Nimrod Rozen
- Orthopedic Department, Emek Medical Center, Afula 1834111, Israel; (E.D.); (N.B.); (A.C.); (G.R.)
- Faculty of Medicine, Technion, Haifa 3525433, Israel
| | - Avi Chezar
- Orthopedic Department, Emek Medical Center, Afula 1834111, Israel; (E.D.); (N.B.); (A.C.); (G.R.)
| | - Guy Rubin
- Orthopedic Department, Emek Medical Center, Afula 1834111, Israel; (E.D.); (N.B.); (A.C.); (G.R.)
- Faculty of Medicine, Technion, Haifa 3525433, Israel
| |
Collapse
|
|
4
|
Zaidman M, Simanovsky N, Goldman V, Saleem-Zedan R, Abu Jabal T, Weisstub E. Titanium Elastic Nail Fixation Versus Spica Cast Application for the Treatment of Diaphyseal Femoral Fractures in Children Under Five Years Old: A Retrospective Study. Cureus 2025; 17:e77422. [PMID: 39949426 PMCID: PMC11823280 DOI: 10.7759/cureus.77422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2025] [Indexed: 02/16/2025] Open
Abstract
Background Femoral fractures are the most common type of injury requiring hospitalization in children. Treatment for femoral shaft fractures (FSFs) in children under six years old using closed reduction and spica cast (SC) application is a widely accepted method. In our institution, we offer the option of titanium elastic nail (TEN) fixation to parents of children under five years old. This study aimed to compare the results of SC treatment and TEN fixation in children under five years of age diagnosed with FSFs. Methodology We retrospectively reviewed medical records of all children under the age of five who had FSF treated at our institution and were managed with either an SC (28 children) or TEN fixation (26 children) between 2016 and 2022. The parents made the choice of treatment following discussions with the surgical team. In our analysis, the primary outcomes focused on radiological fracture healing and alignment, time until ambulation and limb mobilization, and complications. Additionally, we compared epidemiological data, hospitalization course, caregiver satisfaction, and follow-up duration between the two groups. Results No statistically significant differences were observed in time until fracture management or duration of anesthesia between the two groups. However, in the TEN group, short-term clinical and radiological outcomes were superior (coronal angulation: 0.92° vs. 5.9°, p = 0.0018; sagittal angulation: 0.42° vs. 7.82°, p = 0.0005; femoral shortening: 0.12 vs. 1.87 cm, p < 0.0001), although the time until ambulation was longer (5.9 vs. 4.75 weeks, p < 0.0001). Caregiver satisfaction was also higher in this group (p < 0.005). Conversely, children treated with TEN fixation more frequently required strong analgesic prescriptions (90% vs. 42%, p = 0.01), underwent more radiographs (during surgery: 6.73 vs. 3.61, p < 0.0001; during follow-up- 6.42 vs. 4.3, p = 0.003), had longer-lasting follow-up (7.9 vs. 3.2 weeks, p = 0.003), had an extended hospitalization (1.8 vs. 1.2 days, p = 0.004), and needed additional procedures for TEN removal. Both methods exhibited a low complication rate. Conclusions Titanium elastic nailing can be considered a viable treatment option for FSF in children aged two to five years, offering favorable clinical and radiological outcomes, enhanced caregiver satisfaction, and a low incidence of complications.
Collapse
Affiliation(s)
- Michael Zaidman
- Department of Orthopedic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, ISR
| | - Naum Simanovsky
- Department of Orthopedic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, ISR
| | - Vladimir Goldman
- Department of Orthopedic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, ISR
| | - Reem Saleem-Zedan
- Department of Orthopedic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, ISR
| | - Taer Abu Jabal
- Department of Orthopedic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, ISR
| | - Eden Weisstub
- Department of Orthopedic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, ISR
| |
Collapse
|
|
5
|
Hamdy MS, Sabry AO, Helmy BA, Hana AZ, El Zawahry AME, Gamal A. Comparative Study Between Single-limb Versus One-and-a-Half Hip Spica Cast in Fracture Femur in Young Children. J Pediatr Orthop 2025; 45:e23-e29. [PMID: 39145498 DOI: 10.1097/bpo.0000000000002796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
INTRODUCTION Femoral fractures account for ∼1% to 2% of all pediatric bone injuries and are a common occurrence in children. The conservative approach, employing either a single or one-and-a-half spica casts, has been traditionally favored, yielding satisfactory outcomes in select cases. This study aims to compare both procedures regarding functional and radiologic outcomes, complications, and parents' satisfaction. METHODS In this randomized controlled trial, we enrolled 84 pediatric patients, aged between 2 and 6 years, presenting with femoral fractures. Participants were randomly allocated into 2 groups; one receiving single-limb spica cast fixation (n=42) and the other receiving one-and-a-half spica cast fixation (n=42). We assessed postprocedural functional and radiologic outcomes. Other evaluations focused on parental ease in maintaining hygiene for the casted child, the child's mobility capabilities including standing and crawling, and the incidence of skin complications. RESULTS No significant variance was observed between the 2 groups concerning the time to bone union, and the overall complication rates. Parental satisfaction was notably higher in the single-limb spica group, particularly regarding the ease of maintaining hygiene for the casted child and the child's mobility while encased in the cast ( P <0.001). Furthermore, a significant correlation was identified between the one-and-a-half spica application and the increased occurrence of skin pressure ulcers ( P <0.001). CONCLUSION Both single-limb and one-and-a-half spica cast applications demonstrated comparable results in functional and radiologic outcomes, as well as in complication rates. However, parents favored the single-limb method due to its facilitation of a more manageable lifestyle for both the child and their parents. These considerations suggest that the single-limb hip spica cast fixation may be preferable in managing pediatric femoral fractures. LEVEL OF EVIDENCE Level II.
Collapse
Affiliation(s)
- Mohamed S Hamdy
- Orthopedic Surgery Department, Cairo University, Cairo, Egypt
| | | | | | | | | | | |
Collapse
|
|
6
|
Alkan H, Turhan Y, Veizi E, Naldoven ÖF, Aras B, Kanlikaya UG, Yilmaz G, Bekmez S. Elastic Stable Intramedullary Nailing in Length Stable Versus Unstable Pediatric Femoral Shaft Fractures: A Comparison of Clinical, Radiographic, and Pedobarographic Outcomes. J Pediatr Orthop 2024; 44:e711-e716. [PMID: 38809339 DOI: 10.1097/bpo.0000000000002737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
BACKGROUND Pediatric diaphyseal femoral fracture (PDFF) is one of the most common injuries requiring hospitalization. Elastic stable intramedullary nailing (ESIN) is commonly used for PDFFs in ages 5 to 11. The optimal treatment method for length unstable PDFF is a subject of ongoing debate. This study aimed to compare clinical, radiographic, and pedobarographic outcomes of ESIN between length stable and unstable PDFF. METHODS We retrospectively reviewed patients undergoing ESIN treatment for isolated PDFF between 2016 and 2021. Exclusion criteria were (1) history of ipsilateral or contralateral lower extremity fractures, (2) highly comminuted or segmental fractures, (3) body weight >50 kg, and (4) comorbidities affecting bone quality, range of motion, or neurologic status. The patients were divided into 2 groups according to length stability. Clinical, radiographic, and pedobarographic data were then assessed to compare groups. RESULTS Twenty-five patients were included (17 length stable and 8 length unstable PDFF) with a mean age of 73.6±17.8 months. There was no significant difference between groups in age, side of injury, body weight, follow-up duration, and nail-canal diameter ratio. Mean deformity in the fracture site in the early postoperative x-rays was not significantly different between groups ( P =0.661). After a mean follow-up of 27.8±14.2 months (range, 12-67), there was no significant difference in mechanical axis deviation, distal femur joint orientation angle, or limb-length discrepancy in both groups. The pedobarographic assessment revealed that the length unstable group had a significantly higher external foot progression angle in the injured extremity (9.8°±6.9° vs. 1.3°±5.6°, P =0.031). However, the length stable group had no significant difference in the foot progression angle (4.9°±5° vs. 3°±4.3°, P =0.326). There was no significant difference in either group for other pedobarographic parameters. CONCLUSION ESIN is a safe and effective option for length-unstable PDFF, yet attention should be paid to the rotational alignment. Although significant external rotation deformity occurs in length-unstable PDFF, it has no implications for the other pedobarographic parameters. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Hilmi Alkan
- Division of Pediatric Orthopaedic Surgery, Ankara Bilkent Children's Hospital
| | - Yalçin Turhan
- Division of Pediatric Orthopaedic Surgery, Ankara Bilkent Children's Hospital
| | - Enejd Veizi
- Department of Orthopaedics and Traumatology, Ankara Bilkent City Hospital
| | | | - Berke Aras
- Department of Physical Medicine and Rehabilitation, Ankara Bilkent City Hospital
| | - Ufuk Gürsoy Kanlikaya
- Department of Orthopedics and Traumatology, Hacettepe University Faculty of Medicine
| | - Güney Yilmaz
- Department of Orthopedics and Traumatology, Hacettepe University Faculty of Medicine
| | - Senol Bekmez
- Division of Pediatric Orthopaedic Surgery, Ankara Bilkent Children's Hospital
| |
Collapse
|
|
7
|
Wen Y, Wang Q, Song B, Feng W, Zhu D. External fixator versus elastic stable intramedullary nail for treatment of metaphyseal-diaphyseal junction fractures of the pediatric distal femur: a case-control study. BMC Musculoskelet Disord 2024; 25:389. [PMID: 38762453 PMCID: PMC11102165 DOI: 10.1186/s12891-024-07469-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 04/22/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Several methods have been used for the treatment of pediatric distal femoral fractures, such as elastic stable intramedullary nail (ESIN), external fixator (EF) and plate osteosynthesis, but there has been no consensus about the optimal method. The purpose of this study was to compare the clinical outcome between EF and ESIN techniques used in metaphyseal-diaphyseal junction (MDJ) fractures of the pediatric distal femur. METHODS We retrospectively analyzed operatively treated MDJ fractures of pediatric distal femur between January 2015 and January 2022. Patient charts were reviewed for demographics, injury and data of radiography. All of the patients were divided into EF and ESIN groups according to the operation techniques. Malalignment was defined as more than 5 degrees of angular deformity in either plane. Clinical outcomes were measured by Flynn scoring system. RESULTS Thirty-eight patients were included in this study, among which, 23 were treated with EF, and 15 with ESIN. The mean follow-up time was 18 months (12-24 months). At the final follow-up, all of the fractures were healed. Although there were no statistical differences between the two groups in demographic data, length of stay, estimated blood loss (EBL), rate of open reduction, time to fracture healing and Flynn score, the EF was superior to ESIN in operative time, fluoroscopic exposure and time to partial weight-bearing. The EF group had a significantly higher rate of skin irritation, while the ESIN had a significantly higher rate of malalignment. CONCLUSION EF and ESIN are both effective methods in the treatment of MDJ fractures of the pediatric distal femur. ESIN is associated with lower rates of skin irritation. However, EF technique has the advantages of shorter operative time, reduced fluoroscopic exposure, and shorter time to partial weight-bearing, as well as lower incidence of malalignment. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Yuwei Wen
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nalishi Road, Beijing, 100045, China
| | - Qiang Wang
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nalishi Road, Beijing, 100045, China.
| | - Baojian Song
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nalishi Road, Beijing, 100045, China
| | - Wei Feng
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nalishi Road, Beijing, 100045, China
| | - Danjiang Zhu
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No. 56, Nalishi Road, Beijing, 100045, China
| |
Collapse
|
|
8
|
Wen Y, Zhu D, Wang Q, Song B, Feng W. External fixator as a safe method in the treatment of distal tibial fractures in children. J Pediatr Orthop B 2024; 33:233-239. [PMID: 37040653 DOI: 10.1097/bpb.0000000000001088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
OBJECTIVE The objective of this study is to evaluate the functional and radiological results of external fixator application in the treatment of distal tibial metaphyseal diaphyseal junction (MDJ) fractures in children and to analyze differences between stable and unstable fractures. METHODS Medical records of children with distal tibial MDJ fracture confirmed by imaging from January 2015 to November 2021 were retrospectively analyzed. Patients were divided into stable and unstable groups and parameters, including clinical and imaging data and Tornetta ankle score were compared. RESULTS Twenty-five children, comprising 13 with stable and 12 with unstable fractures, were included in our study. The mean age was 7 years (range, 2-13.1 years), and there were 17 males and 8 females. All children had closed reduction, and the basic clinical data of the two groups were comparable. Stable fractures showed shorter intraoperative fluoroscopy, operation, and fracture healing times than unstable fractures. No significant difference in Tornetta ankle score was observed. Twenty-two patients had excellent ankle score, and three had a good ankle score, for a combined incidence of 100%. Two patients in the stable fracture group and one in the unstable fracture group developed a pin site infection, and one patient with unstable fracture showed a length discrepancy (discrepancy<1 cm). CONCLUSION External fixator is safe and effective for the treatment of distal tibial MDJ fractures, whether the fracture is stable or not. It has the advantages of minimally invasive, excellent ankle function score, few major complications, needless auxiliary cast fixation, and early functional exercise and weight bearing. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Yuwei Wen
- Department of Orthopaedics, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | | | | | | | | |
Collapse
|
|
9
|
Qiao F, Shang X, Jiang F. Closed reduction and intramedullary nails for acute completely displaced femoral diaphysis fracture in children aged 2-6. Front Pediatr 2024; 12:1346456. [PMID: 38665374 PMCID: PMC11043553 DOI: 10.3389/fped.2024.1346456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/02/2024] [Indexed: 04/28/2024] Open
Abstract
Background The management of femoral fractures in children aged two to six years is still controversial. The purpose of this study was to assess the results of closed reduction and elastic stable intramedullary nail (ESIN) fixation in completely displaced fractures of the femoral diaphysis in children in this age group. Methods A retrospective review of all children with acute completely displaced fractures of the femoral diaphysis in children aged 2-6 years treated from 2013 to 2020 was performed. A total of 34 patients were treated who met the inclusion criteria: Group 1: 21 fractures (transverse and short oblique); Group 2: 13 fractures (long oblique and spiral) that underwent closed reduction and elastic stable intramedullary nail (ESIN) fixation. No differences existed between the 2 groups with respect to age, extremity, sex, time to treatment, mechanism of injury, or fracture displacement. Demographic characteristics and radiographs were reviewed, and the following parameters were documented: surgery time, time to union, return to activities, range of motion of knee joints, and complications. Major complications were defined as those with presumptive long-term side effects or those requiring a reoperation. No major complications were observed in the two groups. All included fractures were treated by a single senior paediatric surgeon. The mean follow-up period was 28.4 months (range 24-45 months). The level of significance was set at p < 0.05. Results Thirty-four children with acute completely displaced fractures of the femoral diaphysis were included: Group 1: 21 fractures; Group 2: 13 fractures. The patients included 15 girls (44.1%) and 19 boys (55.9%), with an average age of 4.4 years (range 2.8 to 6.5 years). The mean follow-up period was 28.4 months (range 24.2-45.0 months). The demographic characteristics did not differ between the two groups of patients. Overall, successful closed reduction and elastic stable intramedullary nail (ESIN) fixation could be achieved in all 34 patients. The mean surgical time was 40.4 and 43.0 min in Group 1 and Group 2, respectively (p = 0.857). Fluoroscopy time was not significantly different between the two groups (37.0 vs. 36.1 s, respectively; p = 0.247). Cosmetic results were described as good and satisfactory by all patients. There were no refractures and no incidences of nonunion or growth arrest in the proximal epiphysis. Only two patients suffered from a superficial infection, which was resolved after the pins were shortened and oral antibiotics were administered. Conclusion Closed reduction and elastic stable intramedullary nail (ESIN) fixation can be successfully used to treat completely displaced fractures of the femoral diaphysis in children aged two to six years. This technique is efficient and minimally invasive, and the results are satisfactory.
Collapse
Affiliation(s)
- Fei Qiao
- Department of Pediatric Orthopaedic, Dalian Women and Children’s Medical Group, Dalian, Liaoning, China
| | | | | |
Collapse
|
|
10
|
Laitakari E, Koukkula T, Huttunen TT, Mattila VM, Salonen A. The incidence, trends, and costs of treatment of femoral shaft fractures among Finnish children aged 2-12 years between 1998 and 2016. J Child Orthop 2024; 18:49-53. [PMID: 38348435 PMCID: PMC10859116 DOI: 10.1177/18632521231217267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 11/12/2023] [Indexed: 02/15/2024] Open
Abstract
Purpose The purpose of this study was to determine the incidence and trends of both hip spica casting and elastic stable intramedullary nailing in children aged 2-12 years who sustained femoral diaphyseal fracture between 1998 and 2016 in Finland. We also evaluated the actual hospital costs of both treatment methods as well as calculating the length of hospital stay. Methods This study included all 2- to 12-year-old children with femoral diaphyseal fracture who were treated in Finland between 1998 and 2016. Data were collected from the National Hospital Discharge Register of Finland. Children were classified by age into five groups. The annual incidences per 100,000 persons were calculated using annual mid-year population census data obtained from Statistics Finland. Data on the annual actual daily hospital costs were collected from the Finnish Institute for Health and Welfare. Results In total, 1064 patients aged 2-12 years who had sustained femoral diaphyseal fracture were treated with elastic stable intramedullary nailing or hip spica casting between 1998 and 2016. In children aged 4-5 years, the incidence of elastic stable intramedullary nailing increased during the study period from 5.4 per 100,000 persons in 1998 to 8.1 per 100,000 persons in 2016. Conclusions The length of hospitalization in patients treated with elastic stable intramedullary nailing was shorter and, therefore, the total costs of hospital treatment were lower than in those children treated with hip spica cast. Level of evidence level III.
Collapse
Affiliation(s)
- Elina Laitakari
- Department of Pediatric and Adolescent Surgery, Pediatric Clinic and Pediatric Research Centre, Tampere University Hospital, Tampere, Finland
| | - Topias Koukkula
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | - Tuomas T Huttunen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Tampere University Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Ville M Mattila
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | - Anne Salonen
- Department of Pediatric and Adolescent Surgery, Pediatric Clinic and Pediatric Research Centre, Tampere University Hospital, Tampere, Finland
| |
Collapse
|
|
11
|
Vazquez S, Dominguez JF, Jacoby M, Rahimi M, Grant C, DelBello D, Salik I. Poor socioeconomic status is associated with delayed femoral fracture fixation in adolescent patients. Injury 2023; 54:111128. [PMID: 37875032 DOI: 10.1016/j.injury.2023.111128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 10/06/2023] [Accepted: 10/13/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Healthcare disparities continue to exist in pediatric orthopedic care. Femur fractures are the most common diaphyseal fracture and the leading cause of pediatric orthopedic hospitalization. Prompt time to surgical fixation of femur fractures is associated with improved outcomes. OBJECTIVE The objective of this study was to evaluate associations between socioeconomic status and timing of femoral fixation in adolescents on a nationwide level. METHODS The 2016-2020 National Inpatient Sample (NIS) database was queried using International Classification of Disease, 10th edition (ICD-10) codes for repair of femur fractures. Patients between the ages of 10 and 19 years of age with a principal diagnosis of femur fracture were selected. Patients transferred from outside hospitals were excluded. Baseline demographics and characteristics were described. Patients were categorized as poor socioeconomic status (PSES) if they were classified in the Healthcare Cost and Utilization Project's (HCUP) lowest 50th percentile median income household categories and on Medicaid insurance. The primary outcome studied was timing to femur fixation. Delayed fixation was defined as fixation occurring after 24 h of admission. Secondary outcomes included length of stay (LOS) and discharge disposition. RESULTS From 2016-2020, 10,715 adolescent patients underwent femur fracture repair throughout the United States. Of those, 765 (7.1 %) underwent late fixation. PSES and non-white race were consistently associated with late fixation, even when controlling for injury severity. Late fixation was associated with decreased rate of routine discharge (p < 0.01), increased LOS (p < 0.01) and increased total charges (p < 0.01). CONCLUSION Patients of PSES or non-white race were more likely to experience delayed femoral fracture fixation. Delayed fixation led to worse outcomes and increased healthcare resource utilization. Research studying healthcare disparities may provide insight for improved provider education, implicit bias training, and comprehensive standardization of care.
Collapse
Affiliation(s)
- Sima Vazquez
- School of Medicine, New York Medical College, Valhalla, NY, USA.
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Michael Jacoby
- Department of Anesthesiology, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
| | - Michael Rahimi
- Department of Anesthesiology, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
| | - Christa Grant
- Department of Pediatric Surgery, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
| | - Damon DelBello
- Department of Orthopaedic Pediatric Surgery, Maria Fareri Children's Hospita, Westchester Medical Center, Valhalla, NY, USA
| | - Irim Salik
- Department of Anesthesiology, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
| |
Collapse
|
|
12
|
Niknam K, Gatto A, Swarup I. Trends in the Management of Femur Fractures in Young Children. JOURNAL OF THE PEDIATRIC ORTHOPAEDIC SOCIETY OF NORTH AMERICA 2023; 5:766. [PMID: 40432942 PMCID: PMC12088140 DOI: 10.55275/jposna-2023-766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Indexed: 05/29/2025]
Abstract
Background: Femoral shaft fractures in young children are commonly treated with closed reduction and spica casting; however, there is increasing literature and interest focusing on internal fixation. This study aims to assess trends in the management of femoral shaft fractures in patients under the age of 6. Methods: This is a retrospective study utilizing the Pediatric Health Information System (PHIS) database. We queried for patients aged 1 to 6 years who had an isolated, closed femoral shaft fracture from October 2015 to December 2020. ICD10 procedure codes were used to determine treatment of the injury. Descriptive statistics and tests of trend were utilized in the analysis of this study. Results: We identified 4608 patients with a femoral shaft fracture during the study period. The majority of patients were treated with spica casting (n=3398, 73.7%), followed by intramedullary fixation (n=600, 13.0%) and plate osteosynthesis (n=449, 9.7%). In this cohort, 3236 patients were between the ages of 1-3 years, and 1372 patients were between the ages of 4-6 years. There was a significant difference in management between these two age groups with lower rates of spica casting in older patients (92.1% vs. 30.5%) and higher rates of intramedullary fixation (37.3% vs. 2.7%) and plate osteosynthesis (28.2% vs. 1.9%) (p<0.01). There was a significant correlation with increasing rates of intramedullary fixation and plate osteosynthesis from 2016 to 2020 (p=0.03 and 0.01, respectively), and a decrease in rate of spica casting over time (p=0.04). Conclusion: Femur fractures in young children are treated with spica casting, intramedullary nails, and plate osteosynthesis. There is a significant change in management over time, and children between the ages of 4 and 6 are more likely to be treated with intramedullary nails compared to younger children. Additional studies are needed to understand these trends as well as justify the increase in rates of intramedullary nails and plate osteosynthesis in young children. Level of Evidence: Level III; Retrospective Cohort Comparison using Large Database Key Concepts•Historically, spica casting was the gold standard for femur fracture treatment in younger patients.•There has been recent interest in the utilization of internal fixation for treatment of femur fractures in young children.•The use of intramedullary nails and plate osteosynthesis in young patients with femur fractures has increased by 34% and 25%, respectively, from 2015 to 2020.•Spica casting has remained the main treatment option for patients aged 1-3.•Intramedullary nails and plate osteosynthesis have been used increasingly over time for patients aged 4-6.
Collapse
Affiliation(s)
- Kian Niknam
- School of Medicine, University of California San Francisco, San Francisco, CA
| | - Andrew Gatto
- California College of Osteopathic Medicine, Touro University, Vallejo, CA
| | - Ishaan Swarup
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA
| |
Collapse
|
|
13
|
Singh A, Bierrum W, Wormald J, Ramachandran M, Firth G, Eastwood D. Plate fixation versus flexible intramedullary nails for management of closed femoral shaft fractures in the pediatric population: A systematic review and meta-analysis of the adverse outcomes. J Child Orthop 2023; 17:442-452. [PMID: 37799319 PMCID: PMC10549696 DOI: 10.1177/18632521231190713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 07/13/2023] [Indexed: 10/07/2023] Open
Abstract
Purpose Fractures of the femoral diaphysis are associated with a risk of morbidity in children. Various fixation methods have been developed, but with only limited evidence to support their use. This systematic review assesses the evidence regarding clinical outcomes of closed femoral diaphyseal fractures in children treated with plate fixation or flexible intramedullary nails. Methods A PROSPERO-registered, PRISMA-compliant systematic review and meta-analysis were conducted. MEDLINE, Embase, and Web of Science (WoS) databases were searched from inception to February 2023. Inclusion criteria included clinical studies reporting adverse outcomes following surgical treatment of pediatric closed femoral diaphyseal fractures using plate fixation and flexible intramedullary nails. The ROBINS-I and RoB 2 tools evaluated the risk of bias. Results Thirteen papers (2 prospective randomized controlled trials and 11 retrospective cohorts) reported 805 closed diaphyseal femoral fractures in 801 children (559 males, 242 females). There were 360 plate fixations and 445 flexible intramedullary nails. Two cases of osteomyelitis and one nonunion were reported. Meta-analysis showed that plate fixation had a lower risk of soft tissue infection (relative risk 0.26 (95% confidence interval 0.07-0.92)). There was no difference in the following outcomes: malunion (relative risk 0.68 (95% confidence interval 0.32-1.44)); unplanned reoperation (relative risk 0.59 (95% confidence interval 0.31-1.14)), and leg-length difference (relative risk 1.58 (95% confidence interval 0.66-3.77)). The risk of bias was high in all studies. Conclusions An analysis of 805 fractures with minimal differences in meta-analyses is considered high quality even when the quality of the evidence is low. The findings are limited by important flaws in the methodology in the published literature. Well-designed multicentre prospective studies using standardized core outcomes are required to advise treatment recommendations. Level of evidence III.
Collapse
Affiliation(s)
- Abhinav Singh
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Orthopaedic Surgery, Imperial College NHS Healthcare Trust, London, UK
| | - William Bierrum
- Department of Acute Internal Medicine, University College London Hospital NHS Trust, London, UK
| | - Justin Wormald
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Gregory Firth
- Department of Orthopaedic Surgery, Barts Health NHS Trust, London, UK
| | - Deborah Eastwood
- Department of Orthopaedic Surgery, Great Ormond Street Hospital, London, UK
- University College London, London, UK
| |
Collapse
|
|
14
|
Shu W, Yu L, Slongo T, Rai S, Zhong H, Tang X. A novel pre-bending tool for elastic stable intramedullary nailing: An efficient and accurate study. J Child Orthop 2023; 17:453-458. [PMID: 37799320 PMCID: PMC10549693 DOI: 10.1177/18632521231193713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/22/2023] [Indexed: 10/07/2023] Open
Abstract
Purpose The elastic stable intramedullary nail has been recognized as an accepted technique for treating pediatric long bone fractures. The principle of the technique is "3-point support and fixation," and it should be followed to achieve the optimum outcome without implant failure and complications. However, tools have yet to be reported for pre-bending of the elastic stable intramedullary nail. This study aims to present a novel tool for pre-bending the elastic stable intramedullary nails and the results of using this tool by surgeons. Methods A designed case of femoral shaft fracture was provided to the participants. All participants were divided into three groups according to their experience with the elastic stable intramedullary nail technique: resident, fellow, and attending groups. The time of completing the pre-bending and coronal plane deviation of the nails after pre-bending was recorded. Statistical analysis compared the data in a conventional way and with the new tools in each group. Results A total of 30 physicians were recruited in this study. The pre-bending duration with the new tool was significantly shorter than that of the conventional method for all physicians (p < 0.001). The coronal plane deviation of nails after pre-bending by the new tool was significantly smaller than that of the conventional method for all physicians (p < 0.001). Conclusion This novel tool for elastic stable intramedullary nail pre-bending was convenient and easy to use in achieving the principal role of the elastic stable intramedullary nail technique. Physicians could reduce the coronal plane deviation when pre-bending elastic stable intramedullary nails, especially for physicians with less experience with the elastic stable intramedullary nail technique. Level of evidence IV.
Collapse
Affiliation(s)
- Wen Shu
- Department of Trauma Orthopaedics, Liuzhou People’s Hospital, Liuzhou, China
| | - LongJun Yu
- Department of Orthopaedics, Yangxin People’s Hospital, Huangshi, China
| | - Theddy Slongo
- Department of Paediatric Surgery, University Children’s Hospital, Bern, Switzerland
| | - Saroj Rai
- Department of Orthopedics, Al Ahalia Hospital, Abu Dhabi, United Arab Emirates
| | - Haobo Zhong
- Department of Orthopaedics, Huizhou First Hospital, Huizhou, China
| | - Xin Tang
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
|
15
|
Hu D, Xu Z, Shi T, Zhong H, Xie Y, Chen J. Elastic stable intramedullary nail fixation versus submuscular plate fixation of pediatric femur shaft fractures in school age patients: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e35287. [PMID: 37773849 PMCID: PMC10545301 DOI: 10.1097/md.0000000000035287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 08/29/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Studies of clinical outcomes that compare the elastic stable intramedullary nail (ESIN) with the submuscular plate (SMP) were controversial. The meta-analysis was performed to summarize existing evidence, aiming to determine whether ESIN was superior to SMP in pediatric femur shaft fractures. METHODS Search strategies followed the recommendations of the Cochrane collaboration. Electronic searches such as PubMed, Embase, Web of Science, Cochrane were systematically searched for publications concerning ESIN and SMP from the inception date to March 2023. Two investigators independently searched, screened, and reviewed the full text of the article. Disagreements generated throughout the process were resolved by consensus, and if divergences remain, they were arbitrated by a third author. RESULTS This study included 8 articles, comprising a total of 561 patients with a similar baseline. Compared to the SMP, the ESIN had shorter operation time (mean difference = -16.16; 95% CI = -22.83 to -9.48, P < .00001), and less intraoperative blood loss (mean difference = -53.62; 95% CI = -58.89 to -48.36, P < .00001), but had a higher incidence of implant irritation (odds ratio [OR] = 6.49; 95% CI = 3.01 to 13.98, P < .0001), lower limb malalignment (OR = 2.60; 95% CI = 1.12 to 6.04, P = .96) and overall complications(OR = 4.14; 95% CI = 2.51 to 6.84, P < .0001). And there was no significant difference in radiation time, length of hospital stay, limb length discrepancy, infection rate, delayed union rate and unplanned revised surgery rate (P > .05). CONCLUSIONS Compared to the SMP, the ESIN offers shorter operative time, and less blood loss. However, the SMP is superior to ESINs in complication rates, especially regarding implant irritation and malalignment. Both methods could achieve excellent satisfactory functional outcomes. Thus, the SMP is an alternative choice in the pediatric femur shaft fracture.
Collapse
Affiliation(s)
- Donglai Hu
- Department of Pediatric Surgery, Jinhua Central Hospital, Jinhua, China
| | - Zihang Xu
- Department of Pediatric Orthopedic Surgery, Jinhua Maternity and Child Health Care Hospital, Jinhua, China
| | - Tao Shi
- Department of Pediatric Orthopedic Surgery, Jinhua Maternity and Child Health Care Hospital, Jinhua, China
| | - Hui Zhong
- Department of Pediatric Orthopedic Surgery, Jinhua Maternity and Child Health Care Hospital, Jinhua, China
| | - Yuting Xie
- Department of Pediatric Orthopedic Surgery, Jinhua Maternity and Child Health Care Hospital, Jinhua, China
| | - Junjie Chen
- Department of Pediatric Surgery, Jinhua Central Hospital, Jinhua, China
| |
Collapse
|
|
16
|
Hancerli CO, Agus H. Efficacy of Single Titanium Elastic Nail in the Treatment of Child Femur Fractures. Cureus 2023; 15:e46099. [PMID: 37900429 PMCID: PMC10604661 DOI: 10.7759/cureus.46099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Femoral shaft fractures in childhood constitute an important part of emergency visits to orthopedic clinics. The aim of this study was to investigate the efficacy and reliability of a method in the treatment of simple fractures in the middle of the femoral diaphysis in patients with multiple injuries or in the treatment of cases with a medullary canal that is too narrow for two nails, with a single stretch nail thicker than half the diameter of the canal. METHODS Between July 2002 and November 2006, examinations were made of 11 femoral fractures in 11 patients who were admitted to the pediatric emergency department of Tepecik Training and Research Hospital with a diagnosis of femoral fracture and who were hospitalized and treated with a single flexible intramedullary titanium nail. RESULTS In the follow-up, no problem was found in terms of union and length difference in any of the cases, except for a 10º varus deformity present after surgery in one case. CONCLUSIONS Elastic intramedullary nailing is an effective method in the treatment of simple femoral fractures in children. A single elastic nail provides adequate stability following open reduction with minimal incision in patients whose short operating time must be kept short such as those with head trauma, thoracic trauma, or intra-abdominal pathology, or patients with a narrow medullary canal where two flexible nails cannot pass. We think that it is a feasible method because it causes minimal soft tissue damage.
Collapse
Affiliation(s)
- Cafer Ozgur Hancerli
- Orthopedics, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, TUR
| | - Haluk Agus
- Orthopedics, Tepecik Training and Research Hospital, Izmir, TUR
| |
Collapse
|
|
17
|
Grauberger J, Larson DR, Stans AA, Shaughnessy WJ, Larson AN, Milbrandt TA. Opioid Prescription Trends for Isolated Diaphyseal Femur Fractures in Pediatric Patients. JOURNAL OF THE PEDIATRIC ORTHOPAEDIC SOCIETY OF NORTH AMERICA 2023; 5:663. [PMID: 40433334 PMCID: PMC12088172 DOI: 10.55275/jposna-2023-663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Indexed: 05/29/2025]
Abstract
Purpose: Despite the ongoing opioid epidemic, there is a lack of research on narcotic prescribing in the pediatric orthopaedic population. The Pediatric Orthopaedic Society of North America (POSNA) therefore published a survey on pain management to provide recommendations for opioid dosing. The goal of this study was to characterize opioid prescribing patterns for pediatric femur fractures in the context of the opioid epidemic and emerging national studies/guidelines.Methods: A retrospective review of 128 pediatric patients (age < 16) with isolated diaphyseal femur fractures was conducted between 2003-2019 at a level I pediatric trauma center. Comparison groups included before distribution of the POSNA survey (pre-POSNA = 01/01/2016 or earlier, N = 85) and after the survey (post-POSNA, N = 43).Results: Median total hospital postoperative opioids prescribed was 27.2 morphine milligram equivalents (MME). The two groups differed in age (pre-POSNA = 9.0 years, post-POSNA = 3.7 years, P = 0.0381), hospital length of stay (LOS) (pre-POSNA = 2 days, post-POSNA = 1 day, P < 0.0001), and procedural incision required for fracture reduction (pre-POSNA = 28.3%, post-POSNA = 58.1%, P = 0.0019). Adjusted postoperative opioid dosing was significantly lower post-POSNA (median reduction of 18.351 MME per year, P = 0.0408).Conclusions: The period following the POSNA survey was associated with a significant decline in postoperative narcotic prescriptions for pediatric femur fractures. The timing of the survey likely represents an increased concern for pediatric opioid use and a shift in clinical practice. Further work is needed to optimize injury and patient-specific narcotic prescribing.Level of Evidence: Therapeutic Level III. Key Concepts •The 2016 POSNA survey identified a lack of consensus on opioid prescribing practices for common orthopaedic procedures in the United States.•The 2016 POSNA survey and subsequent 2019 published narcotic prescription recommendations represent a shift in the specialty of orthopaedic surgery regarding opioid usage in the pediatric population.•Postoperative morphine milligram equivalents significantly decreased for the treatment of pediatric diaphyseal femur fractures at a single-level I pediatric trauma center following administration of the 2016 POSNA survey.
Collapse
Affiliation(s)
- Jennifer Grauberger
- Division of Plastic and Reconstructive Surgery, UMass Chan Medical School, Worcester, MN
| | - Dirk R. Larson
- Department of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN
| | - Anthony A. Stans
- Division of Pediatric Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | | | - A. Noelle Larson
- Division of Pediatric Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Todd A. Milbrandt
- Division of Pediatric Orthopedic Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
|
18
|
Jain M, Ponugoti G, Bhansal S, Shah S, Sangole C, Bohra V, Rabbi Q, Gupta G, Shah M. Hip Spica Table: A Technical Note. Indian J Orthop 2023; 57:1318-1322. [PMID: 37525738 PMCID: PMC10387040 DOI: 10.1007/s43465-023-00935-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/12/2023] [Indexed: 08/02/2023]
Abstract
Introduction Hip spica is a widely used treatment modality in the management of various paediatric orthopaedic conditions. A standardized hip spica table is not universally available and various centerres have devised their own designs. In collaboration with the local engineering team, we have designed a light weight yet sturdy, economical and portable hip spica table. Materials and Methods Components of the spica table and their measurements are described. Technique of mounting and unmounting the patient off the table has been discussed. We have applied the hip spica using the current design in 141 children between 2009 and 2023. The same table has been used for the children aged 6 months to 10 years. We have not experienced any table breakage during spica application. The acrylic sheet was changed only once during the study period due to attrition. Conclusion Our design has been used successfully at our center for more than 14 years. It is simple, economical, portable and durable. It can be used in dedicated pediatric orthopedic centers and can be carried easily to the field hospitals. Supplementary Information The online version contains supplementary material available at 10.1007/s43465-023-00935-1.
Collapse
Affiliation(s)
- Meet Jain
- Orthokids Clinic, 7thFloor, Golden Icon, Opp. Medilink Hospital, Nr. Shivranjani Flyover, 132 Feet Ring Rd, Shyamal, Ahmedabad, Gujarat 380015 India
| | - Godhasiri Ponugoti
- Orthokids Clinic, 7thFloor, Golden Icon, Opp. Medilink Hospital, Nr. Shivranjani Flyover, 132 Feet Ring Rd, Shyamal, Ahmedabad, Gujarat 380015 India
| | - Sheenam Bhansal
- Orthokids Clinic, 7thFloor, Golden Icon, Opp. Medilink Hospital, Nr. Shivranjani Flyover, 132 Feet Ring Rd, Shyamal, Ahmedabad, Gujarat 380015 India
| | - Shalin Shah
- Orthokids Clinic, 7thFloor, Golden Icon, Opp. Medilink Hospital, Nr. Shivranjani Flyover, 132 Feet Ring Rd, Shyamal, Ahmedabad, Gujarat 380015 India
| | - Chinmay Sangole
- Orthokids Clinic, 7thFloor, Golden Icon, Opp. Medilink Hospital, Nr. Shivranjani Flyover, 132 Feet Ring Rd, Shyamal, Ahmedabad, Gujarat 380015 India
| | - Vikas Bohra
- Orthokids Clinic, 7thFloor, Golden Icon, Opp. Medilink Hospital, Nr. Shivranjani Flyover, 132 Feet Ring Rd, Shyamal, Ahmedabad, Gujarat 380015 India
| | - Qaisur Rabbi
- Orthokids Clinic, 7thFloor, Golden Icon, Opp. Medilink Hospital, Nr. Shivranjani Flyover, 132 Feet Ring Rd, Shyamal, Ahmedabad, Gujarat 380015 India
| | - Gaurav Gupta
- Orthokids Clinic, 7thFloor, Golden Icon, Opp. Medilink Hospital, Nr. Shivranjani Flyover, 132 Feet Ring Rd, Shyamal, Ahmedabad, Gujarat 380015 India
| | - Maulin Shah
- Orthokids Clinic, 7thFloor, Golden Icon, Opp. Medilink Hospital, Nr. Shivranjani Flyover, 132 Feet Ring Rd, Shyamal, Ahmedabad, Gujarat 380015 India
| |
Collapse
|
|
19
|
Park K, Cardin S, Fan B, Toledano J, Birnbaum M, Herrera-Soto JA. Can Rigid Femoral Nailing Be Used for Pediatric Femoral Shaft Fracture in Children 8 to 10 Years? Use of RIN in Patients With Femoral Shaft Fracture. J Pediatr Orthop 2023; 43:362-367. [PMID: 36922002 DOI: 10.1097/bpo.0000000000002395] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND The treatment modalities for pediatric femoral shaft fractures are determined by their age, weight, and fracture pattern. Rigid intramedullary nailing (RIN) is usually recommended for patients >11 years of age, and elastic intramedullary nailing (EIN) has been used for patients under 10 years. However, little is known about the use of RIN in patients aged 8 to 10 years. We examined the differences in patients with femoral shaft fractures who were treated with EIN or RIN in terms of (1) fracture healing; (2) changes of anatomic parameters; and (3) related complications. METHODS We retrospectively reviewed 54 patients between 8 and 10 years of age, with femoral shaft fractures, who were treated with either EIN or RIN between 2011 and 2020. Lateral trochanteric entry was used for RIN procedure. The mean follow-up period was 26.4 months (range, 6 to 113 mo). There were 17 patients in the EIN group and 37 patients in the RIN group. The mean age at the time of surgery was 1 year younger in the EIN group ( P <0.01). The mean weight of the patient was significantly heavier in the RIN group compared with the EIN group. RESULTS Complete union of the fracture was achieved slightly faster in the RIN group at 3.4 months compared with 3.7 months in the EIN group ( P =0.04). There were no clinically significant changes of the anatomic parameters in either group, including neck shaft angle and articulotrochanteric distance. There was no evidence of avascular necrosis at the time of final follow-up for either group. There were no significant differences in postoperative complications between the groups. CONCLUSION RIN using lateral trochanteric entry is a feasible surgical option for femoral shaft fractures in patients 8 to 10 years of age that are heavier than 40 kg or with unstable fracture patterns. LEVEL OF EVIDENCE Level III, retrospective cohort study. See the Guidelines for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Kwangwon Park
- Center for Orthopaedics at the Arnold Palmer Hospital for Children, 1222 S. Orange Avenue, Orlando, FL, 32806
| | | | | | | | | | | |
Collapse
|
|
20
|
Catanzano AA, Hutyra C, Risoli TJ, Green CL, Mather RC, Alman B. Cast or Nail? Using a Preference-Based Tool for Shared Decision-Making in Pediatric Femoral Shaft Fracture Treatment. J Pediatr Orthop 2023:01241398-990000000-00316. [PMID: 37390506 DOI: 10.1097/bpo.0000000000002463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
BACKGROUND Femoral shaft fractures are common injuries in children 2 to 7 years of age, with treatments ranging from casting to flexible intramedullary nails (FIN). Each treatment has unique attributes and outcomes are overall similar. Given equivalent outcomes, we hypothesized that a shared decision-making process, using adaptive conjoint analysis (ACA), can be used to assess individual family situations to determine ultimate treatment choice. METHODS An interactive survey incorporating an ACA exercise to elicit the preferences of individuals was created. Amazon Mechanical Turk was used to recruit survey respondents simulating the at-risk population. Basic demographic information and family characteristics were collected. Sawtooth Software was utilized to generate relative importance values of five treatment attributes and determine subjects' ultimate treatment choice. Student's t-test or Wilcoxon rank sum test was used to compare relative importance between groups. RESULTS The final analysis included 186 subjects with 147 (79%) choosing casting as their ultimate treatment choice, while 39 (21%) chose FIN. Need for second surgery had the highest overall average relative importance (42.0), followed by a chance of serious complications (24.6), time away from school (12.9), effort required by caregivers (11.0), and return to activities (9.6). Most respondents (85%) indicated the generated relative importance of attributes aligned "very well or well" with their preferences. For those who chose casting instead of FIN, the need for secondary surgery (43.9 vs. 34.8, P<0.001) and the chance of serious complications (25.9 vs. 19.6, P<0.001) were the most important factors. In addition, returning to activities, the burden to caregivers, and time away from school were all significantly more important to those choosing surgery versus casting (12.6 vs. 8.7 P<0.001, 12.6 vs. 9.8 P=0.014, 16.6 vs. 11.7 P<0.001, respectively). CONCLUSIONS Our decision-making tool accurately identified subjects' treatment preferences and appropriately aligned them with a treatment decision. Given the increased emphasis on shared decision-making in health care, this tool may have the potential to improve shared decision-making and family understanding, leading to improved satisfaction rates and overall outcomes. LEVEL OF EVIDENCE Level-III.
Collapse
Affiliation(s)
| | | | | | - Cynthia L Green
- Division of Biostatistics, Department of Biostatistics, Epidemiology, and Research Design (BERD) Methods Core, Durham, NC
| | - R Chad Mather
- Department of Orthopaedic Surgery, Duke University Health System
| | - Benjamin Alman
- Department of Orthopaedic Surgery, Duke University Health System
| |
Collapse
|
|
21
|
Qiao F, Ma J, Lv P, Jiang F. Treatment of pathological fracture of the femoral diaphysis in a child with acute lymphatic leukaemia: A case report. Asian J Surg 2023:S1015-9584(23)00324-X. [PMID: 36931927 DOI: 10.1016/j.asjsur.2023.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/02/2023] [Indexed: 03/18/2023] Open
Affiliation(s)
- Fei Qiao
- Department of Pediatric Orthopaedic, Dalian Women and Children's Medical Group, Dalian, Liaoning, 116012, China.
| | - Jingyu Ma
- Department of Pediatric Orthopaedic, Dalian Women and Children's Medical Group, Dalian, Liaoning, 116012, China.
| | - Ping Lv
- Department of Otorhinolaryngology, Dalian Women and Children's Medical Group, Dalian, Liaoning, 116012, PR China.
| | - Fei Jiang
- Department of Pediatric Orthopaedic, Dalian Women and Children's Medical Group, Dalian, Liaoning, 116012, China.
| |
Collapse
|
|
22
|
Length Unstable Pediatric Tibial Shaft Fracture Treated With Cerclage Augmented Elastic Intramedullary Nails: A Novel Technique. Tech Orthop 2022. [DOI: 10.1097/bto.0000000000000597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
|
23
|
Muhammad H, Filza MR, Siwendro AB, Ismiarto YD. Pediatric neglected distal femoral fracture with growth arrest. Int J Surg Case Rep 2022; 93:106929. [PMID: 35298979 PMCID: PMC8927706 DOI: 10.1016/j.ijscr.2022.106929] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 03/02/2022] [Accepted: 03/05/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction and importance Distal femoral growth plate fracture is one of the most common growth plate fractures in the pediatric age, and associated with growth disturbance risk. Consequences that may arise are hindered growth, irreversible decrease in range of motion, instability, angular deformity and neurovascular issues. Fractures of the lateral condyle show a higher risk of developing sequelae compared to the medial side. Case presentation Corrective osteotomy of the distal femur was performed in patient with history of femoral fracture which undergone an ORIF procedure for the shaft at the previous hospital, while the lateral condyle fracture was treated conservatively. We did close wedge osteotomy medially and transferred the bone fragment to the lateral side as an open wedge to lengthen the lateral cortex. The leg-length discrepancy was reduced from 5 to 2 cm even though subsequent deformities may possibly occur. Clinical discussion The management approach for fracture of distal femoral physis can be done conservatively or surgically. Unfavorable outcomes from the conservative approach gave more reasons to opt for a surgical approach. The growth plate location should be considered when deciding which level of osteotomy is best and the fixation points in younger patients. When physeal bars are formed due to the fracture stress on the growth plate, the treatment is based on the patient's age and the bar's size. Conclusion Fractures of the distal femur involving a growth plate in children should not be considered a trivial case, and a comprehensive treatment plan should be coordinated.
Distal femoral fracture is one of the most common growth plate fracture in pediatric associated with growth disturbance and growth arrest Fracture occurring on the lateral condyle show a higher risk of developing sequelae compared to the medial condyle fracture Pediatric distal femoral fractures managed conservatively using a long-leg cast only would not sustain reduction and often ended up losing the reduction Internal fixation being recommended to be done regardless of displacement severity occurring with distal femoral fracture Growth plate location should be considered when deciding the level of osteotomy and fixation points
Collapse
|
|
24
|
Turgut A, Kumbaraci M, Yalçın E, Gezer MC, Bozkurt S, Kalenderer Ö. Analysis of the factors that are important in re-displacement in pediatric diaphyseal femur fractures treated with a spica cast. Injury 2022; 53:1013-1019. [PMID: 34627628 DOI: 10.1016/j.injury.2021.09.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/19/2021] [Accepted: 09/26/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is no detailed data on the factors affecting the re-displacement in pediatric femoral fractures treated with closed reduction and early spica casting. This study aimed to investigate the factors effective in re-displacement in pediatric diaphyseal femur fractures (PDFF) treated with spica casting. METHODS In all, 151 displaced PDFF were evaluated retrospectively. Demographic data of the patients were evaluated. Type of fractures, anteroposterior and lateral angulations, amount of shortening, translation ratio, cast index (CI), gap index (GI), and three-point index (TPI) measurements were evaluated radiologically. Thigh flexion angle (TFA) and knee flexion angle (KFA) were measured. After casting, angulation of more than 10° in any plane and a shortening of more than 10 mm was accepted as re-displacement. Binary logistic regression analysis was used to evaluate the risk factors of re-displacement. Receiver operating characteristic analysis was performed for TFA and KFA. RESULTS Re-displacement was detected in 40 patients (26.5%). Transverse type fracture (p = 0.001), TFA ˂71.4° (p <0.001), and KFA ˂52.6° (p = 0.002) were found to be statistically significant factors on re-displacement. It was determined that the combination of transverse femoral fracture and TFA ˂71.4° increased the probability of re-displacement by approximately 14 times. It has been observed that indices such as CI, GI, and TPI were not effective in predicting the risk of re-displacement. CONCLUSION When treating a PDFF with spica casting, one should be aware of re-displacement if the fracture type is transverse, TFA is ˂71.4°, and KFA is ˂52.6°. LEVEL OF EVIDENCE Level III, prognostic.
Collapse
Affiliation(s)
- Ali Turgut
- Tepecik Training and Research Hospital, Department of Orthopaedics and Traumatology, İzmir, Turkey.
| | - Mert Kumbaraci
- Tepecik Training and Research Hospital, Department of Orthopaedics and Traumatology, İzmir, Turkey
| | - Eren Yalçın
- Tepecik Training and Research Hospital, Department of Orthopaedics and Traumatology, İzmir, Turkey
| | - Mehmet Can Gezer
- Tepecik Training and Research Hospital, Department of Orthopaedics and Traumatology, İzmir, Turkey
| | - Safa Bozkurt
- Tepecik Training and Research Hospital, Department of Orthopaedics and Traumatology, İzmir, Turkey
| | - Önder Kalenderer
- Tepecik Training and Research Hospital, Department of Orthopaedics and Traumatology, İzmir, Turkey
| |
Collapse
|
|
25
|
Baghdadi S, Mahmoud MAH, Flynn JJM, Arkader A. Unplanned Return to the Operating Room (UpROR) After Pediatric Diaphyseal Femoral Fractures. J Pediatr Orthop 2022; 42:e120-e125. [PMID: 34923506 DOI: 10.1097/bpo.0000000000002032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Femoral fractures are the most common cause of fracture-related admissions. Unplanned return to the operating room (UpROR) is a major event and imposes a substantial burden on the family and health care system. The purpose of this study was to determine the incidence of complications and early UpROR during the first 6 months following treatment of femoral fractures and their risk factors. METHODS In an institutional review board-approved study, a retrospective review of all patients who were treated for a femoral fracture during a 10-year period at a pediatric tertiary care center was performed. Patients less than 18 years old with a diaphyseal fracture and complete records were included, and nondiaphyseal or pathologic fractures, as well as underlying metabolic or genetic disorders, were excluded. All clinic visits in the first 6 months after treatment were reviewed, and all complications and UpRORs were extracted. Patients were grouped based on their age (below 5, 5 to 11, above 11 y old) at initial treatment, and statistical tests were used to infer differences between groups. RESULTS Overall, 841 fractures in 832 patients were included, with a mean age of 5.5±4.8 years fracture, of which 72% were male. A total of 106 complications (12.6%) and 45 UpRORs (5.3%) were encountered during the study period. Patients with and without UpROR had similar demographics and injury and treatment characteristics. Loss of reduction was the most common reason for UpROR (58%), followed by implant-related complications. Flexible nails had the highest risk of UpROR among patients who were initially treated surgically (P=0.03). CONCLUSIONS Our findings indicate that children under the age of 5 years have a 5% risk of UpROR in the first 6 months after the fracture, mainly for repeat spica casting due to loss of reduction. Patients aged 5 years or older have an ∼6% risk of UpROR, mainly related to complications of flexible nails. The findings of this study are important when consulting families on different treatments of diaphyseal femoral fractures. LEVEL OF EVIDENCE Therapeutic level III-retrospective cohort study.
Collapse
Affiliation(s)
- Soroush Baghdadi
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia
| | | | - John Jack M Flynn
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Alexandre Arkader
- Division of Orthopedic Surgery, Children's Hospital of Philadelphia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
|
26
|
Barnett SA, Song BM, Yan J, Lucak TJ, Leonardi C, Kadhim M, Heffernan MJ. The Feasibility of Utilizing Malunion Criteria to Limit Radiographs After Spica Casting for Pediatric Femur Fractures. J Pediatr Orthop 2022; 42:e115-e119. [PMID: 34995257 DOI: 10.1097/bpo.0000000000002009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND There are no existing guidelines regarding the timing or frequency of postoperative radiographs following spica casting for pediatric femur fractures. The purpose of this study was to evaluate established femoral malunion criteria as a potential screening tool to limit postoperative radiographs by identifying patients at risk for unacceptable alignment in the early treatment period. METHODS A retrospective chart review was conducted for pediatric femoral shaft fractures presenting to a tertiary pediatric referral hospital from 2012 to 2017. Pediatric femur malunion criteria were applied to radiographs at initial presentation, first follow-up visit, and final follow-up visit. The primary outcome was a change in management based on radiographic findings in the early postoperative period. Secondary outcomes included radiographic measures, number of follow-up visits, and complications. RESULTS Of 449 consecutive pediatric femur fractures treated at our center, 149 patients aged 1 to 4 years (mean age: 2.5±1.6 y) met inclusion criteria. At initial presentation, 36.9% (55/149) of patients met malunion criteria. Only 4.0% (6/149) of patients had a change in management following initial closed reduction and spica cast application due to radiographic findings at subsequent follow-up. Of these patients, 67% (4/6) were identified on preoperative imaging, and 83.3% (5/6) were identified by their first clinic appointment. Four of the 149 patients were converted to definitive surgical fixation, and 2 patients required cast wedging due to either unacceptable fracture shortening or coronal/sagittal angulation. CONCLUSIONS Routine early postoperative radiographs may not be necessary for all pediatric femur fractures managed with closed reduction and spica casting. The value of this study is that it is the first to demonstrate the feasibility of limiting postoperative radiographs using a preoperative screening tool. However, the established femoral malunion criteria utilized in this study were limited in their predictive value, and further work is necessary to improve the sensitivity and specificity before widespread clinical application. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
| | | | | | | | - Claudia Leonardi
- School of Public Health, LSU Health Sciences Center, New Orleans, LA
| | | | | |
Collapse
|
|
27
|
ÇAĞLAR C, EMRE F. Clinical and radiographic evaluation of femoral shaft fractures in a pediatric population treated with titanium elastic nails. EGE TIP DERGISI 2021. [DOI: 10.19161/etd.1036963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
|
28
|
Flexible Intramedullary Nail Versus Submuscular Locked Plate with the Cluster Technique in Pediatric Femoral Shaft Fractures Fixation. Indian J Orthop 2021; 56:580-586. [PMID: 35342514 PMCID: PMC8921348 DOI: 10.1007/s43465-021-00571-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 11/11/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE OF THE STUDY The aim of this study is the comparison between the flexible intramedullary nail and submuscular Locked Plate with the cluster technique in fixation of pediatric femoral shaft fractures at the age group between 6 and 12 years old with simple diaphyseal closed or Gustilo open grade I fractures. METHODS Fifty children aged 6-12 years with femoral fractures were enrolled in this study. The children were randomly assigned equally to the two groups for fractures fixation. The follow-up period was 1 year. A comparison of various parameters and outcomes between both groups was documented. RESULTS No significant differences were detected between both groups regarding the age, gender, affected side, mechanisms of fracture, or fracture classifications. The operative time and radiation time were longer in the plating group, while the amount of blood loss was lesser in the nail group. The patients treated with plating had better results concerning knee range of motion, weight-bearing, malalignment, and length discrepancy, with fewer complications and better functional outcomes. CONCLUSION The result of the present study supports the use of submuscular locked plate with cluster technique in the treatment of studied fractures over flexible IMN.
Collapse
|
|
29
|
Hip Spica Stroller: A Technical Note. Indian J Orthop 2021; 56:634-638. [PMID: 35342529 PMCID: PMC8921444 DOI: 10.1007/s43465-021-00568-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/04/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Care of the child after hip-spica application is the most challenging issue faced by parents. Reduced mobility and recumbency can cause respiratory problems, skin irritation and discomfort for the child. Parents need to lift the child in a spica to make him upright and to mobilize. To improve the comfort of the family in post spica care, we have designed a 'Hip Spica Stroller' which is low profile, comfortable, easy to construct and relatively inexpensive. This manuscript discusses our early experience with this hip-spica stroller use. METHODS A sturdy, relatively lightweight and portable stroller was designed in collaboration with local mechanical engineering team. The stroller allowed safe upright placement of the child with spica and their easy mobility. From the second post-operative day, children were mobilised in the stroller. We looked for development of any complications related to the stroller such as spica breakage, skin irritation or excoriation development. Parents were also inquired about their feedback and satisfaction with the device upon spica removal. RESULTS We used the spica stroller in nine patients after Developmental Dysplasia Hip (DDH) treatment and in eight patients post shaft femur fracture treatment. None of the patients experienced any stroller-related complications. All the patients maintained the joint reduction and the fractured bone fragment alignment. High satisfaction rates were reported by parents. CONCLUSION Hip Spica Stroller is an innovative and easy-to-make device which would enhance the post spica care. It can aid alleviating the fear of parents for their child's hip-spica treatment. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43465-021-00568-2.
Collapse
|
|
30
|
Rigid intramedullary nail fixation of traumatic femoral fractures in the skeletally immature. OTA Int 2021; 4:e128. [PMID: 34746660 PMCID: PMC8568442 DOI: 10.1097/oi9.0000000000000128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 12/02/2020] [Accepted: 03/14/2021] [Indexed: 11/26/2022]
Abstract
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.
Collapse
|
|
31
|
Collins AC, Adams N, Ostrander JD, Atkinson P, Atkinson TS. Safe transport of spica casted infants: Reducing the risk of traumatic injury in side impact collisions. Am J Surg 2021; 223:164-169. [PMID: 34538481 DOI: 10.1016/j.amjsurg.2021.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 07/29/2021] [Accepted: 08/31/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is limited data on transporting small children in hip spica casts used to treat pediatric femur fractures. Specific challenges include the fixed position of the body in the casted position and the increased size of the child due to cast thickness. Additionally, children less than 2 years old are recommended to be rear facing during transportation. This traveling position requires seats that are specifically designed to accommodate the small size of the child as well as accommodate the rear facing position. While seats able to accommodate casted children are available, it is unclear if they provide adequate protection in side impact collisions for rear facing spica casted infants. Therefore, the aim of this study was to evaluate traumatic injury metrics in a side impact collision model where a spica casted infant crash dummy was restrained in currently available car seats. METHODS Two seats designed for spica casted children (R82 Quokka, Merritt Wallenberg) and two traditional car seats (Britax Emblem, Graco Sequel) able to accommodate a casted one-year-old crash test dummy were identified. Side impact collision testing was performed with the dummy positioned in the rear facing position and injury metrics recorded. RESULTS Testing identified contact between the dummy's head and the door panel for a specialty spica car seat without protective side-wings for the head. All other seats contained side wings and prevented door-head contact. CONCLUSIONS Casted children should be transported in a seat able to accommodate the cast and safely restrain them. Our results demonstrate the importance of side wing protection in any seat used to transport these children as side bolsters may help decrease the potential for head contact with the door and lower the risk of severe head injury.
Collapse
Affiliation(s)
| | - Nate Adams
- McLaren-Flint, 401 S. Ballenger Hwy, Flint, MI, 48532, USA
| | | | - Pat Atkinson
- McLaren-Flint, 401 S. Ballenger Hwy, Flint, MI, 48532, USA; Kettering University, 1700 University Ave, Flint, MI, 48504, USA
| | - Theresa S Atkinson
- McLaren-Flint, 401 S. Ballenger Hwy, Flint, MI, 48532, USA; Kettering University, 1700 University Ave, Flint, MI, 48504, USA.
| |
Collapse
|
|
32
|
Checklists in Femur Fractures: High Adherence After Implementation of Computer-based Pediatric Femur Guidelines. J Am Acad Orthop Surg Glob Res Rev 2021; 5:01979360-202108000-00004. [PMID: 35103636 PMCID: PMC9521745 DOI: 10.5435/jaaosglobal-d-21-00154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 06/26/2021] [Indexed: 11/18/2022]
Abstract
The American Academy of Orthopaedic Surgeons (AAOS) created an evidence-based clinical practice guideline for the care of pediatric diaphyseal femur fractures in 2010. Our institution implemented checklists based off these guidelines embedded in a standardized EMR order. The purpose of this study was to describe compliance with checklist completion and to assess safety improvement in a large urban pediatric hospital.
Collapse
|
|
33
|
Lakhani A, Bhatnagar SM, Singh GP, Gupta N, Sharma E. Role of mini-invasive bridge plate in the complex femoral fracture in school going children: A prospective clinical study of 30 cases. J Family Med Prim Care 2021; 10:1188-1192. [PMID: 34041149 PMCID: PMC8140261 DOI: 10.4103/jfmpc.jfmpc_1210_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/08/2020] [Accepted: 09/13/2020] [Indexed: 12/02/2022] Open
Abstract
Objective: Pediatric femoral fracture including supracondylar and subtrochanteric fracture constitutes 1.6% of all paediatric fracture. Elastic nails remain the standard treatment of choice in a midshaft transverse femoral fracture in children weighing less than 45 kg. But in subtrochanteric and spiral femoral fracture, the failure rate of elastic nails are quite high. Hence, in accordance with AAOS guidelines, we treated complex femoral fracture in children with submuscular mini-invasive bridge plate because of its advantage of minimal incision, early union with proper alignment and lower failure. Material and Methods: We retrospectively reviewed 30 complex femur fracture in children treated with Submuscular bridge plate by mini-invasive approach. Patients were analysed according to their age, type of fracture, time of union in weeks, complication and results were evaluated with modified Flynn's criteria. Result: Out of 30 patients 28 were boys and 2 were females, with an average age of 11.5 years in which Spiral fracture (n = 12), subtrochanteric fracture (n = 9), Complex Shaft fracture (n = 10). All fracture united well on an average of 11 weeks. And 29 patients has excellent results and in 1 patient there is Acceptable result. The single complication was 3 mm limb lengthening but it didn't change gait of the patient. Conclusion: Mini invasive bridge plating is an easy and soft tissue preserving procedure for managing complex femoral fracture in children. It has shown promising results in achieving union without any major complication. We strongly recommend the SBP in a complex femoral fracture in children.
Collapse
Affiliation(s)
- Amit Lakhani
- Department of Orthopedics, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti Solan, Mullana, Ambala, Haryana, India
| | - S M Bhatnagar
- Department of Orthopedics, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti Solan, Mullana, Ambala, Haryana, India
| | - Gobind Pratap Singh
- Department of Orthopedics, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti Solan, Mullana, Ambala, Haryana, India
| | - Nikunj Gupta
- Department of Orthopedics, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti Solan, Mullana, Ambala, Haryana, India
| | - Ena Sharma
- Department of Periodontics, Maharishi Markandeshwar College of Dental Sciences and Research, Mullana, Ambala, Haryana, India
| |
Collapse
|
|
34
|
Guo M, Su Y. Risk factors for refracture of the femoral shaft in children after removal of external fixation. J Orthop Traumatol 2021; 22:4. [PMID: 33625585 PMCID: PMC7905006 DOI: 10.1186/s10195-021-00569-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 02/15/2021] [Indexed: 12/17/2022] Open
Abstract
Background External fixation is the primary treatment option in children for femoral shaft fractures, such as open femoral or multiple fractures. One complication is refracture, which is the biggest limitation of fixation devices. This study aims to investigate the risk factors associated with refracture after the removal of external fixation devices and decrease the frequency of refracture. Materials and methods Retrospectively reviewed clinical data of 165 patients treated at our hospital for fresh femoral shaft fractures with external fixation between May 2009 and February 2018 were included in this study. Patients with pathological fractures, fractures of the femoral neck, fractures that were fixed using plates or elastic stable intramedullary nailing, and old fractures, as well as those who underwent postoperative femoral surgery were excluded. Potential risk factors included: patient age, gender, and weight, fracture sides, open or closed fracture, fracture sites, reduction methods, operation time, perioperative bleeding, number and diameter of the screws, and immobilization time. These factors were identified by univariate and logistic regression analyses. Results Femoral shaft refracture developed in 24 patients. Univariate analysis revealed that refracture was not statistically significantly associated with any of the above factors, except AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) classification type 32-D/4.2 and L2/L3 ratio (L2, length of femur fixed by the two screws farthest from the fracture line; L3, the total length from the greater trochanter to the distal end of femur; P < 0.001 and P = 0.0141, respectively). Multivariate analysis showed that PCCF classification type 32-D/4.2 and L2/L3 ratio were also independent risk factors for femoral refracture. Conclusions Femoral shaft refracture is relatively common in children treated with external fixation. Because of the limited number of cases in this study, we cautiously concluded that the PCCF classification type 32-D/4.2 and L2/L3 ratio were independent risk factors for femoral shaft refracture in these patients. Level of evidence IV
Collapse
Affiliation(s)
- Meizhen Guo
- Department II of Orthopedics, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, The Children's Hospital of Chongqing Medical University, 136# Zhongshan 2road Yuzhong District, Chongqing, 400014, China
| | - Yuxi Su
- Department II of Orthopedics, Chongqing Key Laboratory of Pediatrics, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, The Children's Hospital of Chongqing Medical University, 136# Zhongshan 2road Yuzhong District, Chongqing, 400014, China.
| |
Collapse
|
|
35
|
Atassi O, Fontenot PB, Busel G, De La Fuente G, Donohue D, Maxson B, Shah AR, Watson DT, Infante AF, Downes K, Sanders RW, Mir HR. "Unstable" Pediatric Femoral Shaft Fractures Treated With Flexible Elastic Nails Have Few Complications. J Orthop Trauma 2021; 35:e56-e60. [PMID: 33060381 DOI: 10.1097/bot.0000000000001886] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine our complication rate in pediatric femoral shaft fractures treated with flexible elastic nailing and to determine fracture characteristics that may predict complications. DESIGN Retrospective cohort study. SETTING One Level 1 and One Level 2 academic trauma centers. PATIENTS/PARTICIPANTS One hundred one pediatric femoral shaft fractures treated from 2006 to 2018. MAIN OUTCOME MEASUREMENT Major and minor complications. RESULTS One hundred one femurs met inclusion criteria. The average age was 7 years (range 3-12 years). The average weight was 29.0 kg (range 16-55 kg). The average follow-up was 11 months (6-36 months). Ninety-three patients underwent elective implant removal at our institution. Fifty-one of the 101 (50%) fractures were "unstable" patterns. Ninety-three percent had implants that filled >80% of the canal (69 titanium and 32 stainless steel). Seventeen percent (18) had cast immobilization. All fractures went on to union. No patient required revision surgery for malunion as follows: 6 had coronal/sagittal malalignment >10 degrees, 3 had malrotation >15 degrees, and none had a leg length inequality >1 cm. Three patients had an unplanned surgery as follows: 2 for prominent implants and 1 for refracture after a second injury. There were no patient, fracture, or treatment characteristics that were predictive of complications or unplanned surgery, including "unstable" fractures (P = 0.78). CONCLUSION Our study demonstrates that flexible elastic nailing can be safely used in most pediatric femoral shaft fractures, including those previously described as "unstable." LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Omar Atassi
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; and
| | - Philip B Fontenot
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; and
- Department of Orthopaedic Surgery, University of South Florida, Tampa, FL
| | - Gennadiy Busel
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; and
| | | | - David Donohue
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; and
- Department of Orthopaedic Surgery, University of South Florida, Tampa, FL
| | - Benjamin Maxson
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; and
- Department of Orthopaedic Surgery, University of South Florida, Tampa, FL
| | - Anjan R Shah
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; and
- Department of Orthopaedic Surgery, University of South Florida, Tampa, FL
| | - David T Watson
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; and
- Department of Orthopaedic Surgery, University of South Florida, Tampa, FL
| | - Anthony F Infante
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; and
- Department of Orthopaedic Surgery, University of South Florida, Tampa, FL
| | - Katheryne Downes
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; and
| | - Roy W Sanders
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; and
- Department of Orthopaedic Surgery, University of South Florida, Tampa, FL
| | - Hassan R Mir
- Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; and
- Department of Orthopaedic Surgery, University of South Florida, Tampa, FL
| |
Collapse
|
|
36
|
Abstract
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.
Collapse
|
|
37
|
Abstract
BACKGROUND Femoral shaft fractures in children are common in low and middle income countries. In high-income countries, patient age, fracture pattern, associated injuries, child/family socioeconomic status, and surgeon preference dictate fracture management. There is limited literature on treatment patterns for pediatric femur fractures in resource-limited settings. This study surveys surgeons from low (LIC), lower-middle (LMIC), and upper-middle income (UMIC) countries regarding treatment patterns for pediatric femur fractures. METHODS Surgeons completed an electronic survey reporting surgeon demographics and treatment preference for pediatric femur fractures. Treatment preferences and indications for treatment were separated into 4 groups: infant (0 to 6 mo); toddler (7 mo to 4 y); child (5 to 12 y); adolescent (12 to 17 y). The survey was available in English, Spanish, and French. Analysis was completed with t test and χ test for continuous and categorical variables, respectively, and weighted Pearson correlation (P<0.05). RESULTS Survey respondents consisted of 413 surgeons from 83 countries (20 LIC, 33 LMIC, 30 UMIC). The majority of respondents were fellowship trained (83%) most commonly in pediatrics (26%) and trauma (43%). Most treated >10 pediatric femur fractures per year (68%). Respondents reported treating infant femur fractures nonoperatively using Pavlik harness (19%), spica cast (60%), or traction with delayed spica cast (14%). Decreasing socioeconomic status was associated with higher nonoperative treatment rate in toddlers, children, and adolescents. Respondents commonly utilize bed rest and traction for child femur fractures in LICs (63%) and LMICs (65%) compared with UMICs (35%) (UMIC vs. LMIC P<0.001; UMIC vs. LIC P<0.001). Surgeries in children more commonly involve open reduction with internal fixation (UMIC 19%, LMIC 33%, LIC 40%; P<0.05 between UMIC-LMIC and UMIC-LIC). CONCLUSION This is one of the largest surveys describing treatment patterns for pediatric femur fractures in low and middle income countries. Differences are evident including lower operative treatment rate in younger children and lower intramedullary fixation rates in older children. Future studies should investigate the value of treatment options in resource-limited settings. LEVEL OF EVIDENCE Level II-prospective comparative study.
Collapse
|
|
38
|
Mussell EA, Jardaly A, Gilbert SR. Length unstable femoral fractures: A misnomer? World J Orthop 2020; 11:380-390. [PMID: 32999858 PMCID: PMC7507079 DOI: 10.5312/wjo.v11.i9.380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/28/2020] [Accepted: 08/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Flexible intramedullary nailing (FIMN) is relatively contraindicated for pediatric length unstable femoral fractures.
AIM To evaluate FIMN treatment outcomes for pediatric diaphyseal length unstable femoral fractures in patients aged 5 to 13 years.
METHODS This retrospective study includes pediatric patients (age range 5-13 years) who received operative treatment for a diaphyseal femoral fracture at a single institution between 2013 and 2019. Length unstable femur fractures treated with FIMN were compared to treatment with other fixation methods [locked intramedullary nailing (IMN), submuscular plating (SMP), and external fixation] and to length stable fractures treated with FIMN. Exclusion criteria included patients who had an underlying predisposition for fractures (e.g., pathologic fractures or osteogenesis imperfecta), polytrauma necessitating intensive care unit care and/or extensive management of other injuries, incomplete records, or no follow-up visits. Patients who had a length stable femoral fracture treated with modalities other than FIMN were excluded as well.
RESULTS Ninety-five fractures from ninety-two patients were included in the study and consists of three groups. These three groups are length unstable fractures treated with FIMN (n = 21), length stable fractures treated with FIMN (n = 45), and length unstable fractures treated with either locked IMN, SMP, or external fixator (n = 29). P values < 0.05 were considered statistically significant. Patient characteristic differences that were statistically significant between the groups, length unstable with FIMN and length unstable with locked IMN, SMP, or external fixator, were average age (7.4 years vs 9.3 years, respectively), estimated blood loss (29.2 mL vs 98 mL, respectively) and body mass (27.8 kg vs 35.1 kg, respectively). All other patient characteristic differences were statistically insignificant. Regarding complications, length unstable with FIMN had 9 total complications while length unstable with locked IMN, SMP, or external fixator had 10. Grouping these complications into minor or major, length unstable with locked IMN, SMP, or external fixator had 6 major complication while length unstable with FIMN had 0 major complications. This difference in major complications was statistically significant. Lastly, when comparing patient characteristics between the groups, length unstable with FIMN and length stable with FIMN, all characteristics were statistically similar except time to weight bearing (39 d vs 29 d respectively). When analyzing complication differences between these two groups (9 total complications, 0 major vs 20 total complications, 4 major), the complication rates were considered statistically similar.
CONCLUSION FIMN is effective for length unstable fractures, having a low rate of complications. FIMN is a suitable option for length stable and length unstable femur fractures alike.
Collapse
Affiliation(s)
- Eric Andrew Mussell
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, and Andrews Sports Medicine and Orthopaedic Center, Birmingham, AL 35205, United States
| | - Achraf Jardaly
- Department of Orthopedic Surgery, University of Alabama at Birmingham and Lebanese American University, Gilbert and Rose-Marie Chagoury School of Medicine, Byblos 00000, Lebanon
| | - Shawn R Gilbert
- Department of Pediatric Orthopaedics, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| |
Collapse
|
|
39
|
Expert Consensus for a Principle-based Classification for Treatment of Diaphyseal Pediatric Femur Fractures. J Pediatr Orthop 2020; 40:e669-e675. [PMID: 32251113 DOI: 10.1097/bpo.0000000000001550] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Recent studies demonstrate considerable deviation from the American Academy of Orthopaedic Surgeons (AAOS) evidence-based guidelines for the treatment of pediatric diaphyseal femur fractures (PDFFs). This study aimed to determine if expert-consensus can be reached on a principle-based classification to be applied broadly to a wide variety of PDFF scenarios and if outcomes correspond to adherence to the classification. METHODS A 2-stage study was performed. First, a survey of experts using a principle-based approach to PDFF. We conducted a survey of 17 thought-leaders (criteria≥20 y' experience+authors of the seminal pediatric femur fracture studies) who were asked to classify 15 cases of PDFF using the principle-based classification for agreement. Next, we conducted a retrospective review of 289 consecutive PDFF treated (2011-2015) at a level 1 pediatric trauma center. For each case, we compared the actual treatment and proposed "ideal" principle-based classification. We then compared clinical results and outcome data points including the length of stay, physician visits, and hospital charge data. RESULTS A substantial (κ=0.7) expert-agreement was noted for assigning treatment principles with near-perfect (κ=0.93) agreement on conservative versus surgical management. We obtained agreement on employing a flexible implant (κ=0.84) rigid fixation (κ=0.75) and damage control philosophy (κ=0.64). Suboptimal clinical results were noted in 43% of the undertreated patients (24/56), 18.8% of the adequately treated, and 14.3% of overtreated (P<0.01) patients. An increasing trend for the length of hospital stay and a number of clinic visits was noted as the treatment class increased (P<0.01). Charges were 4.2 times higher for an episode of operative versus nonoperative care (P<0.01). Rigid fixation (class 4) had significantly (P=0.01) higher total and material charges than flexible fixation (class 3). DISCUSSION The proposed classification has a substantial agreement among thought-leaders. Clinical results demonstrated significantly more suboptimal results in undertreated fractures, compared with ideally treated or more invasively treated fractures. More invasive treatments led to increased burden to families and the system in terms of length of stay and hospital charges. LEVEL OF EVIDENCE Level III.
Collapse
|
|
40
|
Enhancing stability by penetrating the apophysis of greater trochanter or the posterior neck cortex during titanium elastic nailing of paediatric subtrochanteric femoral fractures in children aged 5-12 years. J Pediatr Orthop B 2020; 29:478-484. [PMID: 31856039 DOI: 10.1097/bpb.0000000000000699] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
Collapse
|
|
41
|
Flexible intramedullary nailing of femoral shaft fractures: closed versus open reduction. J Pediatr Orthop B 2020; 29:472-477. [PMID: 31651747 DOI: 10.1097/bpb.0000000000000685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Children's femoral shaft fractures are commonly treated with flexible intramedullary nailing after closed or open reduction, but there is little information concerning indications for open reduction. The purpose of this study was to determine radiographic and clinical features likely to lead to open reduction before flexible intramedullary nailing. Record review identified 158 femoral shaft fractures treated with flexible intramedullary nailing. In addition to patient demographics and mechanism of injury, data obtained included surgeon name, estimated blood loss, type of reduction, type and diameter of nail, type of operating table, the use of percutaneous reduction techniques or supplemental casting, time to and duration of surgery, total time in operating room, and time to union. Fracture ratios were calculated based on established radiographic protocol. Of 158 fractures, 141 were treated with closed reduction and 17 with open reduction. The anteroposterior fracture index (1.3 ± 0.4, P = 0.0007), surgeon (P = 0.002), and flattop operating table (0.05) were associated with open reduction. Smaller lateral diameter of bone at the fracture site, transverse fracture, and surgeon were all found to be independent risk factors for open reduction; patient characteristics, including age, sex, and BMI, did not seem to influence the choice of open reduction. Fractures with a lower fracture index or pattern resembling a transverse fracture rather than oblique or spiral had an increased risk of converting to an open reduction. Surgeon preference and use of flattop tables also had a significant influence on how the fracture was treated.
Collapse
|
|
42
|
External fixator-augmented flexible intramedullary nailing of an unstable pediatric femoral shaft fracture model: a biomechanical study. J Pediatr Orthop B 2020; 29:485-489. [PMID: 31305363 DOI: 10.1097/bpb.0000000000000648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The objective of this study was to test the compressive strength and torsional stiffness provided by the addition of a two-pin external fixator to an unstable pediatric femoral shaft fracture model after being instrumented with flexible intramedullary nailing (FIMN), and to compare this to bridge plating and FIMN alone. A length-unstable oblique diaphyseal fracture was created in 15 pediatric sized small femur models. Fracture stabilization was achieved by three constructs: standard retrograde FIMN with two 3.5-mm titanium (Ti) nails (Group 1), FIMN augmented with a two-pin external fixator (Group 2), and a 4.5-mm bridge plate (Group 3). Groups I and II were tested in 10 cycles of axial rotation to 10° in both directions at 0.1 Hz under 36 kg of compression. Torsional stiffness was calculated. Compressive strength was calculated by applying an axial load of 5 mm/min until failure was encountered. Failure was defined as the force required to achieve 10° varus at the fracture site or shortening of 2 cm. Group II demonstrated a greater compressive strength compared to Group I (1067.32 N vs 453.49 N, P < 0.001). No significant difference in torsional stiffness was found between Groups I and II (0.45 vs 0.38 Nm/deg, P = 0.18). Group III showed superior compressive strength and rotational stiffness compared to Groups I and II. In an unstable pediatric femoral shaft fracture model, augmenting FIMN with a two-pin external fixator increased the compressive strength by 147%, but did not increase torsional stiffness. Bridge plating with a 4.5-mm plate provided superior compressive strength and torsional stiffness.
Collapse
|
|
43
|
Canavese F, Alberghina F, Cravino M, Paonessa M, Dimeglio A, Andreacchio A. Intraoperative Issues and Clinical and Radiographic Outcomes of Femur Fractures Treated With Flexible Nails: A Comparison of Cases Utilizing Skeletal Traction and a Traction Table to Cases Using Manual Traction Only. J Pediatr Orthop 2020; 40:e676-e682. [PMID: 32118797 DOI: 10.1097/bpo.0000000000001538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The use of the orthopaedic traction table (OTT) during elastic stable intramedullary nailing (ESIN) in the management of displaced diaphyseal femur fractures (DFFs) is still debated. In most centers, children with displaced DFF are treated using an OTT. In some other institutions, however, fracture reduction and stabilization by ESIN are performed on a radiolucent table without an OTT. The aim of this study was to evaluate the clinical and radiologic outcome of children with displaced DFF managed by ESIN with and without the use of an OTT. METHODS Charts and radiographs were retrospectively reviewed for all pediatric patients sustaining DFF managed by ESIN from 2011 to 2017 at 2 different institutions. In all, 69 consecutive children with displaced DFF were recorded, of whom 35 underwent operative treatment by ESIN with the use of an OTT with skeletal traction (Group A), and 34 by ESIN without OTT (Group B). The titanium elastic nails outcome measure scale score and Beaty radiologic criteria were used to evaluate the results. RESULTS Average patient age at time of injury was 9 years (range, 5 to 13) and 10 years (range, 4 to 15) in Groups A and B, respectively. The mean follow-up was 54 months (range, 24 to 96). Overall, complications were observed in 6 patients (8.6%). Complication rate was higher among children managed without OTT (11.8%) than among children treated with OTT (2.5%); no complication related to pin insertion for skeletal traction was recorded. However, the number of patients with a poor outcome according to the titanium elastic nails outcome score was higher in Group A (20%) than in Group B (5.8%). Beaty radiologic criteria were comparable between the 2 groups. Mean length of surgery and mean cumulative time of radiation exposure during surgery were similar between the 2 groups. CONCLUSIONS Overall, both techniques work equally well although patients treated by ESIN with the use of an OTT and skeletal traction tended to have a lower rate of complications and radiologic outcome was worse than for patients treated without using an OTT; however, no statistically significant difference was found.Despite their limitations, the results of this study suggest that displaced DFF can be safely managed by ESIN with or without the use of intraoperative OTT and skeletal traction, according to the surgeon's preference. Further studies are now needed to consolidate these conclusions and clarify the role of the OTT. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Federico Canavese
- Pediatric Surgery Department, University Hospital Estaing, Clermont Ferrand, France
| | - Flavia Alberghina
- Pediatric Orthopedic Surgery Department, "Regina Margherita" Children's Hospital, Torino, Italy
| | - Mattia Cravino
- Pediatric Orthopedic Surgery Department, "Regina Margherita" Children's Hospital, Torino, Italy
| | - Matteo Paonessa
- Pediatric Orthopedic Surgery Department, "Regina Margherita" Children's Hospital, Torino, Italy
| | - Alain Dimeglio
- Pediatric Surgery Department, Clinique St. Roch, Montpellier, France
| | - Antonio Andreacchio
- Pediatric Orthopedic Surgery Department, "Regina Margherita" Children's Hospital, Torino, Italy
| |
Collapse
|
|
44
|
Abstract
BACKGROUND Closed reduction (CR) is sufficient to reduce the majority of femur fractures treated with flexible intramedullary nailing (FIN). No previous study has examined factors associated with failed CR of pediatric femoral shaft fractures treated with FIN. We sought to determine preoperative factors associated with failed CR. We hypothesized that fracture, patient, and surgeon characteristics would impact the need for open reduction (OR). METHODS A retrospective review of children treated for femur fracture between 2012 and 2017 at a tertiary pediatric hospital was performed. Comparisons were made between 2 groups: FIN with CR group and FIN that required OR group. Demographic and baseline characteristics were compared between treatment groups using either χ tests or Fisher exact tests for categorical variables and general linear models for continuous variables. Odds ratios with 95% confidence intervals were calculated using univariate logistic regression tests. RESULTS Of 449 consecutive pediatric femur fractures treated at our center, 85 children were treated with FIN and constituted the study cohort. CR failed in 14 patients (16.5%) necessitating OR of the fracture site. Significant differences between study groups were found in fracture location (P=0.018), the mechanism (P=0.003), and displacement on the anteroposterior radiograph (P=0.027). Surgical time was found to be longer in the OR group (P=0.010). We identified 3 preoperative predictors of OR for FIN including fractures caused by high energy mechanisms (odds ratio=7.5), distal third fractures (odds ratio=15.3), and fracture displacement on the anteroposterior view (odds ratio=1.06). Surgeon years in practice, patient weight, age, and time from injury to surgery were not associated with OR. CONCLUSIONS This study presents 3 preoperative risk factors that predict the need for OR of femur fractures treated with FIN. Surgical time was longer in cases that required OR. Our findings suggest that surgeons should avoid lengthy attempts at CR and consider a lower threshold for OR of at-risk fractures or use another technique other than flexible nails. LEVEL OF EVIDENCE Level III-prognostic.
Collapse
|
|
45
|
Titanium Elastic Nails Are a Safe and Effective Treatment for Length Unstable Pediatric Femur Fractures. J Pediatr Orthop 2020; 40:e560-e565. [PMID: 31770170 DOI: 10.1097/bpo.0000000000001474] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Controversy exists regarding the treatment of length unstable pediatric femoral shaft fractures. The purpose of this study was to investigate the outcomes of skeletally immature children with length unstable femur fractures treated with titanium elastic nails (TENs). METHODS A retrospective review was conducted on all patients with femoral shaft fractures at a tertiary care pediatric hospital from April 2006 to January 2018. Patients with femoral shaft fractures treated with TEN and minimum 6 months follow-up were included. Exclusion criteria were age 11 years or above, weight >50 kg, pathologic fracture, and neuromuscular disorders. Femur fractures were categorized into 2 groups: length unstable (spiral, comminuted, or long oblique fractures) versus length stable (transverse and short oblique). Complications and reoperations were compared between the groups. RESULTS A total of 57 patients with 58 femoral shaft fractures were included. The mean age was 5±2 (1 to 11) years and mean follow-up was 20.4±18.1 (6.0 to 81.2) months. The mean weight was 22.9±7.7 (11.0 to 40.5) kg. There was no difference in age (P=0.32), weight (P=0.28) or follow-up length (P=0.57) between patients with length unstable fractures and those with length stable fractures. A total of 32/58 (55%) fractures were length unstable and 26/58 (45%) were length stable. Mean time to union was 4.6 months, and there was no significant difference in mean time to union between the 2 groups (P=0.71). Thirty-one complications occurred in 27 patients. There was no difference between groups in the incidence of major complications requiring revision surgery (P=0.68) and minor complications that did not require revision surgery (P>0.99). CONCLUSIONS In children with femoral shaft fractures treated with TEN, there was no difference in the incidence of complications or reoperations between those with length unstable fractures and those with length stable fractures. TEN are a safe and effective choice for operative fixation of length unstable femoral shaft fractures in children. LEVEL OF EVIDENCE Level III-retrospective comparative study.
Collapse
|
|
46
|
Gordon JE, Anderson JT, Schoenecker PL, Dobbs MB, Luhmann SJ, Hoernschemeyer DG. Treatment of femoral fractures in children aged two to six. Bone Joint J 2020; 102-B:1056-1061. [DOI: 10.1302/0301-620x.102b8.bjj-2019-1060.r3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims Current American Academy of Orthopaedic Surgeons (AAOS) guidelines for treating femoral fractures in children aged two to six years recommend early spica casting although some individuals have recommended intramedullary stabilization in this age group. The purpose of this study was to compare the treatment and family burden of care of spica casting and flexible intramedullary nailing in this age group. Methods Patients aged two to six years old with acute, non-pathological femur fractures were prospectively enrolled at one of three tertiary children’s hospitals. Either early closed reduction with spica cast application or flexible intramedullary nailing was accomplished under general anaesthesia. The treatment method was selected after discussion of the options by the surgeon with the family. Data were prospectively collected on patient demographics, fracture characteristics, complications, pain medication, and union. The Impact on Family Scale was obtained at the six-week follow-up visit. In all, 75 patients were included in the study: 39 in the spica group and 36 in the nailing group. The mean age of the spica group was 2.71 (2.0 to 6.9) years and the mean age of the nailing group was 3.16 (2.0 to 6.9) years. Results All fractures healed without evidence of malunion or more than 2.0 cm of shortening. The mean Impact on Family score was 70.2 for the spica group and 63.2 (55 to 99) for the nailing group, a statistically significant difference (p = 0.024) in a univariate analysis suggesting less impairment of the family in the intramedullary nailing group. There was no significant difference between pain medication requirements in the first 24 hours postoperatively. Two patients in the spica group and one patient in the intramedullary nailing group required additional treatment under anaesthesia. Conclusion Both early spica casting and intramedullary nailing were effective methods for treating femoral fractures in children two to six years of age. Intramedullary stabilization provides an option in this age group that may be advantageous in some social situations that depend on the child’s mobility. Fracture treatment should be individualized based on factors that extend beyond anatomical and biological factors. Cite this article: Bone Joint J 2020;102-B(8):1056–1061.
Collapse
Affiliation(s)
- J. Eric Gordon
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
- St. Louis Children’s Hospital, St. Louis, Missouri, USA
- St. Louis Shriner’s Hospital for Children, St. Louis, Missouri, USA
| | - John T. Anderson
- Children's Hospital, University of Missouri, Columbia, Missouri, USA
- Department of Orthopaedic Surgery, University of Missouri, Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Perry L. Schoenecker
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
- St. Louis Children’s Hospital, St. Louis, Missouri, USA
- St. Louis Shriner’s Hospital for Children, St. Louis, Missouri, USA
| | - Matthew B. Dobbs
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
- St. Louis Children’s Hospital, St. Louis, Missouri, USA
- St. Louis Shriner’s Hospital for Children, St. Louis, Missouri, USA
| | - Scott J. Luhmann
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
- St. Louis Children’s Hospital, St. Louis, Missouri, USA
- St. Louis Shriner’s Hospital for Children, St. Louis, Missouri, USA
| | - Daniel G. Hoernschemeyer
- Department of Orthopaedic Surgery, University of Missouri, Columbia School of Medicine, Columbia, Missouri, USA
- Children's Mercy Hospital, Kansas City, Missouri, USA
| |
Collapse
|
|
47
|
Grauberger J, O’Byrne M, Stans AA, Shaughnessy WJ, Larson AN, Milbrandt TA. Does Shorter Time to Treatment of Pediatric Femur Shaft Fractures Impact Clinical Outcomes? J Pediatr Orthop 2020; 40:e435-e439. [PMID: 32501907 PMCID: PMC7283976 DOI: 10.1097/bpo.0000000000001544] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Annual rankings by US News and World Report are a widely utilized metric by both health care leaders and patients. One longstanding measure is time to treatment of femur shaft fractures. Hospitals able to provide at least 80% of pediatric patients with an operating room start time within 18 hours of admission to the emergency department score better as part of the overall pediatric orthopaedic ranking. Therefore, it is important to determine whether the 18-hour treatment time for pediatric femur shaft fractures is a clinically meaningful metric. METHODS A retrospective review of clinical outcomes of 174 pediatric patients (aged below 16 y) with isolated femur shaft fractures (Injury Severity Score=9) was conducted from 1997 to 2017 at a single level I pediatric trauma center. The 2 comparison groups were patients receiving fracture reduction within 18 hours of emergency department admission (N=87) or >18 hours (N=87). RESULTS Patient, injury, and surgical characteristics were similar between the 2 groups. Both groups had a similar mean age (treatment <18 h=7.5 y; treatment >18 h=8.1 y). Patients who received treatment within 18 hours were more often immobilized postoperatively (70.1% vs. 53.5%; P=0.0362) and had a shorter median hospital length of stay (2 vs. 3 d; P=0.0047). There were no statistically significant differences in any outcomes including surgical site infection, time to weight-bearing (treatment <18 h mean=48.1 d vs. 52.5 d), time to complete radiographic fracture healing (treatment <18 h mean=258.9 d vs. 232.0 d), decreased range of motion, genu varus/valgus, limb length discrepancy, loss of reduction, or persistent pain. CONCLUSIONS Treatment of pediatric femur shaft fractures within 18 hours does not impact clinical outcomes. National quality measures should therefore use evidence-based metrics to help improve the standard of care. LEVEL OF EVIDENCE Therapeutic level III.
Collapse
Affiliation(s)
| | - Megan O’Byrne
- Department of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, MN
| | - Anthony A. Stans
- Division of Pediatric Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | | | - A. Noelle Larson
- Division of Pediatric Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Todd A. Milbrandt
- Division of Pediatric Orthopedic Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
|
48
|
COSKUN HS, USTA MB, SAY F, YILDIRIM AM. Factors affecting post-traumatic stress disorder in children with orthopedic injury. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2020. [DOI: 10.25083/2559.5555/5.1/24.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
|
|
49
|
Siddiqui AA, Illingworth KD, Abousamra OA, Meisel EM, Kay RM. Femoral shaft fractures in children with non-ambulatory neuromuscular disorders can be effectively treated using flexible intramedullary nails. J Child Orthop 2020; 14:132-138. [PMID: 32351626 PMCID: PMC7184642 DOI: 10.1302/1863-2548.14.190154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE There is little information in the literature regarding flexible intramedullary nails (FIN) for treating femur fractures in children with neuromuscular disorders. The purpose of this study is to investigate the outcomes of FIN for femoral shaft fractures in non-ambulatory children with neuromuscular disorders. METHODS A retrospective review was conducted on patients with femur fractures at a paediatric hospital between 2004 and 2018. Inclusion criteria were femoral shaft fracture treated with FIN. Outcomes were compared between patients with neuromuscular disorders (NM group) and a control group of those without neuromuscular disorders. RESULTS A total of 37 patients with 37 femoral shaft fractures were studied (12 patients in the NM group and 25 in the control group). All NM group patients were non-ambulatory at baseline. Fractures were length stable in all 25 patients in the control group and in 2/12 (17%) patients in the NM group. All fractures healed in both groups. Three complications (all nail migrations) requiring reoperation before fracture union occurred in the NM group, yielding a major complication rate of 25% (3/12) in the NM group versus 0% (0/25) in controls (p = 0.03). Angular deformity occurred in 5/12 (42%) NM group patients and 1/25 (4%) control group patient (p = 0.009); none required reoperation. CONCLUSION Femur fractures in non-ambulatory children with neuromuscular disorders can be successfully treated with FIN. Angular deformities are common in this population, but had no functional impact in the non-ambulatory NM group patients. Surgeons must also be vigilant for implant prominence and skin breakdown in these patients. LEVEL OF EVIDENCE III.
Collapse
Affiliation(s)
- Ali A. Siddiqui
- Children’s Orthopaedic Center, Children’s Hospital Los Angeles, USA,Keck School of Medicine of University of Southern California, USA
| | - Kenneth D. Illingworth
- Children’s Orthopaedic Center, Children’s Hospital Los Angeles, USA,Keck School of Medicine of University of Southern California, USA
| | - Oussama A. Abousamra
- Children’s Orthopaedic Center, Children’s Hospital Los Angeles, USA,Keck School of Medicine of University of Southern California, USA
| | - Erin M. Meisel
- Children’s Orthopaedic Center, Children’s Hospital Los Angeles, USA,Keck School of Medicine of University of Southern California, USA
| | - Robert M. Kay
- Children’s Orthopaedic Center, Children’s Hospital Los Angeles, USA,Keck School of Medicine of University of Southern California, USA,Correspondence should be sent to Robert M. Kay, Children’s Orthopaedic Center, Children’s Hospital Los Angeles, 4650 Sunset Blvd, MS#69, Los Angeles, CA 90027, USA. E-mail:
| |
Collapse
|
|
50
|
Compton E, Andras LM, Murgai RR, Skaggs DL, Illingworth KD. Isolated femoral shaft fractures in children rarely require a blood transfusion. Injury 2020; 51:642-646. [PMID: 31964504 DOI: 10.1016/j.injury.2020.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 01/02/2020] [Accepted: 01/04/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND No recent study has examined how a trend toward surgical fixation for pediatric femoral shaft fractures has impacted blood loss and transfusion requirements. The purpose of this study was to determine the factors influencing transfusions in the treatment of pediatric femoral shaft fractures. METHODS A retrospective review of patients with femoral shaft fractures treated surgically from 2004 - 2017 at a tertiary pediatric hospital was conducted. Electronic medical records were reviewed for fixation method, additional injuries, blood loss (estimated blood loss (EBL), hemoglobin, hematocrit) and transfusion. The relationship between fixation method with blood loss and transfusion was examined. Two groups were compared, those with and without additional injuries. Additional injuries were defined as additional fractures and/or abdominal, chest, or head injuries. RESULTS 172 patients met inclusion criteria. There were 129 patients with isolated femoral shaft fractures and 43 patients with femoral shaft fractures and concomitant additional injuries. The transfusion rate in patients with isolated femoral shaft fractures was 0.8% (1/129) which was significantly lower than in patients with additional injuries; 39.5% (17/43) (p < 0.05). In patients with additional injuries, there was a significant relationship between number of additional surgeries and odds of transfusion (OR=2.1, CI: 1.2-3.6, p < 0.05). In patients with isolated femoral shaft fractures, EBL was higher in patients treated with rigid intramedullary nails (148.5 ± 119.0 mL) than flexible intramedullary nails (34.1 ± 56.3 mL) (p < 0.05). However, there was no significant difference in transfusion or changes in hemoglobin/hematocrit between fixation methods in patients with isolated femoral shaft fractures. CONCLUSION Pediatric patients with surgically treated isolated femoral shaft fractures rarely require transfusion (<1%), while patients with femoral shaft fractures and additional injuries had a high transfusion rate (39.5%). Surgical fixation method had a significant impact on EBL, with rigid intramedullary nail fixation having a significantly higher EBL than flexible intramedullary nails, however it did not lead to higher rates of transfusions. Blood transfusions are rarely needed in isolated femoral shaft fractures, despite the trend towards increase in surgical fixation and newer fixation techniques.
Collapse
Affiliation(s)
- Edward Compton
- Children's Orthopaedic Center, Children's Hospital Los Angeles 4650 Sunset Blvd, MS#69, Los Angeles, CA 90027 United States
| | - Lindsay M Andras
- Children's Orthopaedic Center, Children's Hospital Los Angeles 4650 Sunset Blvd, MS#69, Los Angeles, CA 90027 United States
| | - Rajan R Murgai
- Children's Orthopaedic Center, Children's Hospital Los Angeles 4650 Sunset Blvd, MS#69, Los Angeles, CA 90027 United States
| | - David L Skaggs
- Children's Orthopaedic Center, Children's Hospital Los Angeles 4650 Sunset Blvd, MS#69, Los Angeles, CA 90027 United States
| | - Kenneth D Illingworth
- Children's Orthopaedic Center, Children's Hospital Los Angeles 4650 Sunset Blvd, MS#69, Los Angeles, CA 90027 United States.
| |
Collapse
|