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Intramedullary nailing versus submuscular plating in adolescent femoral fracture
Injury, Int. J. Care Injured 43 (2012) 870–875
Contents lists available at SciVerse ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Intramedullary nailing versus submuscular plating in adolescent femoral fracture Ki-Chul Park a, Chang-Wug Oh b,*, Young-Soo Byun c, Jong-Keon Oh d, Hyun-Joo Lee b, Kyung-Hyun Park b, Hee-Soo Kyung b, Byung-Chul Park b a
Hanyang University Guri Hospital, Guri, Republic of Korea Kyungpook National University Hospital, Daegu, Republic of Korea c Fatima Hospital, Daegu, Republic of Korea d Korea University-Guro Hospital, Seoul, Republic of Korea b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 31 October 2011
Background: Femoral fractures in adolescents usually need operative treatment, but the optimal method is unclear. The purpose of this study is to compare intramedullary nailing (IN) and submuscular plating (SP) in adolescent femoral fractures. Materials and methods: We performed the prospective, comparison study of IN and SP in adolescent femoral shaft fractures at a mean age of 13.9 years (11–17.4). Twenty-two cases of IN and 23 cases of SP were followed for a minimum of 1 year. We compared radiological and clinical results, surgical parameters, and complications of two techniques. Results: Bony union was achieved in all cases except one case of IN. Time to union was similar in both groups. None showed mal-union over 108 or limb length discrepancy over 1 cm. None of SP group and 2 in IN group experienced re-operation; one patient had deep infection with nonunion. The other patient sustained mal-rotation. Both patients healed after revision procedure. All patients showed excellent or satisfactory results of Flynn’s criteria. The time to full-weight bearing was shorter in IN (IN: 57.3 days, SP: 89.2 days, p < 0.05). In surgical parameters, operative time seemed shorter in IN (IN: 94.7 min, SP: 104 min, p = 0.095), and fluoroscopy time was shorter in IN (IN: 58 s, SP: 109 s, p < 0.05) than SP group. Conclusion: Although both IN and SP yield good results and minimal complication in adolescent femoral fractures, IN may be advantageous in less need of fluoroscopy, technical easiness in reduction and early weight bearing. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Adolescent femoral fractures Intramedullary nailing Submuscular plating
Femoral fractures in younger children are generally thought to heal satisfactorily irrespective of the form of treatment, but the management of femoral fractures in adolescents presents specific challenges. As the body weight and the size of children approach those of adults, there are greater demands on the stability afforded by implants used to treat these fractures. The ideal treatment method should provide adequate stability to permit early mobilisation, preserve or optimise fracture biology, minimise scarring, avoid serious complications and achieve these goals in a cost-effective manner. Currently, elastic stable intramedullary nail (ESIN) fixation is the most popular method for paediatric femoral fractures.1 On the other hand, this method can cause shortening or
* Corresponding author at: Department of Orthopedic Surgery, Kyungpook National University Hospital, 50, 2-Ga, Samdok, Chunggu, Daegu 700-721, Republic of Korea. Tel.: +82 53 420 5630; fax: +82 53 422 6605. E-mail addresses: [email protected] (K.-C. Park), [email protected] (C.-W. Oh), [email protected] (Y.-S. Byun), [email protected] (J.-K. Oh), [email protected] (H.-J. Lee), [email protected] (K.-H. Park), [email protected] (H.-S. Kyung), [email protected] (B.-C. Park). 0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2011.10.032
rotation at fracture sites, particularly in older or heavier children.2,3 Conventional plating after open reduction is effective to obtain anatomic union, but it can cause problems of re-fracture, overgrowth, fixation failure, and needs longer incision than other methods. From this point of view, submuscular plating (SP), a new method of bridging plate fixation, is an attractive method to treat paediatric femoral fractures. It has the advantages of stable biological fixation through minimally invasive approach and preserving the physeal plate.4 Intramedullary nailing (IN), as in adults, has been reported to be effective in older children. However, nailing through the piriformis fossa may provoke avascular necrosis or disturb the vascular supply of the proximal femur.5 Recently, IN through a trochanteric entry portal may eliminate this complication.6 Therefore, IN and SP seem to be good options for the treatment of adolescent femoral fractures. However, there has been no study to compare these options. The purposes of this prospective study were to (1) investigate radiological/clinical results of each technique, (2) explore any possible complications and (3) provide recommendatory method, if possible.
K.-C. Park et al. / Injury, Int. J. Care Injured 43 (2012) 870–875
Materials and methods Between January 2006 and December 2009, a consecutive series of patients with a femoral diaphyseal fracture were enrolled in this prospective multicentre, Institutional Review Board-approved study (two centres, two surgeons). Both surgeons had more than 10 years of orthopaedic trauma experience. Each centre communicated and selected the operation method. Patients were alternatively treated by IN or SP, according to the time of arrival. The criteria used for selection were: (1) age of patients over 10 years, (2) a fracture located 3 cm distal to the lesser trochanter and 5 cm proximal to the distal femoral physis and (3) closed or grade I or II open fracture. Pathologic fractures, re-fractures and grade III open fractures were excluded. Also, patients with closed physes at the date of surgery and patients with a follow-up shorter than 1 year were excluded. Forty-seven patients met the criteria (49 femora, including two bilateral fractures). Two patients who expired early during the postoperative period and two with insufficient follow-up were excluded from the analysis which resulted in 43 patients (45 femora, including two bilateral fractures) remaining. Patient demographics are shown in Table 1. There was no statistically significant difference between the two groups except gender distribution. Operative methods IN (Fig. 1) – Patients were treated in the supine or lateral position on a radiolucent table. A small 3–4 cm incision was made just proximal to the greater trochanter, and the dissection was carried out beneath the iliotibial band to expose the lateral aspect of the greater trochanter. A curved awl was then used to mark the starting point at the lateral aspect of the greater trochanter distal and lateral to its tip. The awl was then inserted into the cortex, and a nail of adequate size was passed through the fracture site from the proximal fragment to the distal fragment without reaming. A short nail was chosen not to harm the distal femoral physis, and nail diameters were 1–2 mm less than preoperatively measured diameters of the femoral canal. The nails used were either the unreamed tibial nail (UTN, Synthes, Oberdorf, Switzerland) or the Sirus femoral nail (Zimmer, Warsaw, United States). All nails were locked at proximal and distal sites of fractures. SP (Fig. 2) – Patients were placed supine on a radiolucent operating table with the leg free. A 4.5/5.0-mm narrow or broad locking compression plate (LCP) (Synthes, Oberdorf, Switzerland) was used. Plate length depended on femur size and fracture location. In general, a 12–16-hole plate was used to span the distance between the trochanteric apophysis and distal femoral physes. A plate was pre-bent to the contour of the contralateral femur. Incisions were made (approximately 3–4 cm), and submuscular tunnels for plate insertion were developed at the proximal and distal femoral sides. In each case, the plate was inserted into the tunnel and the fracture site was not exposed. At least six cortices (three screws) of fixation were achieved on each side of the fracture. Follow-up Patients were followed up and physical and radiographic examinations were performed at 1, 2, 3, 6 and 12 months postoperatively. Frontal and sagittal plane angulations were assessed on antero-posterior and lateral plain radiographs obtained postoperatively and at the regular follow-ups. At the 12-month and every 12-month follow-up, a long-standing radiograph was performed to examine the leg-length discrepancy or any bony differences between the injured and uninjured femurs.
871
Table 1 Patient characteristic.
Number of fractures (patients) Follow-up Age Gender Weight Mean No over 50 kg Height AO-OTA classfication 32A 32B 32C Stability of fracture Length stable Length unstable Location Proximal Middle Distal Open fracture Patients with associated injuries
Intramedullary nailing
Submuscular plating
22 (21)
23 (22)
22.4 (13–42) months 20.9 (12–40) months 14.2 (11–17.2) years-old 13.6 (11–17.4) years-old M: 16, F: 5 M: 18, F: 4 51.2 (37–73.5) kg 14 157.4 (139–176) cm
50.6 (36.3–69) kg 13 159.6 (140.5–172.5) cm
10 8 4
11 7 5
15 7
15 8
7 12 3 2 (grades I & II) 12
6 13 4 1 (grade I) 9
After 1 year, the patients were followed every 6 months (usually at summer and winter school vacations) with the issues of implant removal, osteonecrosis and leg-length discrepancy up to the skeletal maturity. All patients started knee and hip motion exercises, postoperatively. Patients in the SP group started toe-touch weight bearing with crutches at approximately 4 weeks postoperatively. These patients were allowed to bear limited weight only when radiographic evidence of healing had been achieved. In the IN group, patients with a stable fracture were allowed to bear weight immediately postoperatively as tolerated and immediate toetouch weight bearing was allowed in those with a comminuted fracture pattern. The patients were permitted to bear more weight gradually based on clinical and radiographic evidence of healing. Outcome measures and statistical analysis Time to union was defined as the number of weeks until there was radiographic and clinical evidence of union. Radiographic evidence of union was defined as callus bridging at, at least, three of the four cortices seen on two orthogonal views of the femur. Clinical union was inferred from the absence of tenderness at the fracture site along with full weight bearing without pain. Complications of interest included loss of reduction, malunion, nonunion, re-fracture, infection and the need for a re-operation. Nonunion was defined as the absence of fracture union at 6 months postoperatively, and delayed union was defined as slow fracture healing extending beyond 6 months. Malunion was defined as one or more of the following: >108 of angulation in the coronal/sagittal plane (varus or valgus), clinically obvious mal-rotation (an asymmetric foot progression angle with corresponding asymmetry of internal or external rotation of the hip) or a limb-length discrepancy of >1.0 cm. A clinically relevant loss of reduction was defined as any change in the postoperative alignment that prompted operative intervention or resulted in malunion as defined by the criteria described above. A re-operation was defined as any fracture-related procedure, other than routine hardware removal, performed after the initial fixation. In clinical results, pain and limping were recorded at the recent follow-up. Knee and hip motion were checked and compared to the non-injured side. Time to full weight bearing was recorded. The
872
K.-C. Park et al. / Injury, Int. J. Care Injured 43 (2012) 870–875
Fig. 1. (A) A 12-year-old boy with a closed fracture of the left femur. (B) Postoperative radiograph showing satisfactory alignment after intramedullary nailing through trochanteric entry. (C) Photograph showing the small incisions required for inserting the nail and locking screws. (D) Radiograph taken at 1 year showing that the fracture had healed with good alignment. (E) The patient had no leg-length discrepancy or osteonecrosis.
Fig. 2. (A) Antero-posterior radiograph showing a femoral shaft fracture in a 13-year-old boy. (B) Postoperative radiograph showing good reduction and fixation with a locking plate. (C) Photograph showing the several incisions of submuscular plating required for the percutaneous insertions of plate and screws. (D) One and a half years after the operation, antero-posterior radiograph showed that the fracture had healed with good alignment. (E) The patient had minimal leg-length discrepancy.
K.-C. Park et al. / Injury, Int. J. Care Injured 43 (2012) 870–875
873
Table 2 Flynn’s outcome scoring.
Leg length inequality Malalignment Pain Complication
Excellent result
Satisfactory result
Poor result
<1.0 cm 58 None None
<2.0 cm 108 None Minor and resolved
>2.0 cm >108 Present Major complication and/or lasting morbidity
Table 3 Results after operation.
Complications Intramedullary nailing Submuscular plating
Radiological results Union rate Time to union (weeks) Nonunion Delayed union LLD over 1 cm Mal-rotation Clinical results Deep infection Patients needed re-operation Time to weight bearing (days) Functional outcome (Flynn) Excellent Satisfactory Poor
95.5% (21/22) 16.3 1 1 None 1
100% (23/23) 16.7 None 1 None None
1 2 57.3
None None 89.2
13 9 None
12 11 None
final functional outcomes were evaluated using Flynn’s system1 (Table 2), which was based on maximum allowable LLD, degree of malunion, amount of pain and the presence of other complications. From the viewpoint of surgical aspects, operation time was defined as time from skin incision to dressing application. Amount of bleeding was recorded. Radiation time (in seconds) was recorded from C-arm machine which was used for the operative procedure. When the removal procedure was done, we recorded any difficulty to remove the implant. All statistical analyses (Chi square test, Mann–Whitney U-test) were performed using Statistical Package for the Social Sciences (SPSS) version 12.0.1 (SPSS Inc., Chicago, IL, USA), and p values of <0.05 were considered significant. Results The mean follow-up time was 21.8 months (range, 12–42). Sixteen of the 22 IN and 17 of the 23 SP were followed for more than 2 years (Table 3). Radiological results Twenty-one of the 22 fractures in the IN group and all 23 fractures in the SP group healed after index procedures. The mean time to union was 16.3 weeks in the IN group and 16.7 weeks in the SP group, which was not significantly different. There was one nonunion in the IN group and two delayed unions (one in each group). There was no loss of reduction during follow-up period. At the final follow-up, no patient had rotational malalignment of more than 108, as determined by comparing internal and external rotation of the hip, and no patient experienced malunion of more than 108 of angulation. The deformities ranged from 88 of varus to 78 of valgus and from 98 of procurvatum (apex-anterior) to 98 of recurvatum (apex-posterior). At the most recent follow-up, the mean femoral LLD was 3.2 mm (range, 2–7) and none of the patients had an LLD greater than 1 cm. The final deformities and LLD were not different in both groups. None in both groups showed osteonecrosis of the femoral head or growth disturbances of the proximal femur.
None in the SP group experienced re-operation, but two of the 22 in the IN group needed re-operation; one patient in the IN group had an external rotation deformity of 208. He underwent correction of the mal-rotation deformity and distal locking screws re-fixation a day after index surgery. The other patient suffered delayed deep infection, which resulted in nonunion. He needed the procedures of debridement and bone graft. But, there was no statistically significant difference of re-operation incidence between the two groups. No patient in either group showed implants failure or refracture. Clinical results At the final follow-up, all patients were able to walk without limping and had full symmetric range of motion in the hip and knee joints. Time to full weight bearing in the IN group (57.3 days) was shorter than that in the SP group (89.2 days) (p < 0.05). In terms of functional outcomes, all patients in both groups had an excellent or a satisfactory result but no poor result, based on Flynn’s criteria (IN – 13 excellent, nine satisfactory; SP – 12 excellent, 11 satisfactory). The functional outcome was not different between the two groups (p < 0.05). Surgical parameters Average operation time in the IN group was 94.7 min (range, 75–170) and in the SP group it was 104 min (range, 70–160) (p = 0.095). The mean estimated blood loss during the procedure was 185 cc (range, 85–390) in IN and 220 cc (range, 100–415) in the SP group, which was not significantly different. The average radiation exposure time in the IN group was 58 s (range, 21–110) and in the SP group it was 109 s (range, 60–162). Furthermore, this 87% increase in radiation exposure in the SP group was significant (p < 0.05). Until the latest follow-up, hardware removal was performed in 16 of the 22 patients in the IN group, and 17 of the 23 patients in the SP group. In the IN group, all implants were removed, uneventfully. However, in the three cases of the SP group, we encountered difficulty in removing the locking plate and screws due to the stripping of the hexagonal recess and cold-weld threads of the locking screw head. To remove stripped locking screws, one patient needed an additional procedure using a conical extraction screw. In the other two patients, we cut the plates around stripped screw holes with a metal cutting carbide-tipped burr (Table 4). Table 4 Optional demographics.
Surgical demographics Operation time (min) Bleeding amount (cc) Radiation exposure (s) Difficulty in hardware removal
Intramedullary nailing
Submuscular plating
94.7 185 58 None
104 220 109 3
Difficulty in hardware removal – It means the removal procedure needed other additive procedures or implants except the original equipments.
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K.-C. Park et al. / Injury, Int. J. Care Injured 43 (2012) 870–875
Discussion Only a few studies are known that specifically deal with the operative treatment of femoral fractures in adolescents,7–10 Although ESIN is widely used in paediatric femoral fractures, the high incidence of malunion is reported in older children.11,12 It has been suggested that a direct relationship exists between patient’s weight and complications when ESIN was used for paediatric femoral shaft fractures.2,3,8 Therefore, stability of the implant is important to maintain the reduction of adolescent femoral fractures. This led us to hypothesise that IN through trochanteric entry and LCP using SP may be a biomechanically stable implant in older or heavy children, comparing to ESIN. We observed no reduction loss, implant failure or malunion in both methods of this study including patients weighed over 50 kg. Severity of the comminution and the fracture stability are also known to associate with complications after ESIN.13 Sink et al.14 found a significantly higher rate of complications in their ‘‘length unstable’’ group. In our study, the fracture comminution or unstable fracture pattern did not affect the alignment issue. We assume that the stiffness of nail or locking plate is strong enough to maintain the length of unstable fractures. Ramseier et al.7 reported a shorter healing time after elastic or rigid nailing than external fixation. However, no study compared IN and SP in adolescent femoral fractures. Our study showed that both techniques had a similar healing time. Also, all fractures healed except one case of deep infection with the nonunion. Therefore, in terms of bony healing, both IN and SP may be ideal options because of their minimal invasiveness to the fracture site. In adolescent femoral fractures, the distal femoral physis should be spared to prevent growth-related problems. Although both IN and SP are not harmful to this, the major difference between the two techniques is from the intrusion of nail through the immature proximal femur. The osteonecrosis, a rare but devastating complication,5,15 is always concerned after IN of adolescent femoral fractures. As per many reports of nailing through trochanteric entry, none of the children in IN of this study had osteonecrosis during the mean follow-up over 21 months. A theoretical drawback of the trochanteric entry is growth changes in the proximal femur, including femoral neck valgus or neck narrowing.16,17 In this study, the patients in IN group did not show any changes compared to the non-injured side. Gordon et al.6 also did not find any statistically significant growth changes secondary to the use of trochanteric entry. Of course, SP is the theoretically safer procedure than IN and none in the SP group in this series showed such complications. Although the chronological age and follow-up period may not be enough to explain our results, we suppose that both techniques may be free from the growth disturbance or osteonecrosis. The reproducibility of operative techniques is one of the important selection issues. Since the fracture is usually reduced by closed reduction through the soft-tissue window away from the fracture site, SP is technically demanding with frequent malalignments and resultant malunions.18 To reduce this complication, several tips concerning temporary reduction under fluoroscopic control are necessary. In this study, we could achieve union with low rate of malunion in the SP group, similar to IN. However, the SP group needed a longer operation time and more radiation exposure than IN. From this viewpoint, IN has a benefit of reducing radiation hazards to medical staff and patients, since closed reduction by nailing is usually easier and more reproducible than SP. In the present study, we observed that time to full weight bearing in the IN group was shorter than in the SP group. Although children usually recover the function completely, early weight bearing is beneficial to the early return to school. Keeler et al.19 also reported that patients treated with an IN (even those that had
experienced multiple traumas) could ambulate sooner than those treated using other methods. Furthermore, IN is advantageous because it allows early rehabilitation and return to school life. Although the removal procedure should be simple and free from complications, implant removal may be challenging and lead to complications.20 Pate et al.21 reported that submuscular plate removal is substantially more complicated than plate insertion, because of bone overgrowth at the leading edge. Bae et al.22 noted technical difficulties when removing LCPs, because of stripping of the hexagonal recess of the 3.5-mm locking screw. In our study, we experienced the stripping of 5.0-mm locking screws in two patients in the SP group. In two cases, the plates were cut with the high-speed carbide-tipped burr to remove the implant. This proved to be an extensive procedure, with markedly longer operation time and larger incisions than expected. Otherwise, all nails were removed without difficulty. From this point of view, IN has a definite advantage over SP. Our study has the limitation of small patient numbers. However, the baseline characteristics of the patients in the two study groups were similar with respect to age, fracture classification and fracture location. Another limitation was that we used two different nails for IN, that is, a tibial nail was used for small femoral canals and a femoral nail for larger canals. The configuration of the tibial nail23 is similar to that of a recently designed implant, since the tibial nail has a bend in its proximal region. However, we encountered no reduction or alignment difficulties, as was reported for a humeral nail in similar patients.24 In summary, both IN and SP produced good results with low complication rates when used to treat adolescent femoral fractures. However, IN may be the rational choice due to its benefits of shorter fluoroscopy and operation times, and an earlier return to daily life. Conflict of interest statement None. Acknowledgement This work was supported by Kyungpook National University Research Fund, 2011. References 1. Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, Kasser J. Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop 2001;21:4–8. 2. Moroz LA, Launay F, Kocher MS, Newton PO, Frick SL, Sponseller PD, et al. Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome. J Bone Joint Surg Br 2006;88:1361–6. 3. Weiss JM, Choi P, Ghatan C, Skaggs DL, Kay RM. Complications with flexible nailing of femur fractures more than double with child obesity and weight >50 kg. J Child Orthop 2009;3:53–8. 4. Kanlic EM, Anglen JO, Smith DG, Morgan SJ, Pesantez RF. Advantages of submuscular bridge plating for complex pediatric femur fractures. Clin Orthop Relat Res 2004;426:244–51. 5. O’Malley DE, Mazur JM, Cummings RJ. Femoral head avascular necrosis associated with intramedullary nailing in an adolescent. J Pediatr Orthop 1995;15:21– 3. 6. Gordon JE, Swenning TA, Burd TA, Szymanski DA, Schoenecker PL. Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children. J Bone Joint Surg Am 2003;85:1295–301. 7. Ramseier LE, Janicki JA, Weir S, Narayanan UG. Femoral fractures in adolescents: a comparison of four methods of fixation. J Bone Joint Surg Am 2010;92:1122–9. 8. Sagan ML, Datta JC, Olney BW, Lansford TJ, McIff TE. Residual deformity after treatment of pediatric femur fractures with flexible titanium nails. J Pediatr Orthop 2010;30:638–43. 9. Momberger N, stevens P, Smith J, Santora S, Scott S, Anderson J. Intramedullary nailing of femoral fractures in adolescents. J Pediatr Orthop 2000;20:482–4. 10. Townsend DR, Hoffinger S. Intramedullary nailing of femoral shaft fractures in children via the trochanter tip. Clin Orthop Relat Res 2000;376:113–8. 11. Ho CA, Skaggs DL, Tang CW, Kay RM. Use of flexible intramedullary nails in pediatric femur fractures. J Pediatr Orthop 2006;26:497–504.
K.-C. Park et al. / Injury, Int. J. Care Injured 43 (2012) 870–875 12. Luhmann SJ, Schootman M, Schoenecker PL, Dobbs MB, Gordon JE. Complications of titanium elastic nails for pediatric femoral shaft fractures. J Pediatr Orthop 2003;23:443–7. 13. Narayanan UG, Hyman JE, Wainwright AM, Rang M, Alman BA. Complications of elastic stable intramedullary nail fixation of pediatric femoral fractures, and how to avoid them. J Pediatr Orthop 2004;24:363–9. 14. Sink EL, Gralla J, Repine M. Complications of pediatric femur fractures treated with titanium elastic nails: a comparison of fracture types. J Pediatr Orthop 2005;25:577–80. 15. Thometz JG, Lamdan R. Osteonecrosis of the femoral head after intramedullary nailing of a fracture of the femoral shaft in an adolescent. A case report. J Bone Joint Surg Am 1995;77:1423–6. 16. Gonzalez-Herranz P, Burgos-Flores J, Rapariz JM, Lopez-Mondejar JA, Ocete JG, Amaya S. Intramedullary nailing of the femur in children. Effects on its proximal end. J Bone Joint Surg Br 1995;77:262–6. 17. Raney EM, Ogden JA, Grogan DP. Premature greater trochanteric epiphysiodesis secondary to intramedullary femoral rodding. J Pediatr Orthop 1993;13:516–20. 18. Oh CW, Song HR, Jeon IH, Min WK, Park BC. Nail-assisted percutaneous plating of pediatric femoral fractures. Clin Orthop Relat Res 2007;456:176–81.
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19. Keeler KA, Dart B, Luhmann SJ, Schoenecker PL, Ortman MR, Dobbs MB, et al. Antegrade intramedullary nailing of pediatric femoral fractures using an interlocking pediatric femoral nail and a lateral trochanteric entry point. J Pediatr Orthop 2009;29:345–51. 20. Loder RT, Feinberg JR. Orthopaedic implants in children: survey results regarding routine removal by the pediatric and nonpediatric specialists. J Pediatr Orthop 2006;26:510–9. 21. Pate O, Hedequist D, Leong N, Hresko T. Implant removal after submuscular plating for pediatric femur fractures. J Pediatr Orthop 2009;29:709–12. 22. Bae JH, Oh JK, Oh CW, Hur CR. Technical difficulties of removal of locking screw after locking compression plating. Arch Orthop Trauma Surg 2009;129:91–5. 23. Mehlman CT, Bishai SK. Tibial nails for femoral shaft fractures in large adolescents with open femoral physes. J Trauma 2007;63:424–8. 24. Gordon JE, Khanna N, Luhmann SJ, Dobbs MB, Ortman MR, Schoenecker PL. Intramedullary nailing of femoral fractures in children through the lateral aspect of the greater trochanter using a modified rigid humeral intramedullary nail: preliminary results of a new technique in 15 children. J Orthop Trauma 2004;18:416–22.
Contents lists available at SciVerse ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Intramedullary nailing versus submuscular plating in adolescent femoral fracture Ki-Chul Park a, Chang-Wug Oh b,*, Young-Soo Byun c, Jong-Keon Oh d, Hyun-Joo Lee b, Kyung-Hyun Park b, Hee-Soo Kyung b, Byung-Chul Park b a
Hanyang University Guri Hospital, Guri, Republic of Korea Kyungpook National University Hospital, Daegu, Republic of Korea c Fatima Hospital, Daegu, Republic of Korea d Korea University-Guro Hospital, Seoul, Republic of Korea b
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 31 October 2011
Background: Femoral fractures in adolescents usually need operative treatment, but the optimal method is unclear. The purpose of this study is to compare intramedullary nailing (IN) and submuscular plating (SP) in adolescent femoral fractures. Materials and methods: We performed the prospective, comparison study of IN and SP in adolescent femoral shaft fractures at a mean age of 13.9 years (11–17.4). Twenty-two cases of IN and 23 cases of SP were followed for a minimum of 1 year. We compared radiological and clinical results, surgical parameters, and complications of two techniques. Results: Bony union was achieved in all cases except one case of IN. Time to union was similar in both groups. None showed mal-union over 108 or limb length discrepancy over 1 cm. None of SP group and 2 in IN group experienced re-operation; one patient had deep infection with nonunion. The other patient sustained mal-rotation. Both patients healed after revision procedure. All patients showed excellent or satisfactory results of Flynn’s criteria. The time to full-weight bearing was shorter in IN (IN: 57.3 days, SP: 89.2 days, p < 0.05). In surgical parameters, operative time seemed shorter in IN (IN: 94.7 min, SP: 104 min, p = 0.095), and fluoroscopy time was shorter in IN (IN: 58 s, SP: 109 s, p < 0.05) than SP group. Conclusion: Although both IN and SP yield good results and minimal complication in adolescent femoral fractures, IN may be advantageous in less need of fluoroscopy, technical easiness in reduction and early weight bearing. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Adolescent femoral fractures Intramedullary nailing Submuscular plating
Femoral fractures in younger children are generally thought to heal satisfactorily irrespective of the form of treatment, but the management of femoral fractures in adolescents presents specific challenges. As the body weight and the size of children approach those of adults, there are greater demands on the stability afforded by implants used to treat these fractures. The ideal treatment method should provide adequate stability to permit early mobilisation, preserve or optimise fracture biology, minimise scarring, avoid serious complications and achieve these goals in a cost-effective manner. Currently, elastic stable intramedullary nail (ESIN) fixation is the most popular method for paediatric femoral fractures.1 On the other hand, this method can cause shortening or
* Corresponding author at: Department of Orthopedic Surgery, Kyungpook National University Hospital, 50, 2-Ga, Samdok, Chunggu, Daegu 700-721, Republic of Korea. Tel.: +82 53 420 5630; fax: +82 53 422 6605. E-mail addresses: [email protected] (K.-C. Park), [email protected] (C.-W. Oh), [email protected] (Y.-S. Byun), [email protected] (J.-K. Oh), [email protected] (H.-J. Lee), [email protected] (K.-H. Park), [email protected] (H.-S. Kyung), [email protected] (B.-C. Park). 0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2011.10.032
rotation at fracture sites, particularly in older or heavier children.2,3 Conventional plating after open reduction is effective to obtain anatomic union, but it can cause problems of re-fracture, overgrowth, fixation failure, and needs longer incision than other methods. From this point of view, submuscular plating (SP), a new method of bridging plate fixation, is an attractive method to treat paediatric femoral fractures. It has the advantages of stable biological fixation through minimally invasive approach and preserving the physeal plate.4 Intramedullary nailing (IN), as in adults, has been reported to be effective in older children. However, nailing through the piriformis fossa may provoke avascular necrosis or disturb the vascular supply of the proximal femur.5 Recently, IN through a trochanteric entry portal may eliminate this complication.6 Therefore, IN and SP seem to be good options for the treatment of adolescent femoral fractures. However, there has been no study to compare these options. The purposes of this prospective study were to (1) investigate radiological/clinical results of each technique, (2) explore any possible complications and (3) provide recommendatory method, if possible.
K.-C. Park et al. / Injury, Int. J. Care Injured 43 (2012) 870–875
Materials and methods Between January 2006 and December 2009, a consecutive series of patients with a femoral diaphyseal fracture were enrolled in this prospective multicentre, Institutional Review Board-approved study (two centres, two surgeons). Both surgeons had more than 10 years of orthopaedic trauma experience. Each centre communicated and selected the operation method. Patients were alternatively treated by IN or SP, according to the time of arrival. The criteria used for selection were: (1) age of patients over 10 years, (2) a fracture located 3 cm distal to the lesser trochanter and 5 cm proximal to the distal femoral physis and (3) closed or grade I or II open fracture. Pathologic fractures, re-fractures and grade III open fractures were excluded. Also, patients with closed physes at the date of surgery and patients with a follow-up shorter than 1 year were excluded. Forty-seven patients met the criteria (49 femora, including two bilateral fractures). Two patients who expired early during the postoperative period and two with insufficient follow-up were excluded from the analysis which resulted in 43 patients (45 femora, including two bilateral fractures) remaining. Patient demographics are shown in Table 1. There was no statistically significant difference between the two groups except gender distribution. Operative methods IN (Fig. 1) – Patients were treated in the supine or lateral position on a radiolucent table. A small 3–4 cm incision was made just proximal to the greater trochanter, and the dissection was carried out beneath the iliotibial band to expose the lateral aspect of the greater trochanter. A curved awl was then used to mark the starting point at the lateral aspect of the greater trochanter distal and lateral to its tip. The awl was then inserted into the cortex, and a nail of adequate size was passed through the fracture site from the proximal fragment to the distal fragment without reaming. A short nail was chosen not to harm the distal femoral physis, and nail diameters were 1–2 mm less than preoperatively measured diameters of the femoral canal. The nails used were either the unreamed tibial nail (UTN, Synthes, Oberdorf, Switzerland) or the Sirus femoral nail (Zimmer, Warsaw, United States). All nails were locked at proximal and distal sites of fractures. SP (Fig. 2) – Patients were placed supine on a radiolucent operating table with the leg free. A 4.5/5.0-mm narrow or broad locking compression plate (LCP) (Synthes, Oberdorf, Switzerland) was used. Plate length depended on femur size and fracture location. In general, a 12–16-hole plate was used to span the distance between the trochanteric apophysis and distal femoral physes. A plate was pre-bent to the contour of the contralateral femur. Incisions were made (approximately 3–4 cm), and submuscular tunnels for plate insertion were developed at the proximal and distal femoral sides. In each case, the plate was inserted into the tunnel and the fracture site was not exposed. At least six cortices (three screws) of fixation were achieved on each side of the fracture. Follow-up Patients were followed up and physical and radiographic examinations were performed at 1, 2, 3, 6 and 12 months postoperatively. Frontal and sagittal plane angulations were assessed on antero-posterior and lateral plain radiographs obtained postoperatively and at the regular follow-ups. At the 12-month and every 12-month follow-up, a long-standing radiograph was performed to examine the leg-length discrepancy or any bony differences between the injured and uninjured femurs.
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Table 1 Patient characteristic.
Number of fractures (patients) Follow-up Age Gender Weight Mean No over 50 kg Height AO-OTA classfication 32A 32B 32C Stability of fracture Length stable Length unstable Location Proximal Middle Distal Open fracture Patients with associated injuries
Intramedullary nailing
Submuscular plating
22 (21)
23 (22)
22.4 (13–42) months 20.9 (12–40) months 14.2 (11–17.2) years-old 13.6 (11–17.4) years-old M: 16, F: 5 M: 18, F: 4 51.2 (37–73.5) kg 14 157.4 (139–176) cm
50.6 (36.3–69) kg 13 159.6 (140.5–172.5) cm
10 8 4
11 7 5
15 7
15 8
7 12 3 2 (grades I & II) 12
6 13 4 1 (grade I) 9
After 1 year, the patients were followed every 6 months (usually at summer and winter school vacations) with the issues of implant removal, osteonecrosis and leg-length discrepancy up to the skeletal maturity. All patients started knee and hip motion exercises, postoperatively. Patients in the SP group started toe-touch weight bearing with crutches at approximately 4 weeks postoperatively. These patients were allowed to bear limited weight only when radiographic evidence of healing had been achieved. In the IN group, patients with a stable fracture were allowed to bear weight immediately postoperatively as tolerated and immediate toetouch weight bearing was allowed in those with a comminuted fracture pattern. The patients were permitted to bear more weight gradually based on clinical and radiographic evidence of healing. Outcome measures and statistical analysis Time to union was defined as the number of weeks until there was radiographic and clinical evidence of union. Radiographic evidence of union was defined as callus bridging at, at least, three of the four cortices seen on two orthogonal views of the femur. Clinical union was inferred from the absence of tenderness at the fracture site along with full weight bearing without pain. Complications of interest included loss of reduction, malunion, nonunion, re-fracture, infection and the need for a re-operation. Nonunion was defined as the absence of fracture union at 6 months postoperatively, and delayed union was defined as slow fracture healing extending beyond 6 months. Malunion was defined as one or more of the following: >108 of angulation in the coronal/sagittal plane (varus or valgus), clinically obvious mal-rotation (an asymmetric foot progression angle with corresponding asymmetry of internal or external rotation of the hip) or a limb-length discrepancy of >1.0 cm. A clinically relevant loss of reduction was defined as any change in the postoperative alignment that prompted operative intervention or resulted in malunion as defined by the criteria described above. A re-operation was defined as any fracture-related procedure, other than routine hardware removal, performed after the initial fixation. In clinical results, pain and limping were recorded at the recent follow-up. Knee and hip motion were checked and compared to the non-injured side. Time to full weight bearing was recorded. The
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Fig. 1. (A) A 12-year-old boy with a closed fracture of the left femur. (B) Postoperative radiograph showing satisfactory alignment after intramedullary nailing through trochanteric entry. (C) Photograph showing the small incisions required for inserting the nail and locking screws. (D) Radiograph taken at 1 year showing that the fracture had healed with good alignment. (E) The patient had no leg-length discrepancy or osteonecrosis.
Fig. 2. (A) Antero-posterior radiograph showing a femoral shaft fracture in a 13-year-old boy. (B) Postoperative radiograph showing good reduction and fixation with a locking plate. (C) Photograph showing the several incisions of submuscular plating required for the percutaneous insertions of plate and screws. (D) One and a half years after the operation, antero-posterior radiograph showed that the fracture had healed with good alignment. (E) The patient had minimal leg-length discrepancy.
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Table 2 Flynn’s outcome scoring.
Leg length inequality Malalignment Pain Complication
Excellent result
Satisfactory result
Poor result
<1.0 cm 58 None None
<2.0 cm 108 None Minor and resolved
>2.0 cm >108 Present Major complication and/or lasting morbidity
Table 3 Results after operation.
Complications Intramedullary nailing Submuscular plating
Radiological results Union rate Time to union (weeks) Nonunion Delayed union LLD over 1 cm Mal-rotation Clinical results Deep infection Patients needed re-operation Time to weight bearing (days) Functional outcome (Flynn) Excellent Satisfactory Poor
95.5% (21/22) 16.3 1 1 None 1
100% (23/23) 16.7 None 1 None None
1 2 57.3
None None 89.2
13 9 None
12 11 None
final functional outcomes were evaluated using Flynn’s system1 (Table 2), which was based on maximum allowable LLD, degree of malunion, amount of pain and the presence of other complications. From the viewpoint of surgical aspects, operation time was defined as time from skin incision to dressing application. Amount of bleeding was recorded. Radiation time (in seconds) was recorded from C-arm machine which was used for the operative procedure. When the removal procedure was done, we recorded any difficulty to remove the implant. All statistical analyses (Chi square test, Mann–Whitney U-test) were performed using Statistical Package for the Social Sciences (SPSS) version 12.0.1 (SPSS Inc., Chicago, IL, USA), and p values of <0.05 were considered significant. Results The mean follow-up time was 21.8 months (range, 12–42). Sixteen of the 22 IN and 17 of the 23 SP were followed for more than 2 years (Table 3). Radiological results Twenty-one of the 22 fractures in the IN group and all 23 fractures in the SP group healed after index procedures. The mean time to union was 16.3 weeks in the IN group and 16.7 weeks in the SP group, which was not significantly different. There was one nonunion in the IN group and two delayed unions (one in each group). There was no loss of reduction during follow-up period. At the final follow-up, no patient had rotational malalignment of more than 108, as determined by comparing internal and external rotation of the hip, and no patient experienced malunion of more than 108 of angulation. The deformities ranged from 88 of varus to 78 of valgus and from 98 of procurvatum (apex-anterior) to 98 of recurvatum (apex-posterior). At the most recent follow-up, the mean femoral LLD was 3.2 mm (range, 2–7) and none of the patients had an LLD greater than 1 cm. The final deformities and LLD were not different in both groups. None in both groups showed osteonecrosis of the femoral head or growth disturbances of the proximal femur.
None in the SP group experienced re-operation, but two of the 22 in the IN group needed re-operation; one patient in the IN group had an external rotation deformity of 208. He underwent correction of the mal-rotation deformity and distal locking screws re-fixation a day after index surgery. The other patient suffered delayed deep infection, which resulted in nonunion. He needed the procedures of debridement and bone graft. But, there was no statistically significant difference of re-operation incidence between the two groups. No patient in either group showed implants failure or refracture. Clinical results At the final follow-up, all patients were able to walk without limping and had full symmetric range of motion in the hip and knee joints. Time to full weight bearing in the IN group (57.3 days) was shorter than that in the SP group (89.2 days) (p < 0.05). In terms of functional outcomes, all patients in both groups had an excellent or a satisfactory result but no poor result, based on Flynn’s criteria (IN – 13 excellent, nine satisfactory; SP – 12 excellent, 11 satisfactory). The functional outcome was not different between the two groups (p < 0.05). Surgical parameters Average operation time in the IN group was 94.7 min (range, 75–170) and in the SP group it was 104 min (range, 70–160) (p = 0.095). The mean estimated blood loss during the procedure was 185 cc (range, 85–390) in IN and 220 cc (range, 100–415) in the SP group, which was not significantly different. The average radiation exposure time in the IN group was 58 s (range, 21–110) and in the SP group it was 109 s (range, 60–162). Furthermore, this 87% increase in radiation exposure in the SP group was significant (p < 0.05). Until the latest follow-up, hardware removal was performed in 16 of the 22 patients in the IN group, and 17 of the 23 patients in the SP group. In the IN group, all implants were removed, uneventfully. However, in the three cases of the SP group, we encountered difficulty in removing the locking plate and screws due to the stripping of the hexagonal recess and cold-weld threads of the locking screw head. To remove stripped locking screws, one patient needed an additional procedure using a conical extraction screw. In the other two patients, we cut the plates around stripped screw holes with a metal cutting carbide-tipped burr (Table 4). Table 4 Optional demographics.
Surgical demographics Operation time (min) Bleeding amount (cc) Radiation exposure (s) Difficulty in hardware removal
Intramedullary nailing
Submuscular plating
94.7 185 58 None
104 220 109 3
Difficulty in hardware removal – It means the removal procedure needed other additive procedures or implants except the original equipments.
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Discussion Only a few studies are known that specifically deal with the operative treatment of femoral fractures in adolescents,7–10 Although ESIN is widely used in paediatric femoral fractures, the high incidence of malunion is reported in older children.11,12 It has been suggested that a direct relationship exists between patient’s weight and complications when ESIN was used for paediatric femoral shaft fractures.2,3,8 Therefore, stability of the implant is important to maintain the reduction of adolescent femoral fractures. This led us to hypothesise that IN through trochanteric entry and LCP using SP may be a biomechanically stable implant in older or heavy children, comparing to ESIN. We observed no reduction loss, implant failure or malunion in both methods of this study including patients weighed over 50 kg. Severity of the comminution and the fracture stability are also known to associate with complications after ESIN.13 Sink et al.14 found a significantly higher rate of complications in their ‘‘length unstable’’ group. In our study, the fracture comminution or unstable fracture pattern did not affect the alignment issue. We assume that the stiffness of nail or locking plate is strong enough to maintain the length of unstable fractures. Ramseier et al.7 reported a shorter healing time after elastic or rigid nailing than external fixation. However, no study compared IN and SP in adolescent femoral fractures. Our study showed that both techniques had a similar healing time. Also, all fractures healed except one case of deep infection with the nonunion. Therefore, in terms of bony healing, both IN and SP may be ideal options because of their minimal invasiveness to the fracture site. In adolescent femoral fractures, the distal femoral physis should be spared to prevent growth-related problems. Although both IN and SP are not harmful to this, the major difference between the two techniques is from the intrusion of nail through the immature proximal femur. The osteonecrosis, a rare but devastating complication,5,15 is always concerned after IN of adolescent femoral fractures. As per many reports of nailing through trochanteric entry, none of the children in IN of this study had osteonecrosis during the mean follow-up over 21 months. A theoretical drawback of the trochanteric entry is growth changes in the proximal femur, including femoral neck valgus or neck narrowing.16,17 In this study, the patients in IN group did not show any changes compared to the non-injured side. Gordon et al.6 also did not find any statistically significant growth changes secondary to the use of trochanteric entry. Of course, SP is the theoretically safer procedure than IN and none in the SP group in this series showed such complications. Although the chronological age and follow-up period may not be enough to explain our results, we suppose that both techniques may be free from the growth disturbance or osteonecrosis. The reproducibility of operative techniques is one of the important selection issues. Since the fracture is usually reduced by closed reduction through the soft-tissue window away from the fracture site, SP is technically demanding with frequent malalignments and resultant malunions.18 To reduce this complication, several tips concerning temporary reduction under fluoroscopic control are necessary. In this study, we could achieve union with low rate of malunion in the SP group, similar to IN. However, the SP group needed a longer operation time and more radiation exposure than IN. From this viewpoint, IN has a benefit of reducing radiation hazards to medical staff and patients, since closed reduction by nailing is usually easier and more reproducible than SP. In the present study, we observed that time to full weight bearing in the IN group was shorter than in the SP group. Although children usually recover the function completely, early weight bearing is beneficial to the early return to school. Keeler et al.19 also reported that patients treated with an IN (even those that had
experienced multiple traumas) could ambulate sooner than those treated using other methods. Furthermore, IN is advantageous because it allows early rehabilitation and return to school life. Although the removal procedure should be simple and free from complications, implant removal may be challenging and lead to complications.20 Pate et al.21 reported that submuscular plate removal is substantially more complicated than plate insertion, because of bone overgrowth at the leading edge. Bae et al.22 noted technical difficulties when removing LCPs, because of stripping of the hexagonal recess of the 3.5-mm locking screw. In our study, we experienced the stripping of 5.0-mm locking screws in two patients in the SP group. In two cases, the plates were cut with the high-speed carbide-tipped burr to remove the implant. This proved to be an extensive procedure, with markedly longer operation time and larger incisions than expected. Otherwise, all nails were removed without difficulty. From this point of view, IN has a definite advantage over SP. Our study has the limitation of small patient numbers. However, the baseline characteristics of the patients in the two study groups were similar with respect to age, fracture classification and fracture location. Another limitation was that we used two different nails for IN, that is, a tibial nail was used for small femoral canals and a femoral nail for larger canals. The configuration of the tibial nail23 is similar to that of a recently designed implant, since the tibial nail has a bend in its proximal region. However, we encountered no reduction or alignment difficulties, as was reported for a humeral nail in similar patients.24 In summary, both IN and SP produced good results with low complication rates when used to treat adolescent femoral fractures. However, IN may be the rational choice due to its benefits of shorter fluoroscopy and operation times, and an earlier return to daily life. Conflict of interest statement None. Acknowledgement This work was supported by Kyungpook National University Research Fund, 2011. References 1. Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, Kasser J. Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop 2001;21:4–8. 2. Moroz LA, Launay F, Kocher MS, Newton PO, Frick SL, Sponseller PD, et al. Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome. J Bone Joint Surg Br 2006;88:1361–6. 3. Weiss JM, Choi P, Ghatan C, Skaggs DL, Kay RM. Complications with flexible nailing of femur fractures more than double with child obesity and weight >50 kg. J Child Orthop 2009;3:53–8. 4. Kanlic EM, Anglen JO, Smith DG, Morgan SJ, Pesantez RF. Advantages of submuscular bridge plating for complex pediatric femur fractures. Clin Orthop Relat Res 2004;426:244–51. 5. O’Malley DE, Mazur JM, Cummings RJ. Femoral head avascular necrosis associated with intramedullary nailing in an adolescent. J Pediatr Orthop 1995;15:21– 3. 6. Gordon JE, Swenning TA, Burd TA, Szymanski DA, Schoenecker PL. Proximal femoral radiographic changes after lateral transtrochanteric intramedullary nail placement in children. J Bone Joint Surg Am 2003;85:1295–301. 7. Ramseier LE, Janicki JA, Weir S, Narayanan UG. Femoral fractures in adolescents: a comparison of four methods of fixation. J Bone Joint Surg Am 2010;92:1122–9. 8. Sagan ML, Datta JC, Olney BW, Lansford TJ, McIff TE. Residual deformity after treatment of pediatric femur fractures with flexible titanium nails. J Pediatr Orthop 2010;30:638–43. 9. Momberger N, stevens P, Smith J, Santora S, Scott S, Anderson J. Intramedullary nailing of femoral fractures in adolescents. J Pediatr Orthop 2000;20:482–4. 10. Townsend DR, Hoffinger S. Intramedullary nailing of femoral shaft fractures in children via the trochanter tip. Clin Orthop Relat Res 2000;376:113–8. 11. Ho CA, Skaggs DL, Tang CW, Kay RM. Use of flexible intramedullary nails in pediatric femur fractures. J Pediatr Orthop 2006;26:497–504.
K.-C. Park et al. / Injury, Int. J. Care Injured 43 (2012) 870–875 12. Luhmann SJ, Schootman M, Schoenecker PL, Dobbs MB, Gordon JE. Complications of titanium elastic nails for pediatric femoral shaft fractures. J Pediatr Orthop 2003;23:443–7. 13. Narayanan UG, Hyman JE, Wainwright AM, Rang M, Alman BA. Complications of elastic stable intramedullary nail fixation of pediatric femoral fractures, and how to avoid them. J Pediatr Orthop 2004;24:363–9. 14. Sink EL, Gralla J, Repine M. Complications of pediatric femur fractures treated with titanium elastic nails: a comparison of fracture types. J Pediatr Orthop 2005;25:577–80. 15. Thometz JG, Lamdan R. Osteonecrosis of the femoral head after intramedullary nailing of a fracture of the femoral shaft in an adolescent. A case report. J Bone Joint Surg Am 1995;77:1423–6. 16. Gonzalez-Herranz P, Burgos-Flores J, Rapariz JM, Lopez-Mondejar JA, Ocete JG, Amaya S. Intramedullary nailing of the femur in children. Effects on its proximal end. J Bone Joint Surg Br 1995;77:262–6. 17. Raney EM, Ogden JA, Grogan DP. Premature greater trochanteric epiphysiodesis secondary to intramedullary femoral rodding. J Pediatr Orthop 1993;13:516–20. 18. Oh CW, Song HR, Jeon IH, Min WK, Park BC. Nail-assisted percutaneous plating of pediatric femoral fractures. Clin Orthop Relat Res 2007;456:176–81.
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19. Keeler KA, Dart B, Luhmann SJ, Schoenecker PL, Ortman MR, Dobbs MB, et al. Antegrade intramedullary nailing of pediatric femoral fractures using an interlocking pediatric femoral nail and a lateral trochanteric entry point. J Pediatr Orthop 2009;29:345–51. 20. Loder RT, Feinberg JR. Orthopaedic implants in children: survey results regarding routine removal by the pediatric and nonpediatric specialists. J Pediatr Orthop 2006;26:510–9. 21. Pate O, Hedequist D, Leong N, Hresko T. Implant removal after submuscular plating for pediatric femur fractures. J Pediatr Orthop 2009;29:709–12. 22. Bae JH, Oh JK, Oh CW, Hur CR. Technical difficulties of removal of locking screw after locking compression plating. Arch Orthop Trauma Surg 2009;129:91–5. 23. Mehlman CT, Bishai SK. Tibial nails for femoral shaft fractures in large adolescents with open femoral physes. J Trauma 2007;63:424–8. 24. Gordon JE, Khanna N, Luhmann SJ, Dobbs MB, Ortman MR, Schoenecker PL. Intramedullary nailing of femoral fractures in children through the lateral aspect of the greater trochanter using a modified rigid humeral intramedullary nail: preliminary results of a new technique in 15 children. J Orthop Trauma 2004;18:416–22.