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Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures
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Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fracturesR Máté Burkus a,∗, Ferenc Tömböl a, Norbert Wiegand b, András Kretzer a a b
˝ Vasvári Pál st. 2-4, Gyor, ˝ Hungary Department of Traumatology and Hand Surgery, Petz Aladár County Teaching Hospital, H - 9023 Gyor, Department of Traumatology and Hand Surgery, Clinical Centre, University of Pécs, H - 7624 Pécs, Ifjúság st. 13, Pécs, Hungary
a r t i c l e
i n f o
Article history: Accepted 9 February 2020 Available online xxx Keywords: Paediatric trauma Tibial fracture Intramedullary nailing Adolescents Open physes
a b s t r a c t Introduction: The first-line treatment of paediatric tibial fractures is non-operative but the number of operatively treated patients is rising. Elastic intramedullary nailing and external fixation are widely used in children while solid intramedullary nailing, the standard procedure in adults, is usually not recommended due to the open physes. Materials and Methods: Between January 2007 and October 2017, unreamed locked solid intramedullary nailing was used in 16 cases of adolescent (mean age 13.7 ± 1.25 years) tibial diaphyseal fractures with open physes. An atypical, physeal-sparing method was used in all cases. Fourteen patients were managed by the standard implant used routinely in adult trauma care. Two patients were treated by a special nail, modified specifically for paediatric care. Results: Good functional healing was found in all cases treated by the atypical method. Partial weight bearing began immediately after surgery in 38% of the cases. Full weight bearing was allowed 7.3 ± 2.4 weeks postoperatively. The average time to fracture union was 11.5 ± 2.9 weeks. Superficial infection and wound healing complication occurred in 3 cases. Deep infection, compartment syndrome or other bone related complications did not arise. Discussion: The treatment of tibial fractures in adolescents is challenging due to larger body size and significant growth potential. The atypical intramedullary nailing method presented in this study can provide optimal functional healing, early mobilization and weight bearing while completely sparing the physis. This method can serve as an alternative in the operative treatment of adolescent tibial diaphyseal fractures. © 2020 Elsevier Ltd. All rights reserved.
Introduction Tibial fractures, as well as femoral and forearm fractures, are amongst the most common fracture types in children [1–5], with a rate of diaphyseal localisation up to 40% and an approximate rate of additional open fractures of 10% [6,7]. During the last decades, the treatment of diaphyseal tibia fractures has undergone major changes in children. Unlike in adults, conservative treatment in children has good results and low complication rates in the majority of cases, even in open fractures [7–10]. Gordon et al. summarized the treatment of paediatric tibial fractures in their literature review stating that most cases should be treated with closed, non-operative methods if adequate alignment can be maintained. However, comminuted fractures and significant swelling can be difficult to control adequately with nonR ∗
This paper is part of a supplement supported by the Hungarian Trauma Society. Corresponding author E-mail address: [email protected] (M. Burkus).
operative means, and therefore operative treatment is indicated in these cases as well as for open fractures, ipsilateral femoral fractures and floating knee injuries [3]. The number of surgeries performed due to paediatric tibial fractures are increasing. These procedures should be performed differently in children compared to adults because of the difference in biological features, including the presence of open physes. The appearance of elastic intramedullary fixation techniques, which provide good functional healing and early mobilization in a relatively simple and effective way, was a great improvement in the development of operative treatment. Many authors reported positive outcomes, good reproducibility and low complication rates using flexible elastic methods even in unstable or open fractures [2,3,7,9,11– 16]. On the other hand, Srivastava et al. considered elastic nailing “less forgiving in the tibia than in the femur” because proper nail balance and rotation is required [13]. The use of external fixator in operative treatment also has satisfactory results in treating primary fractures, fractures with complications and severe soft-tissue damage [3,7,15,17]. Kubiak et al.
https://doi.org/10.1016/j.injury.2020.02.049 0020-1383/© 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: M. Burkus, F. Tömböl and N. Wiegand et al., Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures, Injury, https://doi.org/10.1016/j.injury.2020.02.049
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Fig. 1. Yearly distribution of pediatric and all ambulatory cases (a.), and tibial fractures (b.) at our institution, ∗ In 2007 only the first 9 months are shown.
had compared 16 patients managed with elastic nailing with 15 patients managed with external fixation and found similar outcomes. However, they found the time to fracture union to be significantly shorter in the intramedullary nailing group and the complication rate to be higher in the external fixation group [18]. Other fixation techniques like plate osteosynthesis have limited utilization due to more extended dissection which leads to soft-tissue damage. Moreover, some authors suggested that applying plate osteosynthesis under the age of twelve stimulates growth which may result in leg length discrepancy [19,20]. In spite of good experience with non-operative treatment, optional operative treatment of paediatric tibial fractures remains a challenge. It is especially true in adolescence when body size often resembles adults but epiphyseal plates are usually still active. According to some authors, standard intramedullary nailing, generally used in adults, may be an adequate alternative because physical parameters and full function need to be restored as soon as possible. Setter et al. mentioned in their systematic review that solid nails might be used but are not advised because using the standard entry point potentially damages the epiphyseal plate [3,7]. Having reviewed the literature, we have found only one study where intramedullary nailing was used before epiphyseal closure. Court-Brown et al. performed reamed intramedullary nailing using a hollow, slotted nail with the entry point based lower than usual to reduce the chance of damaging the physis [21]. The aim of the present study was to give an overview of our experience of treating adolescent tibial fractures with atypical locked solid intramedullary nailing. Based on this experience, a special nail, made especially for paediatric care, was created.
Table 1 Age and gender distribution of the examined population. Age (years)
Boy
Girl
11 12 13 14 15 16 n = 16 Average years
1 0 3 3 3 1 11 13,9
0 1 2 2 0 0 5 13,2
Table 2 Origin of injury. ∗One pathological fracture. Origin (n = 16)
Boy
Girl
Winter Sports Football Home accident∗ Motocross Polytrauma
5 3 1 2 0
0 0 4 0 1
Table 3 Distribution of the examined population based on AO fracture classification (n = 16). AO classification: 42/ A1 0
A2 1
A3 1
B1 10
B2 2
B3 0
C1 1
C2 0
C3 1
Materials and methods Between January 1,2007 and September 31,2017, the rate of injured children treated at our emergency care unit was 20.5% of all patients and 18.4% of all tibial fractures. Yearly distributions of outpatients and tibial fracture cases are shown in Fig. 1. During this time period 504 children were admitted with tibial fracture. 98(19.4%) of these patients received operative treatment and 406(80.6%) patients were treated non-operatively. In our present study, we report those cases of diaphyseal tibial fractures with open physes which were managed by solid intramedullary nailing. There were 16 patients, 11 male 5 female, with the mean age of 13.7 ± 1.25 years (range 12–16). Distribution by gender and age is shown in Table 1. Intramedullary nailing was used in 16% of operatively treated children with tibial fracture.
The mechanism of injuries is shown in Table 2. In one case, considered to be pathologic, the fracture was caused by a minor trauma a few weeks after bone cyst surgery. In another case, tibial fracture occurred in a polytraumatized patient, associated with proximal humeral fracture, pulmonary contusion, rib fractures, cerebral contusion and oedema. The remaining cases were not associated with any major trauma. Closed fractures were present in 15 patients and 1 patient had a grade I open fracture. The detailed distribution of fractures according to AO classification is presented in Table 3. The indication for intramedullary nailing was a larger body size, mainly body weight with an average of 62.2 ± 14.5 kg (range 46–102). Surgery was performed right after the injury (within 24 h) in 10 cases and between the third and fourth day after injury in
Please cite this article as: M. Burkus, F. Tömböl and N. Wiegand et al., Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures, Injury, https://doi.org/10.1016/j.injury.2020.02.049
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Fig. 2. Atypical insertion of the modified (a.) and standard (b.) nail.
3 cases. Of these 3 patients, 2 had received initial treatment abroad and we converted their conservative treatment and in one case surgical treatment had to be postponed due to social reasons. In the remaining 3 cases, surgery was performed between the 10th and 14th day after injury. In these cases, conservative therapy had been started (in two cases at our institution, in one case at another hospital), but check-ups showed insufficient bone alignment and shifting so operative treatment became necessary. Fourteen patients were managed by standard unreamed solid locked intramedullary nailing (Medimetal Company, Eger, Hungary), used routinely in adult trauma care. Two patients were treated by a special nail, modified specifically for paediatric care (Junior TK nail system). Surgical technic When operating it was essential to completely avoid causing damage to the physis, so a different method was used to insert the implant other than the standard transligamental insertion technique. A skin incision was made 2–3 cm distal and slightly medial to the tibial tuberosity, then an atypical bony entry site was created here for insertion (Fig. 2). Special attention was paid to avoid shifting in proximal direction in order to leave the physis undamaged. The smallest nail diameter available (8 mm) was used due to the density of the bones (thick cortical, narrow medullary canal). Reposition, nail insertion and locking were completed under radiographic control. During the development of the modified nail, its head was slightly adjusted and its bend was modified to facilitate the atypical insertion, while the nail diameter remained 8 mm. The position of the locking holes was rotated 30° to the medial side of the tibia to further reduce the risk of damaging the physis (Fig. 3). As a result of all modifications, different implants were manufactured for the left and right side. All patients were monitored every two weeks between postoperative week 2 and 12, and every four weeks till 20 weeks postoperatively. After the 20th week check-up, they were examined after 6 months, one year and then yearly, respectively. During followup, we evaluated ankle and knee function compared with the contralateral side, subjective complaints and leg length. Results All fractures treated by the atypical method healed with good function (Figs. 4,5). No malunion, non-union and implant failure occurred during follow-up, so reoperation or changing treatment was not necessary. No external support such as cast or splint was applied after surgeries. The mean length of hospital stay was
Fig 3. The photo shows the differences between the conventional and the modified nail.
6.1 ± 2.3 days excluding the 37-day-long hospital stay of the polytraumatized patient. Postoperative partial weight bearing using crutches began immediately after surgery in 7 cases. Eight patients started weight bearing by 1 /3 body weight 3.3 ± 0.6 weeks postoperatively, then by ½ body weight 5.4 ± 1.6 weeks postoperatively. Full weight bearing was allowed at 7.3 ± 2.4 weeks (range 4–12). Mobilisation of the polytraumatized patient was slower due to the associated injuries. Radiographic union was observed to have occurred in 11.5 ± 2.9 weeks (range 8–16). Patients were allowed to return to normal physical activity and sports at a mean of 18 ± 4.5 weeks. Limited iatrogenic cortical damage was found around the atypical nail entry point in 3 cases which required no further treatment (Fig 6.). Wound dehiscence and bleeding from the wound occurred in one case which had resolved by the 6th postoperative day after regular dressing changes. Two patients developed initially superficial wound infection postoperatively which resolved after antibiotic therapy. Deep infection or neurovascular damage did not occur. None of our patients developed compartment syndrome. Postoperative blood transfusion was necessary in one case. Nail removal was performed in 14 cases after an average of 44 ± 11 weeks. There were no difficulties in nail removal and
Please cite this article as: M. Burkus, F. Tömböl and N. Wiegand et al., Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures, Injury, https://doi.org/10.1016/j.injury.2020.02.049
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Fig. 4. Preoperative (a.,b.) and postoperative (c.,d.) X-rays of a comminuted fracture treated with the modified locked solid intramedullary nail.
Fig. 5. X-rays of 13-year-old girl with diaphyseal tibial fracture. The treatment was initially non-operative (a.,b.). During check-up varus mal alignment was observed (c.,d.), then operation was performed with atypical insertion of standard locked solid intramedullary tibial nail (e.,f.). X- ray g. and h. was performed approximately 2 years after nail removal. With the atypical operative technic good functional healing was achieved.
re-fracture did not occur. One patient presented with delayed wound healing, bleeding and local signs of inflammation after nail removal. This case was managed by debridement and antibiotic therapy. The mean follow-up period was 69 ± 31 months, during which neither physical nor radiological examinations detected leg length discrepancy due to physeal damage. All fractures healed in good functional position except in one case which healed with an asymptomatic 10° malalignment. After 20 weeks postoperatively,
two patients complained of continuous leg pain. One case resolved completely after implant removal but this was only partially true in the other case. Only consecutive physiotherapy could relieve this patient’s symptoms. Discussion Treatment of paediatric diaphyseal tibial fractures has undergone major changes in the last few years [22–25]. In the majority
Please cite this article as: M. Burkus, F. Tömböl and N. Wiegand et al., Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures, Injury, https://doi.org/10.1016/j.injury.2020.02.049
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Fig. 6. Iatrogenic cortical damage caused by the atypical nail insertion. No further intervention, was necessary.
of the cases, fractures that are stable and with optimal alignment, non-operative therapy is still the first-line treatment [3,7–9], often meaning long-term immobilization. Ho et al. in their study about non-operative treatment of adolescent tibial fractures found that immobilization was on average 13.8 weeks long and lasted more than 3 months in 61% of the cases [9]. The rising need for shortening the length of immobilization (e.g. athletes returning to regular training as soon as possible) and improved operative techniques have caused the rate of operative treatment to rise. Berruex et al. in their book (published in 1980) reported an operative rate of 4.5% while in our current 10-year-long period of study we noted an operative rate of 18.4%. Ward et al. suggested that more than 10% of operatively treated paediatric long bone fractures are tibial shaft fractures [7,13,26,27]. Tibial diaphyseal fractures are usually located in the distal third and if the fibula is intact, shortening will not occur. However, there may be a greater chance of drift into varus, especially in comminuted fractures. Therefore, in these cases operative treatment is advised as well as for malalignment, open fractures, ipsilateral femoral fractures and floating knee. Gordon et al. suggested that adolescent fractures are a relative indication for surgical treatment [3,28].
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Surgical stabilization is ideal when it is able to simply, quickly and repeatedly establish stable and weight bearing fixation and optimal healing. It is also important that fixation should not damage the open physes to prevent growth abnormalities. Flexible intramedullary nailing fits most of these criteria and is used widely [3,4,11–13,18,29,30]. However, it may not provide optimal stability in all cases (e.g. larger body size) thus external fixation is required. Sankar et al. applied external fixation after intramedullary nailing for 7 weeks on average [16]. Goodbody et al. conducted a study of 95 patients (mean age 12.1 years) in which they compared results of TEN nailing in older children with a larger body size (above 50 kgs and 14 years) with younger children with smaller body size and found no significant difference in healing. They also used external fixation after surgery in all the cases. They suggested that flexible intramedullary nailing should not be precluded in older and heavier patients [2]. On the contrary, other authors in their studies of femoral fractures found significantly more complications and worse outcomes in older age, higher BMI and more distal localisation [31,32]. Solid intramedullary nailing, widely used in adults, can be a great alternative in paediatric patients with a larger body size and need for early mobilization. Goodwin et al. conducted a study of 19 unstable fracture cases (mean age 12 ± 3 years) and although they had considered using solid intramedullary nailing in 2 cases due to larger body sizes, they recognized the increased chance of damage to the open physes and decided to use double elastic intramedullary nailing with 4 nails [11]. Nandra et al. used intramedullary nailing in one case in their study of 61 open fracture cases, 36 diaphyseal [15]. Court-Brown et al. performed reamed intramedullary nailing using a hollow, slotted nail in 36 adolescent patients, aged between 13 and 16. Though they used a slightly different insertion method than the standard one which potentially could lead to physeal damage, they found no signs of growth abnormality caused by damage to the physis. However, they suggested using other techniques in patients who still have significant growth potential [21]. Due to reservations about procedures that reach the physis directly, we used solid intramedullary nailing with atypical implant insertion in order to completely spare the open physis. Considering this approach, our method can safely be used in patients with a larger body size and significant growth potential. Atypical insertion, i.e. opening the bone and inserting the nail from the medial side, may be more difficult than usual due to the curve of the bone and the shape of the nail. There is an increased chance of causing damage to the cortical bone. This kind of iatrogenic damage was noted in our first cases. In the following cases, larger (3–5 cm) openings were made that facilitated nail insertion. Later we also modified the bend of the nail and the shape of the head to further reduce the chance of damaging the physis. The possibility of drilling the physis was minimized by altering the position of the locking screws. These adjustments improved our method and made it safe for use in patients with open physes and significant growth potential. During the study we found our average time to fracture union (11.5 ± 2.9 weeks) to be similar to the average of 11.5 weeks published by Court-Brown et al. [21]. Nandra et al. reported an average of 13 weeks to fracture union in open diaphyseal fractures. They compared cases managed by external fixator with elastic nailing and noted significantly longer healing in the external fixation group which they attributed to the complexity of the injuries [15]. Using only elastic nailing, Vallamshetla et al. reported 10 weeks to union, Sankar et al. 11 to 13 weeks and Srivastava et al. 20.4 weeks. Kubiak et al. recorded 7 weeks using elastic nailing and 18 weeks using external fixation [12,13,16,18]. One of the most significant complications after tibial shaft fractures is compartment syndrome with an incidence that varies
Please cite this article as: M. Burkus, F. Tömböl and N. Wiegand et al., Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures, Injury, https://doi.org/10.1016/j.injury.2020.02.049
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widely between studies. It is more frequent in children supposedly due to relative muscular hypertrophy. Having monitored all of our patients regularly, we found no signs of compartment syndrome. This is similar to the findings of Ho et al. about non-operative treatment [9]. Our results are likely due to the relatively low number of cases rather the differences between treatment methods. In contrast, the rate of compartment syndrome was found 4.5% by Goodbody et al., 8% by Srivastava et al., 8.3% by Court-Brown et al. and 32% by Goodwin et al. [2,11,13,21]. McQueen et al. conducted a study of 1388 tibial shaft fracture cases (mean age 39, range 12–98 years) and found the incidence of compartment syndrome to be 11.5% in the whole group and 20% in the age group 12–19 years. They found that young age was the strongest predictor while there was no significant difference in the rate of compartment syndrome in low- or high-energy injury or in open versus closed fractures [33]. Our study noted minor complications, such as superficial infection and wound-healing complication, in 3 cases (19%), which is slightly higher than other studies have shown. The infection rate in elastic nailing was 5% by Vallmashetla et al. and 8% by Srivastava et al. Iobst et al. reported an infection rate of 2.5% in nonoperatively treated open fractures. Nandra et al. noted 6.6% superficial and 4.9% deep infection in 61 open fracture cases [10,12,13,15]. It is assumed that our higher infection rate is due to relatively small number of cases in our study and not to the chance of infection caused by increased tissue damage with our technique. The atypical intramedullary nailing, like elastic nailing, can be done simply and repeatedly from a small incision which reduces the chance of additional tissue damage. It does not damage endosteal circulation because it is unreamed. Intra- and perioperative complications of this method and elastic intramedullary nailing are similar, except implant migration only occurs after elastic nailing [34]. This stable fixation may be started on partial weight-bearing even in early postoperative period depending on the type of the fracture and requires no external fixation. These advantages promote the use of this technique. The present study is limited by its relatively small number of cases and limited experience with the new nail which only allows a restricted evaluation of complications. The results of this study are further limited by the lack of control groups: elastic nailing group and non-operatively treated group, respectively. Conclusion In conclusion, the first-line treatment of paediatric tibial shaft fractures is non-operative treatment, but the rate of operative treatment is rising. The most frequently used method is elastic intramedullary nailing which can also be used in patients with a larger body size. The unreamed locked solid intramedullary nailing described in this study is able to provide physis-sparing and stable fixation with low complication rate and early weight bearing capacity, serving as an excellent alternative. Declaration of Competing Interest All the authors declare no conflict of interest regarding the manuscript of this article. Acknowledgements The authors acknowledge the medical staff of Petz Aladár County Teaching Hospital for their careful and devoted work with all the patients concluded in this study. They also thank Medimetal Company for their help in the development process and manufacturing the atypical implant.
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Please cite this article as: M. Burkus, F. Tömböl and N. Wiegand et al., Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures, Injury, https://doi.org/10.1016/j.injury.2020.02.049
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Please cite this article as: M. Burkus, F. Tömböl and N. Wiegand et al., Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures, Injury, https://doi.org/10.1016/j.injury.2020.02.049
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Injury journal homepage: www.elsevier.com/locate/injury
Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fracturesR Máté Burkus a,∗, Ferenc Tömböl a, Norbert Wiegand b, András Kretzer a a b
˝ Vasvári Pál st. 2-4, Gyor, ˝ Hungary Department of Traumatology and Hand Surgery, Petz Aladár County Teaching Hospital, H - 9023 Gyor, Department of Traumatology and Hand Surgery, Clinical Centre, University of Pécs, H - 7624 Pécs, Ifjúság st. 13, Pécs, Hungary
a r t i c l e
i n f o
Article history: Accepted 9 February 2020 Available online xxx Keywords: Paediatric trauma Tibial fracture Intramedullary nailing Adolescents Open physes
a b s t r a c t Introduction: The first-line treatment of paediatric tibial fractures is non-operative but the number of operatively treated patients is rising. Elastic intramedullary nailing and external fixation are widely used in children while solid intramedullary nailing, the standard procedure in adults, is usually not recommended due to the open physes. Materials and Methods: Between January 2007 and October 2017, unreamed locked solid intramedullary nailing was used in 16 cases of adolescent (mean age 13.7 ± 1.25 years) tibial diaphyseal fractures with open physes. An atypical, physeal-sparing method was used in all cases. Fourteen patients were managed by the standard implant used routinely in adult trauma care. Two patients were treated by a special nail, modified specifically for paediatric care. Results: Good functional healing was found in all cases treated by the atypical method. Partial weight bearing began immediately after surgery in 38% of the cases. Full weight bearing was allowed 7.3 ± 2.4 weeks postoperatively. The average time to fracture union was 11.5 ± 2.9 weeks. Superficial infection and wound healing complication occurred in 3 cases. Deep infection, compartment syndrome or other bone related complications did not arise. Discussion: The treatment of tibial fractures in adolescents is challenging due to larger body size and significant growth potential. The atypical intramedullary nailing method presented in this study can provide optimal functional healing, early mobilization and weight bearing while completely sparing the physis. This method can serve as an alternative in the operative treatment of adolescent tibial diaphyseal fractures. © 2020 Elsevier Ltd. All rights reserved.
Introduction Tibial fractures, as well as femoral and forearm fractures, are amongst the most common fracture types in children [1–5], with a rate of diaphyseal localisation up to 40% and an approximate rate of additional open fractures of 10% [6,7]. During the last decades, the treatment of diaphyseal tibia fractures has undergone major changes in children. Unlike in adults, conservative treatment in children has good results and low complication rates in the majority of cases, even in open fractures [7–10]. Gordon et al. summarized the treatment of paediatric tibial fractures in their literature review stating that most cases should be treated with closed, non-operative methods if adequate alignment can be maintained. However, comminuted fractures and significant swelling can be difficult to control adequately with nonR ∗
This paper is part of a supplement supported by the Hungarian Trauma Society. Corresponding author E-mail address: [email protected] (M. Burkus).
operative means, and therefore operative treatment is indicated in these cases as well as for open fractures, ipsilateral femoral fractures and floating knee injuries [3]. The number of surgeries performed due to paediatric tibial fractures are increasing. These procedures should be performed differently in children compared to adults because of the difference in biological features, including the presence of open physes. The appearance of elastic intramedullary fixation techniques, which provide good functional healing and early mobilization in a relatively simple and effective way, was a great improvement in the development of operative treatment. Many authors reported positive outcomes, good reproducibility and low complication rates using flexible elastic methods even in unstable or open fractures [2,3,7,9,11– 16]. On the other hand, Srivastava et al. considered elastic nailing “less forgiving in the tibia than in the femur” because proper nail balance and rotation is required [13]. The use of external fixator in operative treatment also has satisfactory results in treating primary fractures, fractures with complications and severe soft-tissue damage [3,7,15,17]. Kubiak et al.
https://doi.org/10.1016/j.injury.2020.02.049 0020-1383/© 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: M. Burkus, F. Tömböl and N. Wiegand et al., Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures, Injury, https://doi.org/10.1016/j.injury.2020.02.049
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Fig. 1. Yearly distribution of pediatric and all ambulatory cases (a.), and tibial fractures (b.) at our institution, ∗ In 2007 only the first 9 months are shown.
had compared 16 patients managed with elastic nailing with 15 patients managed with external fixation and found similar outcomes. However, they found the time to fracture union to be significantly shorter in the intramedullary nailing group and the complication rate to be higher in the external fixation group [18]. Other fixation techniques like plate osteosynthesis have limited utilization due to more extended dissection which leads to soft-tissue damage. Moreover, some authors suggested that applying plate osteosynthesis under the age of twelve stimulates growth which may result in leg length discrepancy [19,20]. In spite of good experience with non-operative treatment, optional operative treatment of paediatric tibial fractures remains a challenge. It is especially true in adolescence when body size often resembles adults but epiphyseal plates are usually still active. According to some authors, standard intramedullary nailing, generally used in adults, may be an adequate alternative because physical parameters and full function need to be restored as soon as possible. Setter et al. mentioned in their systematic review that solid nails might be used but are not advised because using the standard entry point potentially damages the epiphyseal plate [3,7]. Having reviewed the literature, we have found only one study where intramedullary nailing was used before epiphyseal closure. Court-Brown et al. performed reamed intramedullary nailing using a hollow, slotted nail with the entry point based lower than usual to reduce the chance of damaging the physis [21]. The aim of the present study was to give an overview of our experience of treating adolescent tibial fractures with atypical locked solid intramedullary nailing. Based on this experience, a special nail, made especially for paediatric care, was created.
Table 1 Age and gender distribution of the examined population. Age (years)
Boy
Girl
11 12 13 14 15 16 n = 16 Average years
1 0 3 3 3 1 11 13,9
0 1 2 2 0 0 5 13,2
Table 2 Origin of injury. ∗One pathological fracture. Origin (n = 16)
Boy
Girl
Winter Sports Football Home accident∗ Motocross Polytrauma
5 3 1 2 0
0 0 4 0 1
Table 3 Distribution of the examined population based on AO fracture classification (n = 16). AO classification: 42/ A1 0
A2 1
A3 1
B1 10
B2 2
B3 0
C1 1
C2 0
C3 1
Materials and methods Between January 1,2007 and September 31,2017, the rate of injured children treated at our emergency care unit was 20.5% of all patients and 18.4% of all tibial fractures. Yearly distributions of outpatients and tibial fracture cases are shown in Fig. 1. During this time period 504 children were admitted with tibial fracture. 98(19.4%) of these patients received operative treatment and 406(80.6%) patients were treated non-operatively. In our present study, we report those cases of diaphyseal tibial fractures with open physes which were managed by solid intramedullary nailing. There were 16 patients, 11 male 5 female, with the mean age of 13.7 ± 1.25 years (range 12–16). Distribution by gender and age is shown in Table 1. Intramedullary nailing was used in 16% of operatively treated children with tibial fracture.
The mechanism of injuries is shown in Table 2. In one case, considered to be pathologic, the fracture was caused by a minor trauma a few weeks after bone cyst surgery. In another case, tibial fracture occurred in a polytraumatized patient, associated with proximal humeral fracture, pulmonary contusion, rib fractures, cerebral contusion and oedema. The remaining cases were not associated with any major trauma. Closed fractures were present in 15 patients and 1 patient had a grade I open fracture. The detailed distribution of fractures according to AO classification is presented in Table 3. The indication for intramedullary nailing was a larger body size, mainly body weight with an average of 62.2 ± 14.5 kg (range 46–102). Surgery was performed right after the injury (within 24 h) in 10 cases and between the third and fourth day after injury in
Please cite this article as: M. Burkus, F. Tömböl and N. Wiegand et al., Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures, Injury, https://doi.org/10.1016/j.injury.2020.02.049
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Fig. 2. Atypical insertion of the modified (a.) and standard (b.) nail.
3 cases. Of these 3 patients, 2 had received initial treatment abroad and we converted their conservative treatment and in one case surgical treatment had to be postponed due to social reasons. In the remaining 3 cases, surgery was performed between the 10th and 14th day after injury. In these cases, conservative therapy had been started (in two cases at our institution, in one case at another hospital), but check-ups showed insufficient bone alignment and shifting so operative treatment became necessary. Fourteen patients were managed by standard unreamed solid locked intramedullary nailing (Medimetal Company, Eger, Hungary), used routinely in adult trauma care. Two patients were treated by a special nail, modified specifically for paediatric care (Junior TK nail system). Surgical technic When operating it was essential to completely avoid causing damage to the physis, so a different method was used to insert the implant other than the standard transligamental insertion technique. A skin incision was made 2–3 cm distal and slightly medial to the tibial tuberosity, then an atypical bony entry site was created here for insertion (Fig. 2). Special attention was paid to avoid shifting in proximal direction in order to leave the physis undamaged. The smallest nail diameter available (8 mm) was used due to the density of the bones (thick cortical, narrow medullary canal). Reposition, nail insertion and locking were completed under radiographic control. During the development of the modified nail, its head was slightly adjusted and its bend was modified to facilitate the atypical insertion, while the nail diameter remained 8 mm. The position of the locking holes was rotated 30° to the medial side of the tibia to further reduce the risk of damaging the physis (Fig. 3). As a result of all modifications, different implants were manufactured for the left and right side. All patients were monitored every two weeks between postoperative week 2 and 12, and every four weeks till 20 weeks postoperatively. After the 20th week check-up, they were examined after 6 months, one year and then yearly, respectively. During followup, we evaluated ankle and knee function compared with the contralateral side, subjective complaints and leg length. Results All fractures treated by the atypical method healed with good function (Figs. 4,5). No malunion, non-union and implant failure occurred during follow-up, so reoperation or changing treatment was not necessary. No external support such as cast or splint was applied after surgeries. The mean length of hospital stay was
Fig 3. The photo shows the differences between the conventional and the modified nail.
6.1 ± 2.3 days excluding the 37-day-long hospital stay of the polytraumatized patient. Postoperative partial weight bearing using crutches began immediately after surgery in 7 cases. Eight patients started weight bearing by 1 /3 body weight 3.3 ± 0.6 weeks postoperatively, then by ½ body weight 5.4 ± 1.6 weeks postoperatively. Full weight bearing was allowed at 7.3 ± 2.4 weeks (range 4–12). Mobilisation of the polytraumatized patient was slower due to the associated injuries. Radiographic union was observed to have occurred in 11.5 ± 2.9 weeks (range 8–16). Patients were allowed to return to normal physical activity and sports at a mean of 18 ± 4.5 weeks. Limited iatrogenic cortical damage was found around the atypical nail entry point in 3 cases which required no further treatment (Fig 6.). Wound dehiscence and bleeding from the wound occurred in one case which had resolved by the 6th postoperative day after regular dressing changes. Two patients developed initially superficial wound infection postoperatively which resolved after antibiotic therapy. Deep infection or neurovascular damage did not occur. None of our patients developed compartment syndrome. Postoperative blood transfusion was necessary in one case. Nail removal was performed in 14 cases after an average of 44 ± 11 weeks. There were no difficulties in nail removal and
Please cite this article as: M. Burkus, F. Tömböl and N. Wiegand et al., Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures, Injury, https://doi.org/10.1016/j.injury.2020.02.049
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Fig. 4. Preoperative (a.,b.) and postoperative (c.,d.) X-rays of a comminuted fracture treated with the modified locked solid intramedullary nail.
Fig. 5. X-rays of 13-year-old girl with diaphyseal tibial fracture. The treatment was initially non-operative (a.,b.). During check-up varus mal alignment was observed (c.,d.), then operation was performed with atypical insertion of standard locked solid intramedullary tibial nail (e.,f.). X- ray g. and h. was performed approximately 2 years after nail removal. With the atypical operative technic good functional healing was achieved.
re-fracture did not occur. One patient presented with delayed wound healing, bleeding and local signs of inflammation after nail removal. This case was managed by debridement and antibiotic therapy. The mean follow-up period was 69 ± 31 months, during which neither physical nor radiological examinations detected leg length discrepancy due to physeal damage. All fractures healed in good functional position except in one case which healed with an asymptomatic 10° malalignment. After 20 weeks postoperatively,
two patients complained of continuous leg pain. One case resolved completely after implant removal but this was only partially true in the other case. Only consecutive physiotherapy could relieve this patient’s symptoms. Discussion Treatment of paediatric diaphyseal tibial fractures has undergone major changes in the last few years [22–25]. In the majority
Please cite this article as: M. Burkus, F. Tömböl and N. Wiegand et al., Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures, Injury, https://doi.org/10.1016/j.injury.2020.02.049
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Fig. 6. Iatrogenic cortical damage caused by the atypical nail insertion. No further intervention, was necessary.
of the cases, fractures that are stable and with optimal alignment, non-operative therapy is still the first-line treatment [3,7–9], often meaning long-term immobilization. Ho et al. in their study about non-operative treatment of adolescent tibial fractures found that immobilization was on average 13.8 weeks long and lasted more than 3 months in 61% of the cases [9]. The rising need for shortening the length of immobilization (e.g. athletes returning to regular training as soon as possible) and improved operative techniques have caused the rate of operative treatment to rise. Berruex et al. in their book (published in 1980) reported an operative rate of 4.5% while in our current 10-year-long period of study we noted an operative rate of 18.4%. Ward et al. suggested that more than 10% of operatively treated paediatric long bone fractures are tibial shaft fractures [7,13,26,27]. Tibial diaphyseal fractures are usually located in the distal third and if the fibula is intact, shortening will not occur. However, there may be a greater chance of drift into varus, especially in comminuted fractures. Therefore, in these cases operative treatment is advised as well as for malalignment, open fractures, ipsilateral femoral fractures and floating knee. Gordon et al. suggested that adolescent fractures are a relative indication for surgical treatment [3,28].
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Surgical stabilization is ideal when it is able to simply, quickly and repeatedly establish stable and weight bearing fixation and optimal healing. It is also important that fixation should not damage the open physes to prevent growth abnormalities. Flexible intramedullary nailing fits most of these criteria and is used widely [3,4,11–13,18,29,30]. However, it may not provide optimal stability in all cases (e.g. larger body size) thus external fixation is required. Sankar et al. applied external fixation after intramedullary nailing for 7 weeks on average [16]. Goodbody et al. conducted a study of 95 patients (mean age 12.1 years) in which they compared results of TEN nailing in older children with a larger body size (above 50 kgs and 14 years) with younger children with smaller body size and found no significant difference in healing. They also used external fixation after surgery in all the cases. They suggested that flexible intramedullary nailing should not be precluded in older and heavier patients [2]. On the contrary, other authors in their studies of femoral fractures found significantly more complications and worse outcomes in older age, higher BMI and more distal localisation [31,32]. Solid intramedullary nailing, widely used in adults, can be a great alternative in paediatric patients with a larger body size and need for early mobilization. Goodwin et al. conducted a study of 19 unstable fracture cases (mean age 12 ± 3 years) and although they had considered using solid intramedullary nailing in 2 cases due to larger body sizes, they recognized the increased chance of damage to the open physes and decided to use double elastic intramedullary nailing with 4 nails [11]. Nandra et al. used intramedullary nailing in one case in their study of 61 open fracture cases, 36 diaphyseal [15]. Court-Brown et al. performed reamed intramedullary nailing using a hollow, slotted nail in 36 adolescent patients, aged between 13 and 16. Though they used a slightly different insertion method than the standard one which potentially could lead to physeal damage, they found no signs of growth abnormality caused by damage to the physis. However, they suggested using other techniques in patients who still have significant growth potential [21]. Due to reservations about procedures that reach the physis directly, we used solid intramedullary nailing with atypical implant insertion in order to completely spare the open physis. Considering this approach, our method can safely be used in patients with a larger body size and significant growth potential. Atypical insertion, i.e. opening the bone and inserting the nail from the medial side, may be more difficult than usual due to the curve of the bone and the shape of the nail. There is an increased chance of causing damage to the cortical bone. This kind of iatrogenic damage was noted in our first cases. In the following cases, larger (3–5 cm) openings were made that facilitated nail insertion. Later we also modified the bend of the nail and the shape of the head to further reduce the chance of damaging the physis. The possibility of drilling the physis was minimized by altering the position of the locking screws. These adjustments improved our method and made it safe for use in patients with open physes and significant growth potential. During the study we found our average time to fracture union (11.5 ± 2.9 weeks) to be similar to the average of 11.5 weeks published by Court-Brown et al. [21]. Nandra et al. reported an average of 13 weeks to fracture union in open diaphyseal fractures. They compared cases managed by external fixator with elastic nailing and noted significantly longer healing in the external fixation group which they attributed to the complexity of the injuries [15]. Using only elastic nailing, Vallamshetla et al. reported 10 weeks to union, Sankar et al. 11 to 13 weeks and Srivastava et al. 20.4 weeks. Kubiak et al. recorded 7 weeks using elastic nailing and 18 weeks using external fixation [12,13,16,18]. One of the most significant complications after tibial shaft fractures is compartment syndrome with an incidence that varies
Please cite this article as: M. Burkus, F. Tömböl and N. Wiegand et al., Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures, Injury, https://doi.org/10.1016/j.injury.2020.02.049
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widely between studies. It is more frequent in children supposedly due to relative muscular hypertrophy. Having monitored all of our patients regularly, we found no signs of compartment syndrome. This is similar to the findings of Ho et al. about non-operative treatment [9]. Our results are likely due to the relatively low number of cases rather the differences between treatment methods. In contrast, the rate of compartment syndrome was found 4.5% by Goodbody et al., 8% by Srivastava et al., 8.3% by Court-Brown et al. and 32% by Goodwin et al. [2,11,13,21]. McQueen et al. conducted a study of 1388 tibial shaft fracture cases (mean age 39, range 12–98 years) and found the incidence of compartment syndrome to be 11.5% in the whole group and 20% in the age group 12–19 years. They found that young age was the strongest predictor while there was no significant difference in the rate of compartment syndrome in low- or high-energy injury or in open versus closed fractures [33]. Our study noted minor complications, such as superficial infection and wound-healing complication, in 3 cases (19%), which is slightly higher than other studies have shown. The infection rate in elastic nailing was 5% by Vallmashetla et al. and 8% by Srivastava et al. Iobst et al. reported an infection rate of 2.5% in nonoperatively treated open fractures. Nandra et al. noted 6.6% superficial and 4.9% deep infection in 61 open fracture cases [10,12,13,15]. It is assumed that our higher infection rate is due to relatively small number of cases in our study and not to the chance of infection caused by increased tissue damage with our technique. The atypical intramedullary nailing, like elastic nailing, can be done simply and repeatedly from a small incision which reduces the chance of additional tissue damage. It does not damage endosteal circulation because it is unreamed. Intra- and perioperative complications of this method and elastic intramedullary nailing are similar, except implant migration only occurs after elastic nailing [34]. This stable fixation may be started on partial weight-bearing even in early postoperative period depending on the type of the fracture and requires no external fixation. These advantages promote the use of this technique. The present study is limited by its relatively small number of cases and limited experience with the new nail which only allows a restricted evaluation of complications. The results of this study are further limited by the lack of control groups: elastic nailing group and non-operatively treated group, respectively. Conclusion In conclusion, the first-line treatment of paediatric tibial shaft fractures is non-operative treatment, but the rate of operative treatment is rising. The most frequently used method is elastic intramedullary nailing which can also be used in patients with a larger body size. The unreamed locked solid intramedullary nailing described in this study is able to provide physis-sparing and stable fixation with low complication rate and early weight bearing capacity, serving as an excellent alternative. Declaration of Competing Interest All the authors declare no conflict of interest regarding the manuscript of this article. Acknowledgements The authors acknowledge the medical staff of Petz Aladár County Teaching Hospital for their careful and devoted work with all the patients concluded in this study. They also thank Medimetal Company for their help in the development process and manufacturing the atypical implant.
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Please cite this article as: M. Burkus, F. Tömböl and N. Wiegand et al., Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures, Injury, https://doi.org/10.1016/j.injury.2020.02.049
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Please cite this article as: M. Burkus, F. Tömböl and N. Wiegand et al., Physeal-sparing unreamed locked intramedullary nailing for adolescent tibial fractures, Injury, https://doi.org/10.1016/j.injury.2020.02.049