- Email: [email protected]
Retrospective, multicenter evaluation of complications in the treatment of diaphyseal femur fractures in pediatric patients
Injury, Int. J. Care Injured 50S4 (2019) S60–S63
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Retrospective, multicenter evaluation of complications in the treatment of diaphyseal femur fractures in pediatric patients$ A. Memeoa , E. Panuccioa , R.D. D’Amatoa , M. Colombob,* , S. Boeroc , A. Andreacchiod , C. Origoe , L. Pedrettif a
Pediatric Orthopaedics and Traumatology Department, G. Pini Institute, Milan, Italy 3 Orthopaedics and Traumatology Unit, G. Pini Institute, University of Milan, Italy Orthopaedics and Traumatology Unit, Surgery Department Istituto Giannina Gaslini, Largo G. Gaslini 5-16100, Genova, Italy d Pediatric Orthopedic Department, Regina Margherita Children's Hospital, Torino, Italy e Pediatric Orthopaedics Department, Ospedale Infantile C. Arrigo, Alessandria, Italy f 2 Orthopaedics Clinic G. Pini Institute, University of Milan, Italy b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 December 2018 Accepted 12 January 2019
Introduction: Femoral shaft fractures are the commonest major pediatric fractures. For generations, traction and casting were the standard method of treatment for children. However, over the past two decades there has been growing recognition of the advantages of fixation and rapid mobilization. Methods: A prospective multicenter study was conducted at four Italian centers of reference for pediatric fractures (January 2005 to December 2014). The study involved 62 patients of both sexes, between 6 and 14 years of age, with closed femoral shaft fractures. The aim was to find out more about the short-term complications of titanium elastic nailing in diaphyseal femur fractures in children in order to reduce them. Results: The commonest complication observed in our study was pain at the nail entry point (24.19%) due to a local inflammatory reaction. After 1 year, 3.22% had limbs of different lengths. Proximal migration occurred in 1.61% of cases. Discussion: Over the last two decades, the treatment of femoral shaft fractures in pediatric patients has developed to include internal fixation using Titanium Elastic Nails (TEN). We only observed a few complications in our study, most of which were minor and associated with the surgical technique employed, particularly during the initial phase of the surgeon’s learning curve. Conclusions: TEN are an excellent internal fixation system if used by an expert surgeon and have a very low rate of complications. None of them produced permanent damage in the patients. In older children weighing more than 50 kg, alternative techniques such as subtrochanteric nailing, plates, or external fixation are advisable. © 2019 Elsevier Ltd. All rights reserved.
Keywords: Femoral shaft fracture Titanium elastic nail Surgical complications Paediatric fracture
Introduction Femoral shaft fractures, together with supracondylar and pertrochanteric fractures, represent approximately 1.6% of all bony lesions in children [1]. The boy-to-girl ratio is 2.6:1 with bimodal distribution. Data from Maryland Hospital reviewed by Hilton at al. confirmed the bimodal distribution with an incidence between 2 and 12 years of age [1]. In the past, skeletal traction and casting were the preferred methods of treatment for femoral shaft fractures in children [2,3].
$
This paper is part of a supplement supported by Club Italiano Osteosintesi. * Corresponding author at: G.Pini 9, 20100 Milan, Italy. E-mail address: [email protected] (M. Colombo).
https://doi.org/10.1016/j.injury.2019.01.009 0020-1383/© 2019 Elsevier Ltd. All rights reserved.
However, this method required a long period of hospitalization. Treatment has changed over the last few years, with the introduction of numerous alternative synthesis methods, including external fixation, plates and screws, and intramedullary nails. These techniques have reduced patient disability and hospitalization costs [4,5]. Despite the new treatment options, there is no evidence in literature of an ideal internal fixation for all diaphyseal fractures in pediatric patients. The perfect device would be an easy internal fixation that allows rapid mobilization, holding the fracture in place until it is consolidated. Titanium elastic nails come closest to this ideal, although they are not without complications [6,7]. This study aimed to find out more about the short-term complications of titanium elastic nailing in femoral shaft fractures
A. Memeo et al. / Injury, Int. J. Care Injured 50S4 (2019) S60–S63
in children in order to reduce morbidity and to compare the findings from our study with the data found in literature. Materials and methods Our retrospective study was conducted in 4 Italian centers of reference for pediatric fractures. 62 children between 6 and 14 years of age were treated at our hospitals between June 2005 and June 2014 for femoral shaft fractures (Figs. 1 and 2 ). Data collected included patient details (age, gender), description of the fracture (type, location, pattern), details of fracture healing with initial Xray and final follow-up X-ray (non-weight bearing, partial and full weight-bearing, return to school) along with presence of any complications: skin irritation, functional limitation, nail migration, limb alignment, rotation, length discrepancy, range of motion of hip and knee, and any other complications. Inclusion criteria were children between 6 and 14 years of age with closed fractures. Exclusion criteria were children <6 and >14 years, pathological fractures, metabolic bone disease, non-ambulatory children, children with neuromuscular disorders, segmental and severely comminuted fractures. No control group was used. After full pre-operative evaluation, all cases had surgery within 10 days (mean 3.6 days). Technique Patients were operated on under general anesthesia, on surgical beds used for traction. The diameter of the nails was chosen in advance by calculating the width of the medullary canal at the narrowest point of the diaphysis and dividing it by three. Before insertion, the tip of the nails had to be bent by around 30 . Before starting surgery, the fracture was set and the medial and lateral entry points were located using two needles as markers under fluoroscopic guidance. The nail insertion points were always distal, with one positioned medially and the other laterally and proximal to the distal femoral physis. A hole in the cortical part of the bone was then
Figs. 1 and 2. Mid- shaft left femural fracture: preoperative x-ray.
S61
created with a sharp tip to facilitate the insertion of the nails in the medullary area of the bone. The nails were then drawn back and their direction changed by twisting them under fluoroscopic guidance to prevent them from sticking on the cortical bone and enable them to get past the fracture. Once the fracture had been properly set, the two nails were pushed until reaching the neck of the femur and the greater trochanter. The two nails were then cut around 1 cm distally from the bone insertion hole (Figs. 3 and 4). Post-operative antibiotics were administered for one day. Suture removal was performed on day fifteen. Postoperative external immobilization was used in 5 cases due to an unstable fracture. This cast also helped to reduce pain and muscle spasms. Gradual mobilization was initiated in the other patients. Children were followed up at 1, 4, 6, and 12 weeks, and 6 months. At each visit, the fracture healing progress was assessed by X-ray and tenderness at the fracture site was determined by clinical examination along with limb alignment, rotation, length discrepancy, range of hip and knee motion, and any other complications. Full weight bearing began when the X-ray revealed soft callus formation at the fracture site. Results 62 patients met the inclusion parameters. They were treated at four Italian pediatric orthopedic and traumatology centers (G. Pini Institute, Milan, Italy; Istituto Giannina Gaslini, Genoa, Italy; Regina Margherita Children's Hospital, Turin, Italy; Ospedale Infantile C. Arrigo, Alessandria, Italy) between June 2005 and June 2014. The mean hospital stay was 5.3 days (2–7 days). Hospitalization was longer in children with other injuries. Our study did not involve any post-operative infections and treatment was bloodless. Our study looked at 40 boys and 22 girls with an average age of 8.5 years (range 6–14) at the time of injury. The commonest mechanism of injury was road traffic accidents (n = 44, 70%) followed by falls from height (n = 18, 30%).
Figs. 3 and 4. Mid- shaft left femural fracture: Immediate post- operative radiograph showing good alignment after fixation with TENS.
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A. Memeo et al. / Injury, Int. J. Care Injured 50S4 (2019) S60–S63
Discussion
Figs. 5 and 6. Mid- shaft left femural fracture:, Removal of TEN after 8 months.
18 children had a proximal diaphyseal fracture, 33 had a mid diaphyseal fracture and 11 had a distal diaphyseal fracture, with both right-sided fractures (58%) and left-sided fractures (42%) being observed. 60% had an oblique fracture, 25% had a transverse fracture and 15% had a spiral fracture. In the 62 children available for evaluation, with a mean followup of 12 months (range 8–24 months), consolidation was first noted on the follow-up X-ray at a mean of 8.3 weeks (range of 6–10 weeks). Nails were removed after a period of between 6 and 8 months (Figs. 5 and 6 ). We observed various minor complications: 15 patients suffered from distal pain at the nail insertion point which resolved after their removal; 3 patients suffered from pressure ulcers; 1 patient experienced distal migration of the nails and had to undergo surgery again to reposition them; 1 patient experienced reduction loss and had to be treated again to set the fracture and establish union; 1 patient experienced proximal migration; after 1 year, 2 patients had hypermetria of the fractured lower limb of more than 1 cm; after 1 year, 1 patient had a case of genu valgum (Table 1). There were no cases of infection or delayed consolidation. In 5 cases, the TEN were removed 2–5 months after the operation, while in the remaining cases they were removed after a period of between 6 and 8 months. Table 1 Complications. COMPLICATIONS
PERCENTAGE
Pain at site of nail insertion Inflammatory raction/bursitis at the entry site Superficial infection Deep infection Knee swelling Knee Stiffness Leg lenght discrepancy Proximal nail migration Angulation exceeding the guidelineast at final follow up Delayed Union Non union
25% 2% 0% 0% 0% 0% 2% 1% 0% 0% 0%
The ideal choice of treatment for femoral shaft fractures in pediatric patients has remained a constant challenge for orthopedists given that the choice of non-operative or operative management is still an open question. According to literature, non-operative management leads to complications such as union defects, joint stiffness, delayed functional recovery in older children, and lengthy hospitalization causing financial hardship for families as well as high hospital bed occupancy rates. These aspects have led to an increase in operative fixation for fractures of this kind [28,29,31]. The TEN is an elastically stable intramedullary nail which works on the principle of the symmetrical bracing action of two nails of the same elasticity, which produces three-point fixation – rotational, axial, and transitional – and bending stability by counteracting the distraction and compression forces acting on the fracture site. The dynamic effect produced by the elastic force of the nails tends to stabilize the fracture itself. The principle of the 3 points of pressure within the canal is always present and the coupling of the two wires tends to counter the bending, twisting, and sliding forces, but not the compression forces. In this study all fractures healed within 8 weeks of fixation with no causes of non-union or delayed union. Children with transverse fractures had a shorter healing time. Oh et al. observed that all 31 fractures in his series healed within 12 weeks with no cases of delayed union [28]. Buechsenchuetz et al. reported that in 42 patients treated with ESIN all fractures healed at a mean of 88 days from injury [29]. Our multicenter study was conducted in highly specialized hospitals. Following our analysis, we highlighted that the most frequent complications of the TEN nailing system are due to surgical technique errors and mainly occur during the initial phase of the surgeon’s learning curve. This reflects findings in literature. Mazda et al., in their study of complications related to technical errors, noticed that in 10 out of 34 patients the nails were too long and this caused the development of painful sacs that restricted knee flexion [10–14]. Lascombes et al. reported that 4% of patients with femoral fractures required surgical revision of the skin at the nail insertion point. Cutting the nails 1 cm distally to the insertion point without bending them can minimize this complication [8– 30]. In 3 cases in which early removal (2–5months) was necessary, we did not observe any refractures despite the advice given in literature that states the nails should not be removed until the fracture is no longer visible and a callus has formed around all the cortical areas on the X-rays. In the two cases of hyper growth, we believe this was caused by the type of fracture. In fact, Ozdemir et al. analyzed this point with CT scans and pointed out that the average increase in length after this type of surgery was 1.8 mm, leading us to believe that this technique is free from pathological hyper growth [14]. The loss of fracture alignment observed in 3 cases was associated with the weight of the child (>50 kg) in 2 cases, while in the other case the deviation was due to the fracture type and intraoperative reduction. This was the only case that required the bone to be set again during surgery. We did not observe any other significant complications such as osteomyelitis, delayed consolidation, or refractures. Fracture geometry, location and nail size are important determinants in terms of surgical outcome. Taking all of these aspects into consideration, our results were generally excellent in comparison to other studies. In Narayanan et al.’s series, the smaller and mismatched nail diameters used in three cases were associated with an increased incidence of varus or valgus angulation and malrotation.
A. Memeo et al. / Injury, Int. J. Care Injured 50S4 (2019) S60–S63
This study had certain limitations, such as not comparing other fixation methods with TEN as the long-term results of this treatment have not yet been reported. Conclusions The use of TEN is increasing because of their advantages and relative lack of complications especially when compared to other fixation methods. TEN is an excellent internal fixation system, which is minimally invasive, safe, physically protective, and relatively easy to use. It is an effective treatment for femoral fractures in properly selected children with minimal complications when utilized by an expert surgeon. In fact most of the complications are due to improper use, which can be eliminated by sticking strictly to the basic principles and technical aspects of this fixation system. We agree with Barry, Paterson and Flynn et al., who recommend titanium elastic nails as the ideal implant for stabilizing many femoral fractures in pediatric patients, avoiding prolonged immobilization and the complications of traction and spica casting [3–30]. We recommend TEN for femoral fractures in children aged 6– 16 years weighing under 50 kg. Alternative surgical techniques would be more appropriate for children weighing more than this. Conflict of interest The authors declare that they have no conflicts of interest concerning this article. No financial support has been received by the authors for the preparation of this manuscript. References [1] Loder RT, O’Donnell PW, Feinberg JR. Epidemiology and mechanisms of femur fractures in children. J Pediatr Orthop 2006;26(September-October (5)):561–6. [2] Catena N, Sénès FM, Riganti S, Boero S. Diaphyseal femoral fractures below the age of six years: results of plaster application and long term followup. Indian J Orthop 2014;48(January (1)):30–4, doi:http://dx.doi.org/10.4103/00195413.125487. [3] Flynn JM, Schwend RM, Flynn JM, Schwend RM. Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;1(September-October (5)):347–59. [4] Kosuge D, Barry M. Changing trends in the management of children’s fractures. Bone Joint J 2015;97-B(April):442–8. [5] Flynn JM, Luedtke LM, Ganley TJ, Dawson J, Davidson RS, Dormans JP, et al. Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children. J Bone Joint Surg Am 2004;86-A(April (4)): 770–7. [6] Bopst L, Reinberg O, Lutz N. Femur fracture in preschool children: experience with flexible intramedullary nailing in 72 children. J Pediatr Orthop 2007;27 (April-May (3)):299–303. [7] Winquist RA, Hansen [55_TD$DIFF]Jr ST, Clawson DK. Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. J Bone Joint Surg Am 1984;66(April (4)):529–39. [8] Ligier JN, Prevot MetaizeauJ, Lascombes P. Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:. [9] Miller DJ, Kelly DM, Spence DD, Beaty JH, Warner [55_TD$DIFF]Jr. WC, Sawyer JR. Locked intramedullary nailing in the treatment of femoral shaft fractures in children younger than 12 years of age: indications and preliminary report of outcomes. J Pediatr Orthop 2012;32(December (8)):777–80.
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[10] Mazda K, Khairouni A, Pennecot GF, et al. Closed flexible intramedullary nailing of femoral shaft fracture in children. Pediatr Orthop B 1997;6(3):198–202. [11] 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 Am 2006;66(May (4)):529– 39. [12] Linhart Wolfgang E, Roposch Andreas. Elastic stable intramedullary nailing for unstable femoral fractures in children: preliminary results of a new method. J Trauma-Injury Infect Crit Care 1999;47(August (2)):372–8. [13] Madhuri V, Dutt V, Gahukamble AD, Tharyan P. Interventions for treating femoral shaft fractures in children and adolescents. Evid Based Child Health 2014;9(December (4)):753–826, doi:http://dx.doi.org/10.1002/ebch.1987. [14] Ozdemir HM, Yensel U, Senaran H, Mutlu M, Kutlu A. Immediate percutaneous intramedullary fixation and functional bracing for the treatment of pediatric femoral shaft fracture. J Pediatr Orthop 2003;23:453–7. [15] Karaman I, Halici M, Kafadar IH, Guney A, Oner M, Gurbuz K, Karaman ZF. Midterm results of the elastic intramedullary nailing in paediatric long bone shaft fractures: a prospective study of 102 cases. J Pediatr Orthop B 2014;23(May (3)):212–20. [16] Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am 2000;82(June (6)):781–8. [17] Bhuyan BK, Mohan Singh S. Titanium elastic nailing in pediatric femoral diaphyseal fractures in the age group of 5-16 years - a short term study. J Clin Orthop Trauma 2014;5(December (4))203–10, doi:http://dx.doi.org/10.1016/j. jcot.2014.08.001 Epub 2014 Sep 26. [18] 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. [19] 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. [20] Sanders JO, Browne RH, Mooney JF. Treatment of femoral fractures in children by pediatric orthopaedics: results of a 1998 survey. J Pediatr Orthop 2001;21:436–41. [21] Clinkscales CM, Peterson HA. Isolated closed diaphyseal fractures of the femur in children: comparison of effectiveness and cost of several treatment methods. Orthpaedics 1997;20:1131–6. [22] Skak SV, Overgaard S, Nielsen JD, Andersen A, Nielsen ST. Internal fixation of femoral shaft fractures in children and adolescents: a ten to twenty one year follow up of 52 fractures. J Pediatr Orthop 1996;5:195–9. [23] Flinck M, von Heideken J, Janarv PM, Wåtz V, Riad J. Biomechanical comparison of semi-rigid pediatric locking nail versus titanium elastic nails in a femur fracture model. J Child Orthop 2015;9(February (1))77–84, doi:http://dx.doi. org/10.1007/s11832-014-0629-5 Epub 2014 Dec 16.PMID:25512158. [24] Heffernan MJ, Gordon JE, Sabatini CS, Keeler KA, Lehmann CL, O’Donnell JC, et al. Treatment of femur fractures in young children: a multicenter comparison of flexible intramedullary nails to spica casting in young children aged 2 to 6 years. J Pediatr Orthop 2015;35(March (2)):126–9. [25] Goyal N, Aggarwal AN, Mishra P, Jain A. Randomized controlled trial comparing stabilization of fresh close femoral shaft fractures in children with titanium elastic nail system versus stainless steel elastic nail system. Acta Orthop Belg 2014;80(March (1)):69–75. [26] Bong Matthew R, Koval Kenneth J, Egol Kenneth A. Bulletin of the NYU hospital for joint diseases. Hist Intramedullary Nailing 2006;64(3 & 4). [27] Barry M, Paterson JM. A flexible intramedullary nails for fractures in children. J Bone Joint Surg Br 2004;86(September (7))947–53 Review. [28] Oh CW, Park BC, Kim PT, Kyung HS, Kim SJ, Ihn JC. Retograde flexible intramedulary nailing in children’s femoral fractures. Int Orthop 2002;26 (1):52–5. [29] Buechsenschuetz KE, Mehlman CT, Shaw KJ, Crawford AH. Immerman EB Femoral shaft fracture in children: traction and casting versus casting versus elastic stable intramedullary nailing. J Trauma 2002;53(5)914–21 [PubMed]. [30] Govindasamy Rajesh, Gnanasundaram Ramkumar, Kasirajan Saravanan, Ibrahim Syed, Joseph Jimmy. Melepuram, elastic stable intramedullary nailing of femoral shaft fracture-experience in 48 children. MS Ortho Arch Bone Jt Surg 2018;6(January (1)):39–46. [31] Tisherman RT, Hoellwarth JS, Mendelson SA. Systematic review of spica casting for the treatment of paediatric diaphyseal femur fractures. J Child Orthop 2018;12(April (2)):136–44, doi:http://dx.doi.org/10.1302/18632548.12.170201.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Retrospective, multicenter evaluation of complications in the treatment of diaphyseal femur fractures in pediatric patients$ A. Memeoa , E. Panuccioa , R.D. D’Amatoa , M. Colombob,* , S. Boeroc , A. Andreacchiod , C. Origoe , L. Pedrettif a
Pediatric Orthopaedics and Traumatology Department, G. Pini Institute, Milan, Italy 3 Orthopaedics and Traumatology Unit, G. Pini Institute, University of Milan, Italy Orthopaedics and Traumatology Unit, Surgery Department Istituto Giannina Gaslini, Largo G. Gaslini 5-16100, Genova, Italy d Pediatric Orthopedic Department, Regina Margherita Children's Hospital, Torino, Italy e Pediatric Orthopaedics Department, Ospedale Infantile C. Arrigo, Alessandria, Italy f 2 Orthopaedics Clinic G. Pini Institute, University of Milan, Italy b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 December 2018 Accepted 12 January 2019
Introduction: Femoral shaft fractures are the commonest major pediatric fractures. For generations, traction and casting were the standard method of treatment for children. However, over the past two decades there has been growing recognition of the advantages of fixation and rapid mobilization. Methods: A prospective multicenter study was conducted at four Italian centers of reference for pediatric fractures (January 2005 to December 2014). The study involved 62 patients of both sexes, between 6 and 14 years of age, with closed femoral shaft fractures. The aim was to find out more about the short-term complications of titanium elastic nailing in diaphyseal femur fractures in children in order to reduce them. Results: The commonest complication observed in our study was pain at the nail entry point (24.19%) due to a local inflammatory reaction. After 1 year, 3.22% had limbs of different lengths. Proximal migration occurred in 1.61% of cases. Discussion: Over the last two decades, the treatment of femoral shaft fractures in pediatric patients has developed to include internal fixation using Titanium Elastic Nails (TEN). We only observed a few complications in our study, most of which were minor and associated with the surgical technique employed, particularly during the initial phase of the surgeon’s learning curve. Conclusions: TEN are an excellent internal fixation system if used by an expert surgeon and have a very low rate of complications. None of them produced permanent damage in the patients. In older children weighing more than 50 kg, alternative techniques such as subtrochanteric nailing, plates, or external fixation are advisable. © 2019 Elsevier Ltd. All rights reserved.
Keywords: Femoral shaft fracture Titanium elastic nail Surgical complications Paediatric fracture
Introduction Femoral shaft fractures, together with supracondylar and pertrochanteric fractures, represent approximately 1.6% of all bony lesions in children [1]. The boy-to-girl ratio is 2.6:1 with bimodal distribution. Data from Maryland Hospital reviewed by Hilton at al. confirmed the bimodal distribution with an incidence between 2 and 12 years of age [1]. In the past, skeletal traction and casting were the preferred methods of treatment for femoral shaft fractures in children [2,3].
$
This paper is part of a supplement supported by Club Italiano Osteosintesi. * Corresponding author at: G.Pini 9, 20100 Milan, Italy. E-mail address: [email protected] (M. Colombo).
https://doi.org/10.1016/j.injury.2019.01.009 0020-1383/© 2019 Elsevier Ltd. All rights reserved.
However, this method required a long period of hospitalization. Treatment has changed over the last few years, with the introduction of numerous alternative synthesis methods, including external fixation, plates and screws, and intramedullary nails. These techniques have reduced patient disability and hospitalization costs [4,5]. Despite the new treatment options, there is no evidence in literature of an ideal internal fixation for all diaphyseal fractures in pediatric patients. The perfect device would be an easy internal fixation that allows rapid mobilization, holding the fracture in place until it is consolidated. Titanium elastic nails come closest to this ideal, although they are not without complications [6,7]. This study aimed to find out more about the short-term complications of titanium elastic nailing in femoral shaft fractures
A. Memeo et al. / Injury, Int. J. Care Injured 50S4 (2019) S60–S63
in children in order to reduce morbidity and to compare the findings from our study with the data found in literature. Materials and methods Our retrospective study was conducted in 4 Italian centers of reference for pediatric fractures. 62 children between 6 and 14 years of age were treated at our hospitals between June 2005 and June 2014 for femoral shaft fractures (Figs. 1 and 2 ). Data collected included patient details (age, gender), description of the fracture (type, location, pattern), details of fracture healing with initial Xray and final follow-up X-ray (non-weight bearing, partial and full weight-bearing, return to school) along with presence of any complications: skin irritation, functional limitation, nail migration, limb alignment, rotation, length discrepancy, range of motion of hip and knee, and any other complications. Inclusion criteria were children between 6 and 14 years of age with closed fractures. Exclusion criteria were children <6 and >14 years, pathological fractures, metabolic bone disease, non-ambulatory children, children with neuromuscular disorders, segmental and severely comminuted fractures. No control group was used. After full pre-operative evaluation, all cases had surgery within 10 days (mean 3.6 days). Technique Patients were operated on under general anesthesia, on surgical beds used for traction. The diameter of the nails was chosen in advance by calculating the width of the medullary canal at the narrowest point of the diaphysis and dividing it by three. Before insertion, the tip of the nails had to be bent by around 30 . Before starting surgery, the fracture was set and the medial and lateral entry points were located using two needles as markers under fluoroscopic guidance. The nail insertion points were always distal, with one positioned medially and the other laterally and proximal to the distal femoral physis. A hole in the cortical part of the bone was then
Figs. 1 and 2. Mid- shaft left femural fracture: preoperative x-ray.
S61
created with a sharp tip to facilitate the insertion of the nails in the medullary area of the bone. The nails were then drawn back and their direction changed by twisting them under fluoroscopic guidance to prevent them from sticking on the cortical bone and enable them to get past the fracture. Once the fracture had been properly set, the two nails were pushed until reaching the neck of the femur and the greater trochanter. The two nails were then cut around 1 cm distally from the bone insertion hole (Figs. 3 and 4). Post-operative antibiotics were administered for one day. Suture removal was performed on day fifteen. Postoperative external immobilization was used in 5 cases due to an unstable fracture. This cast also helped to reduce pain and muscle spasms. Gradual mobilization was initiated in the other patients. Children were followed up at 1, 4, 6, and 12 weeks, and 6 months. At each visit, the fracture healing progress was assessed by X-ray and tenderness at the fracture site was determined by clinical examination along with limb alignment, rotation, length discrepancy, range of hip and knee motion, and any other complications. Full weight bearing began when the X-ray revealed soft callus formation at the fracture site. Results 62 patients met the inclusion parameters. They were treated at four Italian pediatric orthopedic and traumatology centers (G. Pini Institute, Milan, Italy; Istituto Giannina Gaslini, Genoa, Italy; Regina Margherita Children's Hospital, Turin, Italy; Ospedale Infantile C. Arrigo, Alessandria, Italy) between June 2005 and June 2014. The mean hospital stay was 5.3 days (2–7 days). Hospitalization was longer in children with other injuries. Our study did not involve any post-operative infections and treatment was bloodless. Our study looked at 40 boys and 22 girls with an average age of 8.5 years (range 6–14) at the time of injury. The commonest mechanism of injury was road traffic accidents (n = 44, 70%) followed by falls from height (n = 18, 30%).
Figs. 3 and 4. Mid- shaft left femural fracture: Immediate post- operative radiograph showing good alignment after fixation with TENS.
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A. Memeo et al. / Injury, Int. J. Care Injured 50S4 (2019) S60–S63
Discussion
Figs. 5 and 6. Mid- shaft left femural fracture:, Removal of TEN after 8 months.
18 children had a proximal diaphyseal fracture, 33 had a mid diaphyseal fracture and 11 had a distal diaphyseal fracture, with both right-sided fractures (58%) and left-sided fractures (42%) being observed. 60% had an oblique fracture, 25% had a transverse fracture and 15% had a spiral fracture. In the 62 children available for evaluation, with a mean followup of 12 months (range 8–24 months), consolidation was first noted on the follow-up X-ray at a mean of 8.3 weeks (range of 6–10 weeks). Nails were removed after a period of between 6 and 8 months (Figs. 5 and 6 ). We observed various minor complications: 15 patients suffered from distal pain at the nail insertion point which resolved after their removal; 3 patients suffered from pressure ulcers; 1 patient experienced distal migration of the nails and had to undergo surgery again to reposition them; 1 patient experienced reduction loss and had to be treated again to set the fracture and establish union; 1 patient experienced proximal migration; after 1 year, 2 patients had hypermetria of the fractured lower limb of more than 1 cm; after 1 year, 1 patient had a case of genu valgum (Table 1). There were no cases of infection or delayed consolidation. In 5 cases, the TEN were removed 2–5 months after the operation, while in the remaining cases they were removed after a period of between 6 and 8 months. Table 1 Complications. COMPLICATIONS
PERCENTAGE
Pain at site of nail insertion Inflammatory raction/bursitis at the entry site Superficial infection Deep infection Knee swelling Knee Stiffness Leg lenght discrepancy Proximal nail migration Angulation exceeding the guidelineast at final follow up Delayed Union Non union
25% 2% 0% 0% 0% 0% 2% 1% 0% 0% 0%
The ideal choice of treatment for femoral shaft fractures in pediatric patients has remained a constant challenge for orthopedists given that the choice of non-operative or operative management is still an open question. According to literature, non-operative management leads to complications such as union defects, joint stiffness, delayed functional recovery in older children, and lengthy hospitalization causing financial hardship for families as well as high hospital bed occupancy rates. These aspects have led to an increase in operative fixation for fractures of this kind [28,29,31]. The TEN is an elastically stable intramedullary nail which works on the principle of the symmetrical bracing action of two nails of the same elasticity, which produces three-point fixation – rotational, axial, and transitional – and bending stability by counteracting the distraction and compression forces acting on the fracture site. The dynamic effect produced by the elastic force of the nails tends to stabilize the fracture itself. The principle of the 3 points of pressure within the canal is always present and the coupling of the two wires tends to counter the bending, twisting, and sliding forces, but not the compression forces. In this study all fractures healed within 8 weeks of fixation with no causes of non-union or delayed union. Children with transverse fractures had a shorter healing time. Oh et al. observed that all 31 fractures in his series healed within 12 weeks with no cases of delayed union [28]. Buechsenchuetz et al. reported that in 42 patients treated with ESIN all fractures healed at a mean of 88 days from injury [29]. Our multicenter study was conducted in highly specialized hospitals. Following our analysis, we highlighted that the most frequent complications of the TEN nailing system are due to surgical technique errors and mainly occur during the initial phase of the surgeon’s learning curve. This reflects findings in literature. Mazda et al., in their study of complications related to technical errors, noticed that in 10 out of 34 patients the nails were too long and this caused the development of painful sacs that restricted knee flexion [10–14]. Lascombes et al. reported that 4% of patients with femoral fractures required surgical revision of the skin at the nail insertion point. Cutting the nails 1 cm distally to the insertion point without bending them can minimize this complication [8– 30]. In 3 cases in which early removal (2–5months) was necessary, we did not observe any refractures despite the advice given in literature that states the nails should not be removed until the fracture is no longer visible and a callus has formed around all the cortical areas on the X-rays. In the two cases of hyper growth, we believe this was caused by the type of fracture. In fact, Ozdemir et al. analyzed this point with CT scans and pointed out that the average increase in length after this type of surgery was 1.8 mm, leading us to believe that this technique is free from pathological hyper growth [14]. The loss of fracture alignment observed in 3 cases was associated with the weight of the child (>50 kg) in 2 cases, while in the other case the deviation was due to the fracture type and intraoperative reduction. This was the only case that required the bone to be set again during surgery. We did not observe any other significant complications such as osteomyelitis, delayed consolidation, or refractures. Fracture geometry, location and nail size are important determinants in terms of surgical outcome. Taking all of these aspects into consideration, our results were generally excellent in comparison to other studies. In Narayanan et al.’s series, the smaller and mismatched nail diameters used in three cases were associated with an increased incidence of varus or valgus angulation and malrotation.
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This study had certain limitations, such as not comparing other fixation methods with TEN as the long-term results of this treatment have not yet been reported. Conclusions The use of TEN is increasing because of their advantages and relative lack of complications especially when compared to other fixation methods. TEN is an excellent internal fixation system, which is minimally invasive, safe, physically protective, and relatively easy to use. It is an effective treatment for femoral fractures in properly selected children with minimal complications when utilized by an expert surgeon. In fact most of the complications are due to improper use, which can be eliminated by sticking strictly to the basic principles and technical aspects of this fixation system. We agree with Barry, Paterson and Flynn et al., who recommend titanium elastic nails as the ideal implant for stabilizing many femoral fractures in pediatric patients, avoiding prolonged immobilization and the complications of traction and spica casting [3–30]. We recommend TEN for femoral fractures in children aged 6– 16 years weighing under 50 kg. Alternative surgical techniques would be more appropriate for children weighing more than this. Conflict of interest The authors declare that they have no conflicts of interest concerning this article. No financial support has been received by the authors for the preparation of this manuscript. References [1] Loder RT, O’Donnell PW, Feinberg JR. Epidemiology and mechanisms of femur fractures in children. J Pediatr Orthop 2006;26(September-October (5)):561–6. [2] Catena N, Sénès FM, Riganti S, Boero S. Diaphyseal femoral fractures below the age of six years: results of plaster application and long term followup. Indian J Orthop 2014;48(January (1)):30–4, doi:http://dx.doi.org/10.4103/00195413.125487. [3] Flynn JM, Schwend RM, Flynn JM, Schwend RM. Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 2004;1(September-October (5)):347–59. [4] Kosuge D, Barry M. Changing trends in the management of children’s fractures. Bone Joint J 2015;97-B(April):442–8. [5] Flynn JM, Luedtke LM, Ganley TJ, Dawson J, Davidson RS, Dormans JP, et al. Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children. J Bone Joint Surg Am 2004;86-A(April (4)): 770–7. [6] Bopst L, Reinberg O, Lutz N. Femur fracture in preschool children: experience with flexible intramedullary nailing in 72 children. J Pediatr Orthop 2007;27 (April-May (3)):299–303. [7] Winquist RA, Hansen [55_TD$DIFF]Jr ST, Clawson DK. Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. J Bone Joint Surg Am 1984;66(April (4)):529–39. [8] Ligier JN, Prevot MetaizeauJ, Lascombes P. Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br 1988;70:. [9] Miller DJ, Kelly DM, Spence DD, Beaty JH, Warner [55_TD$DIFF]Jr. WC, Sawyer JR. Locked intramedullary nailing in the treatment of femoral shaft fractures in children younger than 12 years of age: indications and preliminary report of outcomes. J Pediatr Orthop 2012;32(December (8)):777–80.
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