Treatment of femoral shaft fractures in children and adolescents ≥50 kg : Aretrospective multicenter trial

Abstract

Operative treatment of diaphyseal fractures of the femur in older children and adolescents remains controversial due to multiple surgical options and higher complication rates in single-center studies compared to younger children. This retrospective multicenter study aimed to register early and late complications in day-by-day treatment. Sixteenhospitals with particular expertise in pediatric orthopedic trauma participated in this study. Patients with diaphyseal femur fractures, abody weight ≥50 kg (aged 10-16years) and treated between 2008 and 2012 were included. Age, weight, fracture type, and choice of operative treatment were correlated to complication rate and type. Patients with pathologic fractures and/or metabolic bone disorders were excluded. Fifty-threechildren (15females and 38males; mean age: 14.2y [SD 1.4y]; mean body weight: 60.5 kg [max. 95 kg]) with 54fractures were included. Elastic stable intramedullary nailing (ESIN) was the treatment of choice in 31 of 42fractures with open growth plates. In the subgroup with two nails, 7 of 12patients experienced revision surgery due to instability or shortening. Three patients with ESIN and end caps had no complications. In the subgroup with three inserted nails (11patients), one patient was converted to external fixation. Ninepatients received primary or secondary plate osteosyntheses. Within this group, two patients had deep infections; one implant failure, and one peri-implant fracture were recorded. Adolescent lateral femoral nailing (ALFN), when used as the primary treatment option in two patients, was free of complications. When used as asecondary treatment option in three patients, one patient had apseudarthrosis and one an infection. Both were treated in further operative procedures. In agroup of eight patients with closed physes, regular intramedullary nailing as primary or secondary treatment of choice resulted in one locking screw change. As late complications, leg length discrepancy (LLD) over 15 mm (n= 2) and loss of range of motion (ROM) (n= 4; two knee and three hip) were noted in patients receiving multiple revisions or serious postoperative complication. Children older than 10years of age with abody weight ≥50 kg and open physes are prone to complications regardless of treatment choice. Asmaller revision rate occurred in patients treated with ESIN and end caps or athird nail compared to the other treatment options. When physes are closed, rigid intramedullary nailing is the treatment of choice.