Elastic Stable Intramedullary Nailing Research Articles

Use of flexible nails in children diaphyseal fractures. Five questions and answers

Introduction More than 40 years after the launch of elastic stable intramedullary nailing (ESIN) as a golden standard of the treatment of some fractures in children and adolescents. Material and methods This review is based on answers to five essential questions: The position of ESIN compared with other methods of treatment; The choice of the implants; The indications for ESIN today; How to avoid complications as much as possible? Do we remove the implants or not? Results The aspects of biomechanics, design, indications for ESIN in comparison to other treatment, surgical techniques depending on fractured bones, complications are presented in the article. Conclusion ESIN is an excellent method to fix long bone fractures in children and adolescents. Top one is definitively the fractures of both bones of the forearm, then the diaphyseal fractures of the femur and the tibia before the age to be eligible for a locking nail. However, some unstable fractures cannot be treated conservatively or with a locking nail, and an ESIN remains unstable. In these cases, we are allowed to propose to add an external fixator for 4 to 6 weeks, waiting for a good stabilisation of the fracture.

The advent of elastic stable intramedullary nailing for the treatment of long bone fractures in skeletally immature patients

Introduction Management of pediatric long bones fractures is a complex and rapidly evolving field. Traditionally, casting and conservative techniques played a key-role in the management of fractures in skeletally immature patients. However, the surgical approach has evolved steadily over the past four decades or so and increasing evidence has been published supporting the advantages of fixation techniques over conservative methods. The purpose of this narrative review is to outline how innovations in orthopedic surgery have changed the rationale of treating long bones fractures in children and adolescents with focus on surgical techniques, particularly elastic stable intramedullary nailing (ESIN). Material and methods We aimed to describe the main trends in pediatric long bones fractures management and to identify its specificities and difficulties as well as the best standard of care. Results The introduction of ESIN has profoundly influenced the management of pediatric upper and lower extremity fractures. Overall, in comparison to conservative techniques, advantages of ESIN include minimally invasiveness, short hospital stay, primary bone union, early mobilization and progressive weight bearing, and good outcome with low complication rate. Moreover, the flexible nail can be used as a closed reduction tool itself. Conclusions Irrespective of the technique performed, the key-concepts remain 1) the proper understanding of the injury to treat; 2) the identification the main characteristics of the patient; 3) the pros and cons of each technique; and 4) the potential complications.

Elastic Stable Intramedullary Nailing Femoral Shaft Fractures in Children from Six to Ten Years Age

Background: Diaphyseal fractures of the femur (DFF) are common long-bone injuries in children and adolescents. DFF represent 1.5% of fractures in childhood. Objective: This study aimed to evaluate the clinical, functional and radiological outcome of femoral shaft fractures, which are managed by elastic stable intramedullary nailing (ESIN) in pediatric age 6-10 years. Patients and Methods: A prospective clinical randomized trial study was conducted on18 children underwent elastic stable intramedullary nailing (ESIN) for treating femoral shaft fractures at Orthopedic department, Zagazig University Hospitals during the period from April to December 2020. Plain X- rays of the femur Antero-posterior (AP) & Lateral (Lat.) views (from hip to the knee joint) was taken. Results: The time to surgery was 1.39 ± 1.12 days ranging from 1 to 6 days, the time till full union was 9.4 ± 1.76 weeks ranging from 7 to 12 weeks, more than half of the studied group (55.5%) ranged from 7 to 9 weeks and the time of full weight bearing was 9.6 ± 1.7 weeks ranging from 7 to 12 weeks, half of the studied group (50.0%) ranged from 7 to 9 weeks. So, the final outcome was 83.3% had excellent functional outcome, 11.1% of them had satisfactory functional outcome and 5.6% had poor functional outcome. 88.8% didn’t have any complications, 5.6% of them had irritation and 5.6% had superficial infection. Conclusion: ESIN is the choice treatment for transverse and short oblique shaft fractures in patients aging from 6 to 10 years old.

Fixation of Displaced Midshaft Clavicular Fracture in Adult by Intramedullary Elastic Rod

Background: Intramedullary elastic rod fixation of midshaft clavicular fracture results in rapid free movement of the shoulder and an earlier return to daily activities than the conservative treatment. In comparison with plate fixation, the procedure is less invasive, with no loss of fracture haematoma, rapid union, and less infection. No major surgery for removal with less injury to surrounded neurovascular structures. A smaller incision is required with superior cosmesis. Objective: To study the short-term results of treatment of displaced fractures of the middle third of the clavicle using percutaneous elastic intramedullary nails Patient and Methods: This prospective study was carried out on twenty patients with displaced fractures of the middle third of the clavicle presented to the Hospital and treated by percutaneous elastic intramedullary rod between November 2019 and May 2020. Results: At the end of the follow-up period, the mean score was 89.70 ± 13.55 ranging from 48 to 100 according to the modified Constant and Murley shoulder score. Fourteen patients (70%) had excellent results, four patients (20%) had good results, one patient (5%) had a fair result, and one patient (5%) had a poor result. Conclusion: Elastic stable intramedullary nailing (ESIN) is an image dependant procedure indicated best for young medically free patients with acute simple 2 part middle third clavicle fracture. Delay in surgery may necessitate open reduction. Hammering is not recommended to avoid dorsolateral cortex perforation.

Radiological and functional outcomes of modified Metaizeau technique in displaced radial neck fractures

The management of displaced radial neck fractures in children is still a controversial topic. The objective of this study is to examine the outcomes of modified Metaizeau technique in the children with displaced radius neck fractures. The retrospective study included 15 children with displaced radial neck fracture with an angulation of more than 30° who were managed with the use of leverage technique by mosquito clamps and internal fixation with elastic stable intramedullary nailing (ESIN). Radiological and functional assessments were performed during follow-up. Additionally, the patients were evaluated using Mayo Elbow Per- formance Score (MEPS). All the children could be managed with clamp-assisted closed reduction. The average duration of follow up was 25.5 ± 6.1 months (15-36 months). An excellent elbow function was achieved in all but one patient. Based on Metaizeau classification, excellent, good, fair, and poor outcomes were achieved in 11, 1, 2, and 1 patients, respectively. The average postoperative MEPS score was 98.7 ± 5.1 (80-100). Clamp-assisted closed reduction and fixation with ESIN is a good choice in the children with displaced radial neck fractures. This technique is associated with good functional and radiologic outcomes in the medium-term. Further studies are warranted with larger sample sizes.

Which is the better choice for open tibial shaft fracture in overweight adolescent with open physis: A comparative study of external fixator plus elastic stable intramedullary nail versus external fixator alone

PurposeTo compare the clinical outcomes of external fixator + elastic stable intramedullary nail (EF+ESIN) vs. external fixator (EF) in the treatment for open tibial shaft fracture in overweight adolescents. MethodsPatients of open tibial shaft fractures younger than 14 years old with body weight over 50 Kg treated with EF + ESIN or EF at our institute from 2010 to 2018 were reviewed. Patients with Gustilo Type III open fractures, pathological fractures, previous fracture or instrumentation in the operative leg were excluded. Baseline information and clinical data were collected from the hospital database and during out-patient visits. ResultsForty-six patients, including 27 males and 19 females, were included in the EF group, whereas 35 patients, including 18 males and 17 females, were included in the EF + ESIN group (p = 0.527). The incidence of superficial infection was higher in the EF group (26/46, 56.5%) than the EF + ESIN group (12/35, 34.3%), p < 0.001. The frontal and sagittal angulation was higher in the EF group (p < 0.001), but the degrees in both groups were within the acceptable range. The union time was longer in the EF group (68.0 ± 12.7, d) than the EF + ESIN group (61.9 ± 11.9), p < 0.001. The retaining of EF (11.9 ± 3.2, w) was longer in the EF group than the EF +ESIN group (5.7 ± 1.2, w), p < 0.001. ConclusionEF+ESIN is a safe and alternative choice for selected overweight adolescents with open tibial shaft fracture.

Complication rate after femoral shaft fractures in childhood and adolescence depending on patient factors and treatment measures

HintergrundDie Behandlung der Femurschaftfrakturen bei Kindern war in den letzten Jahren einem zunehmenden Wandel unterzogen. Die früher dominierenden Therapieverfahren wurden durch minimal-invasive Techniken (z. B. elastisch stabile intramedulläre Nagelung [ESIN]) weitgehend abgelöst. Ziel der vorliegenden Studie war der Vergleich der Komplikationsraten in Abhängigkeit sowohl von Patientenfaktoren als auch von verschiedenen Behandlungsverfahren.Material und MethodenBei der vorliegenden Arbeit handelt es sich um eine retrospektive röntgenmorphometrische Datenauswertung. Es wurden die Patientenakten und Röntgenbilder von 101 Kindern, die an zwei Level-I-Traumazentren behandelt wurden, ausgewertet.ErgebnisseIn 19 % der Fälle wurde eine konservative Therapie durchgeführt. Bei den operativen Verfahren dominierte die ESIN-Technik (n = 60). Revisionspflichtige Komplikationen fanden sich nach konservativer Therapie bei ca. 10 % der Kinder. Bei den operativ behandelten Kindern musste in über 6 % der Fälle eine Revisionsoperation durchgeführt werden. Die ESIN-Stabilisierung zeigte bei den operativen Verfahren mit ca. 3 % die niedrigste Revisionsrate. Wurden im Verhältnis zum Markraumdurchmesser zu dünne ESIN-Drähte verwendet, so zeigte sich eine um 30 % höhere Komplikationswahrscheinlichkeit. Bei Kindern unter 3 Jahren und Adoleszenten war die Komplikationswahrscheinlichkeit erhöht.DiskussionIn der durchgeführten Studie zeigt sich ein moderates Komplikationsrisiko bei der Behandlung von Femurschaftfrakturen bei Kindern. Das Komplikationsrisiko nach Fixateur-externe-Anlage und konservativer Behandlung war in dieser Studie am höchsten. Die ESIN-Technik zeigt insgesamt das geringste Komplikationsrisiko. Die vorliegende Arbeit konnte die bekannten Limitationen der ESIN-Technik in Abhängigkeit von Alter und Gewicht bestätigen.

The elastic stable intramedullary nails as an alternative treatment for adult humeral shaft fractures.

Plate and locked intramedullary nailing for humeral fractures are golden standard procedure, but the humerus is a nonweight-bearing bone and can tolerate a larger range of acceptable alignment. We believe the elastic stable intramedullary nails (ESINs) can provide enough relative stability for humeral shaft fractures in certain adult patients. There are four new indications for using ESINs: (1) patient could not tolerate a sugar-tong splint but was a high risk for general anesthesia, (2) intramedullary canal narrowing (<7 mm), (3) long spiral or oblique fracture over the metadiaphyseal junction, and (4) obesity. All patients received retrograde fixation with two titanium elastic nails, except for one patient with a long spiral fracture over the proximal metadiaphysis. Patients had routine follow-up plain radiographs until bone union, and we evaluated functional results of patients by Mayo Elbow Performance Score and asked to complete Quick Disabilities of the Arm, Shoulder and Hand score at the last outpatient clinic visit. A total of 16 patients with a mean age of 54.4 years were included. The mean follow-up time was 14 ± 2.5 months, and the average time to bone union was 16 ± 4.3 weeks. There were no wound infections, loss of reduction, fracture nonunion, implant failure, or skin irritation expect for one nail back-out because of osteoporosis. We have reported good results using ESINs for the displaced fractures of the humerus in the four indication adults who would not be able to tolerate plate fixation or intramedullary nailing. The ESINs fixation method is a simple procedure that provides a small incision, minimal blood loss, short surgical time, and relative stability fixation.

Health-related quality of life after conservatively and surgically-treated paediatric proximal humeral fractures.

PurposeThe health-related quality of life (HRQoL) after conservatively versus surgically treated paediatric proximal humeral fractures is poorly understood. We assessed the HRQoL after this injury and asked if HRQoL was associated with age, radiological classification or treatment chosen.MethodsWe identified 228 patients who were treated for proximal humeral fractures between 2004 and 2017. These patients completed the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) (primary outcome), the Paediatric Quality of Life Inventory (PedsQL) and questions regarding patient satisfaction. Fractures were classified radiologically following the Paediatric Comprehensive AO Classification.ResultsWe were able to follow-up on 190 children; 147 (mean age 8.7 years (0.8 to 15.7)) sustained a metaphyseal and 43 (mean age 11.6 years (3.7 to 15.8)) sustained a Salter Harris type I or II injury. Most fractures (90%) were simple, 10% were multifragmentary. In total, 137 children (72%) were treated nonoperatively, 51 (27%) were treated by elastic stable intramedullary nailing (ESIN). After a median follow-up of 7.6 years (0.8 to 14.3) there was an overall mean Quick-DASH of 4.3 (SD 9.3) for girls and 1.2 (SD 3.1) for boys. The mean function score of the PedsQL was 94.7 (SD 11.1) for girls and 98.0 (SD 6.0) for boys. The mean psychosocial score of the PedsQL was 92.0 (SD 11.1) for girls and 94.1 (SD 11.6) for boys. Most children (79%) were very satisfied with the cosmetic result and 74% were very satisfied with the treatment overall. Surgery and female sex were associated with lower satisfaction.ConclusionIn this cohort of 190 patients, where immobilization for mildly displaced fractures, and closed reduction and ESIN was used for displaced fractures, there was equally excellent mid- and long-term HRQoL when assessed by the Quick-Dash and the PedsQL.Level of EvidenceTherapeutic, Level IV

Elastic stable intra-medullary nailing (ESIN) in management of fracture clavicle

Back ground:Clavicle fractures accounting for 2.6 to 10 % of all adult fractures are usually treated non-operatively. There is an increasing trend toward their surgical fixation. The aim of our study was to investigate the outcome following titanium elastic stable intramedullary nailing (ESIN) for midshaft clavicular fractures.Materials and Methods:A total of 20 patients, which met inclusion criteria, were reviewed retrospectively. There were 14 males and 6 females. The mean age was 37.5 years. 60% of the patients were polytaumatized. The patients were assessed for clinical/radiological union and by Oxford Shoulder and QuickDASH scores. 40% patients required open reduction.Results:90% union was achieved at average of 11.3 weeks. The average follow-up was 6 months. The average Oxford Shoulder and QuickDASH scores were 43.5.6 and 8.5, respectively. No cases of nail migration were reported.Conclusion:In our hands, ESIN is safe and minimally invasive with good patient satisfaction, cosmetic appearance, and early return to daily activities. considering cosmesis the ESIN has much more superior outcome when compared to fixation by plate and screws.

Fractures of the proximal radius in children: management and results of 100 consecutive cases

IntroductionPediatric radial neck and head fractures are rare, accounting for only 1% of all fractures in children. The aim of this study is to describe the management and results of the respective fracture types and different injury characteristics.Materials and methodsThis study performs a retrospective data analysis of 100 consecutive patients with a fracture of the proximal radius treated in a single high-volume pediatric trauma center.ResultsOne hundred patients [mean age 7.5 years (1–15)] were documented with a fracture of the proximal radius between 3/2011 and 12/2019. The gender distribution was 62 girls and 38 boys. Twenty-seven patients had concomitant injuries. Conservative treatment was performed in 63 patients (Judet I = 27; II = 30; III = 6; Mason I = 2) using an above-the-elbow cast for 21 days (6–35). Surgical treatment was performed in 37 patients (Judet II = 3; III = 22; IV = 5; V = 7) using elastic stable intramedullary nailing (ESIN). Open reduction was necessary in five cases, and additional immobilization was performed in 32 cases. Six complications occurred: loss of implant stability (n = 2), healing in malalignment, pseudarthrosis, radioulnar synostosis, and a persisting hypoesthesia at the thumb. As a result, two ESIN osteosynthesis were revised, and one radial head resection was performed. Loss of movement was seen in 11% of cases, overall Mayo elbow performance index (MEPI) was 99.8 (90–100), and none of the patients experienced negative impacts on activities of daily life.ConclusionsProximal radial fractures occur predominately without dislocation. Good results are obtained with conservative treatment throughout. In cases with displacement exceeding growth-related correction, ESIN is the undisputed treatment of choice. Open surgery and long immobilization periods should be avoided whenever possible.

Comparison of two methods in the treatment of congenital pseudarthrosis of clavicle: multicenter experience

BackgroundCongenital pseudoarthrosis of the clavicle (CPC) is an uncommon entity. Owing to its scarce presentation, treatment of this disorder has not been well established. This study aimed (1) to compare surgical treatment methods that included excision of pseudoarthrosis and iliac crest bone graft and fixate with either the elastic stable intramedullary nail (ESIN) or K-wires or plate and screws, and (2) to assess the clinical outcomes of two different surgical methods.MethodsA multi-central retrospective study was performed between 2013 and 2017 in four tertiary teaching hospitals. Fifteen clavicles of 11 children were identified as CPC. All patients underwent pseudarthrosis resection and iliac crest bone autograft. They were divided into two groups as per the surgical treatment they underwent—plate stabilization as group A and elastic stable intramedullary nailing (ESIN) or K-wires as group B. Nine clavicles in 6 patients in group A and 6 clavicles in 5 patients in group B, were included. The Quick Disabilities of the Arm and Shoulder (QuickDASH) score was used to assess patients’ satisfaction and function following treatment at each follow-up.ResultsThere were eight boys and three girls, with an average age of 4.7 years. All patients, except one with intellectual impairments, had radiological healing. Implant removal time was significantly shorter in group B compared to group A. No statistically significant differences existed in terms of age at surgery, time of radiological healing, complication, and clinical outcome between different groups.ConclusionSurgical resection of pseudoarthrosis with an iliac crest bone graft was an effective means of surgical treatment in CPC. However, ESIN or K-wires can achieve shorter union time compared to the plate. Hence, surgical treatment is recommended for congenital pseudarthrosis of clavicular in pediatric patients.Level of evidenceRetrospective comparative study; Level III

Clinical Efficacy of Minimally Invasive Elastic Stable Intramedullary Nailing for Limb Long Bone Fractures in Children.

ObjectiveThe aim of the present paper was to investigate the clinical efficacy of minimally invasive elastic stable intramedullary nailing (ESIN) for long bone fractures in children.MethodsA total of 350 children with limb fractures from June 2012 to June 2018 were recruited and randomized into two groups: an ESIN group (n = 175) treated with elastic stable intramedullary nailing, and an MPIF group (n = 175), treated with metal plate internal fixation. Both groups received the same physical examination and routine medication. Operation related indexes, clinical efficacy, complications, and postoperative quality of life scores were analyzed and compared.ResultsThe operation time, intraoperative blood loss, hospitalization time, and fracture healing time in the ESIN group were 43.74 ± 4.96 min, 8.14 ± 1.34 mL, 5.97 ± 1.88 days, and 55.89 ± 5.61 days, respectively, which were all significantly less than those in the MPIF group (all P < 0.001). In terms of common complications after limb fracture treatment, there were 6 cases of osteomyelitis, 5 cases of skin irritation response, and 7 cases of inflammatory granuloma in the MPIF group. There were 2 cases of skin irritation response and 5 cases of inflammatory granuloma in the ESIN group. The incidence of postoperative complications in the ESIN group was 4.00%, which was significantly lower than that in MPIF group (10.29%) (P < 0.05). The effective rate for recovery condition in the ESIN group (93.71%) was significantly higher than that in the MPIF group (P < 0.001). The quality of life scores after treatment in both groups were improved, while the score in the ESIN group was significantly higher than that in the MPIF group (79.43%) (P < 0.001). The postoperative satisfaction rate in the ESIN group (94.29%) was significantly higher than that in the MPIF group (86.29%) (P < 0.05). The quality of life scores after treatment in both groups were improved, while the score in the ESIN group was significantly higher than that in the MPIF group (P < 0.001). The postoperative satisfaction rate and the acceptance rate for adjacent joint function in the ESIN group (100%) were significantly higher than those in the MPIF group (92.00%) (P < 0.0001).ConclusionElastic stable intramedullary nailing is a minimally invasive procedure for long bone fractures in children. It can effectively improve the operation‐related indicators and postoperative quality of life and reduce the incidence of complications.

English

BACKGROUND Diaphyseal fractures of the forearm are one of the common fractures in the paediatric population. Closed reduction and cast immobilisation remain the standard treatment for paediatric diaphyseal forearm fractures owing to their unique remodelling potential. The main concern of conservative management is re-displacement of fracture in cast resulting in the unacceptable angular deformity in the forearm. Intramedullary fixation with titanium elastic nails for paediatric diaphyseal forearm fractures is becoming the trending surgical technique in those cases that warrant surgical intervention. The purpose of this study was to evaluate the functional outcome of the management of fracture of both bones forearm in the older children with titanium elastic nailing system. METHODS This was a prospective study done among thirty patients aged 5 to 16 years admitted to the Department of Orthopaedics at GEMS &amp; Hospital, Ragolu, Srikakulam with diaphyseal fractures of both bones forearm from September 2017 to September 2019. We treated the patients by closed / open reduction and internal fixation with elastic stable intramedullary nailing. The patients were followed-up for six months. RESULTS We evaluated the patients clinically and radiologically after surgery. We assessed the outcome using modified Anderson’s AO criteria for forearm fractures extracted from the international journal of current pharmaceutical and clinical research functions. All fractures united at an average of 9.1 weeks without any delayed or non-union. The results were excellent in 86.6 % of patients and good in 13.3 % of patients without significant complications. There were minor complications in 6 patients (20 %). CONCLUSIONS Titanium elastic intramedullary nailing is a safe, effective and minimally invasive surgical method for treatment of displaced both bones forearm diaphyseal fractures in older children. This technique gives relative stability with a three-point fixation principle resulting in secondary bone healing by promoting early callus, ideal for early mobilisation. The technique offers several advantages, including minimal incision, preservation of fracture haematoma, dynamic axial stabilisation, and shorter hospitalisation. KEYWORDS Both Bone Fracture Forearm, Titanium Elastic Nailing System, Early Mobilisation

National trends in the treatment of femur fractures in the preschool population: Age and geography play a role

BackgroundSpica casting and elastic stable intramedullary nailing (ESIN) are options for diaphyseal femur fractures in preschool-age children (ages 3-6 years). Clinical practice guidelines (CPG) are only of moderate or limited strength, which may lead to variation in practice. The purpose of this study is to analyze the epidemiology of children undergoing these procedures in the United States. MethodsThe Pediatric Health Information System, a national database consisting of 49 children's hospitals, was queried for patients between the ages of 3 and 6 years undergoing spica casting or ESIN for a diaphyseal femur fracture between 2011 and 2017. Non-diaphyseal fractures, subjects with associated syndromes or neuromuscular disorders, and pathologic fractures were excluded. Census guidelines were used to categorize hospitals geographically into regions and divisions. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders. ResultsAnalysis included 4059 subjects. Spica casting was performed in 2878 children (71%) and ESIN in 1181 (29%). The median age of those undergoing spica casting was 3.0 years [interquartile range (IQR) 1 year] compared to 5.0 years for ESIN (IQR 2 years; p<0.01). When adjusting for covariates in a multivariate model, each year of increasing age resulted in 4.4 times higher odds that ESIN would be performed (95% CI 4.0-4.8, p<0.01). Compared to the Northeast, a child in the Midwest had 3.6 times higher odds of undergoing ESIN rather than spica casting (95% CI 2.6-5.1, p<0.01). Age at time of ESIN was lowest in the Midwest and highest in the Northeast (4.8±1.0 versus 5.3±0.9 years; p<0.01). There was no variation in the ratio of spica casting to ESIN performed in this age group between 2011 and 2017, including after release of the 2015 CPG. ConclusionsIn the United States, there is substantial variation in the chosen treatment for diaphyseal femur fractures in preschool-age children. ESIN is more likely to be chosen for older children. It is also most likely to be performed in the Midwest and least likely in the Northeast. These findings may have implications in terms of cost and resource utilization and suggest the need for more clinical data to guide surgical indications.

Determining the development stage of the ossification centers around the elbow may aid in deciding whether to use ESIN or not in adolescents’ forearm shaft fractures

Background and purpose — Elastic stable intramedullary nailing (ESIN) is the preferred method of operative stabilization of unstable pediatric forearm shaft fractures. However, the decision whether to use ESIN or open reduction and internal fixation (ORIF) in older children or teenagers is not always straightforward. We hypothesized that the development stage of the elbow would aid in evaluating the eligibility of the patient for ESIN. Patients and methods — All eligible children, aged <16 years who were treated with ESIN in Oulu University Hospital, during 2010–2019 were included (N = 70). The development stages of 4 ossification centers were assessed according to the Sauvegrain and Diméglio scoring. The proportion of impaired union vs. union was analyzed according to bone maturity, by using the optimal cutoff-points determined with receiver operating characteristics (ROC). Results — Development stage ≥ 6 in the olecranon was associated with impaired union in 20% of patients, compared with none in stages 1–5 (95% CI of difference 8% to 24%). Trochlear ossification center ≥ 4 was associated with impaired union in 17% of patients (CI of difference 7% to 36%) and lateral condyle ≥ 6 in 13% of patients (CI of difference 3.4% to 30%). Proximal radial head ≥ 5.5 was associated with impaired union in 18% of patients (CI of difference 7% to 39%). Interpretation — Recognizing the rectangular or fused olecranon ossification center, referring to stage ≥ 6, was in particular associated with impaired fracture healing. This finding may aid clinicians to consider between ESIN and plating, when treating forearm shaft fracture of an older child or teenager.

Reliability of RUST and modified RUST scores for evaluation of union in pediatric and adult femoral shaft fractures.

This study aimed to determine the reliability levels of the radiographic union scale for tibial fractures (RUST) and the modified version of the system, mRUST, for femoral shaft fractures in pediatric and adult patients and to evaluate the value of the scores for total and each cortex in the decision making on fracture union. A total of 15 orthopedic surgeons scored the radiographs of 24 pediatric and 24 adult patients with femoral shaft fractures that were obtained at 0, 4, 8, 12, and 16 postoperative weeks treated with elastic stable intramedullary nail in pediatric patients and locked intramedullary nail in adult patients using the RUST and mRUST scores. Intra-class correlation coefficient (ICC) was used in the evaluation of reliability of the RUST and mRUST scores. The Fleiss kappa (k) coefficient was used in the agreement between evaluators regarding union decision (united or non-united). The thresholds for RUST and mRUST for radiographic union decision were determined. Receiver operating curves were created to evaluate the contribution of total and individual cortical scores in the decision of united or non-united. Intra- and inter-rater reliabilities of mRUST (ICC: 0.92 and 0.86, respectively) were slightly higher than those of RUST (ICC: 0.81 and 0.77, respectively) with perfect intra- and inter-rater reliabilities for RUST (ICC: 0.92 and 0.90, respectively) and mRUST (ICC: 0.88 and 0.83, respectively) in pediatric patients and substantial intra- and inter-rater reliabilities in adult patients (ICC: 0.80 and 0.76, respectively, for mRUST, and 0.76 and 0.71, respectively, for RUST). At each time point, the mean mRUST and RUST scores were higher for pediatric fractures (p<0.001). The Fleiss k coefficient for union decision was perfect for pediatric fractures (0.88) and substantial for adult fractures (0.79). The total mRUST score had a higher predictive value of union than the total RUST score (area under the curve: 0.984 vs. 0.922 in adult fractures and 0.990 vs. 0.943 in pediatric fractures). A RUST score of ≥10 and mRUST score of ≥12 were excellent predictors of fracture union. Fracture union of simple two-part pediatric and adult femoral shaft fractures treated with intramedullary fixation can be reliably assessed using the RUST and mRUST scores. The diagnostic value of the mRUST score is more evident in adult fractures. Level II, Diagnostic Study.

Associated injury complicated by pediatric lower limb shaft fractures and clinical efficacy of flexible stainless-steel intramedullary nailing in children less than 15 years old.

Although pediatric lower limb shaft fractures are common, little is known about associated injuries. The purpose of this study was to examine associated injuries complicated by pediatric lower limb shaft fractures and the efficacy of surgical treatment using a flexible stainless-steel intramedullary Ender nail in children less than 15 years old. This is a retrospective review of 29 children younger than 15 years old who were diagnosed with femoral or tibial shaft fractures and treated using Ender nails from 2005 to 2016. Baseline data, etiology, associated injuries, fracture site and patterns, operative and post-operative assessment were evaluated. The average age of the patients was 9.0 years, and mean follow-up was 18.2 months. Eleven patients (79%) had associated injury. At the final follow up, six patients (43%) sustained complications associated with the insertion area of the nail. There was no evidence of deep infection or nonunion at either fracture site. The clinical results were excellent in 10 (67%) fractures, and good in 5 (33%) fractures, based on the modified Flynn criteria. Almost all patients with a femoral fracture had an associated injury including abdominal visceral injury, cerebral contusion or other fractures. This study indicated good clinical and functional outcomes. On the other hand, the minor complications rate was high. Nevertheless, elastic stable intramedullary nailing recently has become available in Japan, and a prospective and comparative study is needed.

Physeal-Sparing Rigid Intramedullary Nailing in Adolescent Tibial Shaft Fractures: A Pilot Study.

Purpose: Elastic stable intramedullary nailing (ESIN) and open reduction internal fixation (ORIF) are literature-supported operative treatments for displaced tibial shaft fractures in skeletally immature patients. Very little is written about rigid intramedullary nails (RIMNs) in adolescents. Our purpose is to describe a physeal-sparing, reamed, locked RIMN technique for adolescent tibial shaft fractures and report its safety.Methods: Adolescent patients with tibial shaft fractures indicated for operative intervention at one institution were retrospectively identified from 2011-2018. Patients were classified based on method of fracture fixation. Primary outcomes included fracture union, reoperation, and complication rates.Results: Thirteen patients were included in the RIMN arm, with an average age of 13.8 years. Two patients in the observational group underwent ESIN and seven patients underwent ORIF, with an average age of 11.5 years. Significant differences were found between time of immobilization (28 days vs 121 days), time to touch down weight bearing release (1 day vs 34 days), and hardware pain (2/13 vs 7/9). The RIMN group sustained fewer reoperations (2/13 vs 5/9). No differences were found in rates of complications or fixation failure between groups.Conclusions: Based on our small pilot study, RIMNs in adolescents should be considered as a potential treatment option when a physeal-sparing distal start point is utilized. Additionally, short-term follow-up suggests safety. Patients who underwent the RIMN procedure required fewer reoperations compared with the observational group. Overall, fracture healing was similar across the two groups. The benefits of RIMN include early immobilization and improved weight-bearing profile.Level of Evidence: IV.

Does the management of osteofibrous dysplasia of the tibia and fibula in children should be tailored to the extent and location of the lesion? A case control study investigating different surgical options

BackgroundOsteofibrous dysplasia (OFD) is a rare non neoplastic, self-limited intracortical fibro-osseous lesion that most commonly affects the diaphysis of the tibia and fibula of children, the best treatment is still debated. Therefore we performed a retrospective study in children mostly under 10 years old with OFD aiming to determine whether early surgery is necessary and which is the best treatment. HypothesisSymptomatic OFD lesions should be treated proactively, and appropriate treatment can achieve favorable outcome. MethodsWe retrospectively reviewed 23 patients with OFD of the tibia (n=22) and fibula. Management varied according to the severity of symptoms (deformity, pain or pathological fracture) and the extent of the lesion. Cases were divided into four groups (Gr.): Gr. 1: observation (n=4); Gr. 2: curettage and allograft (n=6); Gr. 3: curettage, allograft and elastic stable intramedullary nailing (ESIN) fixation (n=9); Gr. 4: extra-periosteal resection and bone transport (n=5). One patient received two different treatments successively (23 patients and 24 cases). All patients had regular clinical and radiographic follow-up to assess bone consolidation and complications. ResultsIn Gr. 1, four asymptomatic patients underwent observation after open biopsy. Gr. 4 had the lowest local recurrence rate: 0 cases (0%) vs. 4 (66.7%; Gr. 2) vs. 1 (11.1%; Gr. 3) (p=0.002), incidence of deformity: 0 case (0%) vs. 0 (0%; Gr. 2) vs. 3 (50%; Gr. 3) (p=0.023), and pathological fracture: 0 case (0%) vs. 0 (0%; Gr. 2) vs. 1 (16.7%; Gr. 3) (p=0.006), although the consolidation time was longer: 6.8 vs. 2 (Gr. 2) vs. 2.7 months (Gr. 3) (p=0.017) and the rate of complication was higher than those of Gr. 2 and Gr. 3 (p<0.05). Gr. 3 had a lower local recurrence rate: 1 case (11.1%) vs. 4 cases (66.7%) (p=0.002), incidence of deformity: 0 case (0%) vs. 3 cases (50%) (p=0.023), and pathological fracture: 0 case vs. 1 case (16.7%) (p=0.006) than Gr. 2. DiscussionOpen biopsy is an important step in the management of patients with imaging suggestive of OFD in order to rule out Adamantinoma and other bone tumors or infection. Observation should be reserved for asymptomatic patients, while surgical treatment is indicated in patients with persistent pain, pathological fracture or significant deformity of the tibia. ESIN is a valid option to preserve the anatomical axis of the tibia in symptomatic patients with lesions of limited size; large circumferential lesions or recurrence can be managed by extra-periosteal resection and bone transport, although the complication rate can be relatively high. Level of evidenceIII; case control study.