Flexible Intramedullary Nailing Research Articles

Stability of Proximal Femoral Osteotomies in Pediatric Bone Models Fixed with Flexible Intramedullary Nails and Evaluated by the Finite Element Method.

Objective To evaluate the stability of osteotomies created in the subtrochanteric and trochanteric regions in a pediatric femur model fixed by flexible intramedullary rods. Method Tomographic sections were obtained from a pediatric femur model with two elastic titanium rods and converted to a three-dimensional model. This model created a mesh with tetrahedral elements according to the finite element method. Three virtual models were obtained, and osteotomies were performed in different regions: mediodiaphyseal, subtrochanteric, and trochanteric. A vertical load of 85N was applied to the top of the femoral head, obtaining the displacements, the maximum and minimum main stress, and the equivalent Von Mises stress on the implant. Results With the applied load, displacements were observed at the osteotomy site of 0.04 mm in the diaphyseal group, 0.5 mm in the subtrochanteric group, and 0.06 mm in the trochanteric group. The maximum stress in the diaphyseal, subtrochanteric, and trochanteric groups was 10.4 Pa, 7.52 Pa, and 26.4 Pa, respectively. That is around 40% higher in the trochanteric group in regards to the diaphyseal (control). The minimum stress of the bone was located in the inner cortical of the femur. The equivalent Von Mises stress on the implants occurred at osteotomy, with a maximum value of 27.6 Pa in the trochanteric group. Conclusion In both trochanteric and subtrochanteric osteotomies, fixation stability was often lower than in the diaphyseal model, suggesting that flexible intramedullary nails are not suitable implants for proximal femoral fixations.

A novel sliding double flexible intramedullary nail technique for the management of lower extremity long bone fractures and deformities in osteogenesis imperfecta.

This study aimed to investigate the effectiveness of the sliding double flexible intramedullary nail technique (SDFIN) in managing lower extremity long bone fractures and deformities in patients with osteogenesis imperfecta (OI) based on radiographic measurements. This study was conducted involving type III or IV Silence OI patients who underwent treatment with SDFIN for fractures, deformity correction, or previous device failure. The surgical technique involved the insertion of two straight flexible intramedullary nails in each bone segment, with one inserted from the caudal epiphysis and the other from the proximal region. Clinical and radiological outcomes were evaluated with a mean follow-up of 62.8 ± 20.3 months. Among the 33 lower extremity long bone segments treated with SDFIN, revision was required in 12 segments, resulting in an overall complication rate of 51.5%. Complications included nail migrations observed in 10 cases, decreased joint range of motion in seven, refractures and malrotations in five, nail fracture, and nail extrusion in one case were observed. The femur group had a complication rate of 50%, while the tibia group had a rate of 53.3%. The SDFIN technique demonstrated satisfactory outcomes in managing leg fractures and deformities in OI patients. The technique showed comparable results to newly designed Faisser-Duval rods at a lower cost. Further research and refinement of the technique are necessary to reduce complications and improve patient outcomes.

Is Elastic Stable Intramedullary Nailing a Viable Treatment Option for Diaphyseal Fractures of the Humerus in Adults? A 29-case Series Prospective Study.

Humerus shaft fractures are common in orthopaedic practice. The emphasis in treatment has shifted from prolonged immobilisation to early mobilisation and internal fixation when needed for a quicker return to normal function. Internal fixation methods include plate osteosynthesis and intramedullary nailing. This study specifically evaluated the effectiveness of flexible intramedullary nails in treating diaphyseal humeral fractures. Between April 2007 and January 2010, Alexandria University Hospital treated 29 patients (21 males, 8 females) with diaphyseal humeral fractures. Treatment involved closed reduction and percutaneous fixation using two flexible nails. Patients, aged 17 to 65 with a mean age of 32, were included if they did not have pathological fractures, were above 16 years old, and were medically suitable. Causes included pedestrian vehicle accidents (17 cases) and falls or sports-related activities (12 cases). Surgical intervention occurred 1 to 8 days after the injury. Between April 2007 and January 2010, Alexandria University Hospital treated 29 patients (21 males, 8 females) for diaphyseal humeral fractures using closed reduction and percutaneous fixation with two flexible nails. Patients, aged 17 to 65, were monitored for an average of 18 months. Radiographic assessments showed complete union in nineteen fractures within 13 to 21 weeks. One patient experienced non-union but was successfully treated with bone grafting and plating. There were no significant intraoperative complications. Notably, four patients with preoperative radial nerve injuries recovered within 6 to 8 weeks. Evaluation using the Stewart and Hundley Scoring technique showed excellent outcomes for 60% of patients, good outcomes for 30%, fair outcomes for 5%, and poor outcomes for 5%. 1.The Elastic Stable Intramedullary Nailing (ESIN) technique shows promise in the treatment of humeral shaft fractures. 2. However, the success of treatment may depend on various factors, including patient age, fracture characteristics, and the presence of complications such as open fractures and radial nerve palsy. 3. Careful consideration of these factors is necessary when selecting a treatment approach for humeral shaft fractures.

Results of Allografts and Synthetic Grafts in Humeral Simple Bone Cysts.

Simple bone cysts (SBCs) are the most common benign bone lesions in childhood. There are many different methods in the treatment of SBCs. There is no consensus on which method to use in the treatment. In this study, we compared the results of allogeneic bone graft or synthetic bone graft in addition to fl exible intramedullary nail (FIN) for SBC located in the humerus. This retrospective study comparing the data of 19 (group 1: 8 curettage, allograft and FIN; group 2: 11 curettage, synthetic graft and FIN) patients with a mean age of 11.4 (6 to 26; seven female, twelve male) who were surgically treated in our hospital for humeral SBC between April 2014 and January 2020. Patient data included age, sex, anatomical side, stage of the cyst, pathological fracture, previous treatments and complications. The mean follow-up period was 33.7 months (12 to 61). The average last follow-up Musculoskeletal Tumor Society functional scores for groups 1 and 2 were 27.8 (20 to 30) and 28.6 (21 to 30) (P > 0.05). Complete or signifi cant partial radiographic healing rates were achieved in group 1 (75%) compared with group 2 (81.9%). The reoperation rates for groups 1 and 2 were 62.5% (5/8; three for nails removed, two for recurrence) and 36.3% (4/11; two for nails removed, two for recurrence). One patient in group 2 had a 15° varus deformity due to recurrence. No other complications were observed. The combination of curettage-grafonage FIN is a common treatment method in recent years, as it provides early cyst healing and limb mobilization in SBCs located in the upper extremity. For defects after curettage of the bone cysts, allogeneic or synthetic grafts (granule b-tricalcium phospate) which have similar results in terms of healing can be used as an alternative to each other. allografts, bone cysts, bone nails, synthetic grafts, humerus.

Percutaneous TENS in Pediatric diaphyseal femoral fractures- Respects biology and ends happily

Femoral shaft fractures are amongst the most common major pediatric injuries treated by orthopaedic surgeons. They represent 1-2% of all fractures in the paediatric population. Paediatric males are affected more commonly than females. [1] There are various methods available for operative stabilization of paediatric femoral shaft fractures, which include external fixation, compression plating and rigid and flexible intramedullary nailing. [2] There is no uniform consensus on the treatment modality for femoral shaft fracture in school-aged children between 6 years to16 years. Titanium elastic nailing system (TENS) is a recent and widely used technique which allows stable reduction, maintenance of reduction and early mobilization. [3] American Academy of Orthopaedic Surgeons (AAOS) recommends with strong evidence based support in favour of the use of flexible intramedullary nailing for treating children age five to eleven years diagnosed with diaphyseal femur fractures. [4, 5] This device exploits a child’s denser bone, rapid healing and ability to remodel during period of bone growth. Here, we establish this axiom by a detailed case presentation, who was successfully treated with flexible intramedullary nailing for diaphyseal fracture of the femur.

Combination of flexible intramedullary nailing and Ilizarov frame for salvage of femur and humerus nonunion in a girl with osteogenesis imperfecta

Background Fixation of pathological long bones with telescopic intramedullary rods is well known to be a technically challenging procedure even in specialist centres, with a high complication rate due to rod migration, hardware failure, nonunion or malunion. However there is very little guidance in the literature regarding salvage treatment options when failure occurs.Aim We demonstrate a surgical technique that can be used for salvage treatment of both femoral and humeral complex nonunions following Fassier-Duval (FD) rodding in a child with osteogenesis imperfecta (OI).Case description A 13 year-old girl with OI type VIII presented sequentially with nonunion and deformity of the femur then the humerus following previous FD rods in those segments. The femur was also complicated with metallosis between the steel rod and an overlying titanium plate. Both segments were treated with pseudarthrosis debridement, removal of metalwork and stabilisation with hydroxyapatite (HA)-coated flexible intramedullary nails, with temporary Ilizarov frame to provide enough longitudinal and rotational stability to allow immediate weight-bearing. The femur Ilizarov frame was removed after 64 days, and the femur remained straight and fully healed at 2.5 years. The frame time for the humerus was 40 days, complete union was achieved and upper limb function restored and maintained at 9 months.Discussion The transphyseal telescopic rod is the traditional implant of choice in terms of treating fractures and stabilising osteotomies for deformity in OI. However, it does not provide enough torsional or longitudinal stability by itself to allow early weight-bearing which is detrimental to bone healing in this vulnerable patient group. The incidence of delayed union or nonunion at osteotomy site in telescopic rod application is not negligible: up to 14.5-51.5 %. Although the technique we have shown in this case may not be applied to all complex OI patients, we believe that the combination of flexible intramedullary nails and Ilizarov frame provides a favourable environment for bone healing in complex or revision cases. As a secondary learning point the initial revision surgery to the left femur demonstrated the perils of using a steel rod and a titanium plate in a biologically active environment which in this case lead to metallosis and lysis.Conclusion We found the technique of HA-coated flexible intramedullary nails combined with the Ilizarov frame effective in the salvage of failed telescopic rods in both femur and humerus and feel this technique can be used as a salvage option in similar cases worldwide. This case also demonstrates the perils of using different metals in combined internal fixation.

Efficacy of Single Titanium Elastic Nail in the Treatment of Child Femur Fractures.

Femoral shaft fractures in childhood constitute an important part of emergency visits to orthopedic clinics. The aim of this study was to investigate the efficacy and reliability of a method in the treatment of simple fractures in the middle of the femoral diaphysis in patients with multiple injuries or in the treatment of cases with a medullary canal that is too narrow for two nails, with a single stretch nail thicker than half the diameter of the canal. Between July 2002 and November 2006, examinations were made of 11 femoral fractures in 11 patients who were admitted to the pediatric emergency department of Tepecik Training and Research Hospital with a diagnosis of femoral fracture and who were hospitalized and treated with a single flexible intramedullary titanium nail. In the follow-up, no problem was found in terms of union and length difference in any of the cases, except for a10º varus deformity present after surgery in one case. Elastic intramedullary nailing is an effective method in the treatment of simple femoral fractures in children. A single elastic nail provides adequate stability following open reduction with minimal incision in patients whose short operating time must be kept short such as those with head trauma, thoracic trauma, or intra-abdominal pathology, or patients with a narrow medullary canal where two flexible nails cannot pass. We think that it is a feasible method because it causes minimal soft tissue damage.

Open Reduction of Pediatric Femur Fracture: A Technical Trick

Open Reduction of Pediatric Femur Fracture: A Technical Trick

Plate fixation versus flexible intramedullary nails for management of closed femoral shaft fractures in the pediatric population: A systematic review and meta-analysis of the adverse outcomes.

Fractures of the femoral diaphysis are associated with a risk of morbidity in children. Various fixation methods have been developed, but with only limited evidence to support their use. This systematic review assesses the evidence regarding clinical outcomes of closed femoral diaphyseal fractures in children treated with plate fixation or flexible intramedullary nails. A PROSPERO-registered, PRISMA-compliant systematic review and meta-analysis were conducted. MEDLINE, Embase, and Web of Science (WoS) databases were searched from inception to February 2023. Inclusion criteria included clinical studies reporting adverse outcomes following surgical treatment of pediatric closed femoral diaphyseal fractures using plate fixation and flexible intramedullary nails. The ROBINS-I and RoB 2 tools evaluated the risk of bias. Thirteen papers (2 prospective randomized controlled trials and 11 retrospective cohorts) reported 805 closed diaphyseal femoral fractures in 801 children (559 males, 242 females). There were 360 plate fixations and 445 flexible intramedullary nails. Two cases of osteomyelitis and one nonunion were reported. Meta-analysis showed that plate fixation had a lower risk of soft tissue infection (relative risk 0.26 (95% confidence interval 0.07-0.92)). There was no difference in the following outcomes: malunion (relative risk 0.68 (95% confidence interval 0.32-1.44)); unplanned reoperation (relative risk 0.59 (95% confidence interval 0.31-1.14)), and leg-length difference (relative risk 1.58 (95% confidence interval 0.66-3.77)). The risk of bias was high in all studies. An analysis of 805 fractures with minimal differences in meta-analyses is considered high quality even when the quality of the evidence is low. The findings are limited by important flaws in the methodology in the published literature. Well-designed multicentre prospective studies using standardized core outcomes are required to advise treatment recommendations. III.

Cast or Nail? Using a Preference-Based Tool for Shared Decision-Making in Pediatric Femoral Shaft Fracture Treatment.

Femoral shaft fractures are common injuries in children 2 to 7 years of age, with treatments ranging from casting to flexible intramedullary nails (FIN). Each treatment has unique attributes and outcomes are overall similar. Given equivalent outcomes, we hypothesized that a shared decision-making process, using adaptive conjoint analysis (ACA), can be used to assess individual family situations to determine ultimate treatment choice. An interactive survey incorporating an ACA exercise to elicit the preferences of individuals was created. Amazon Mechanical Turk was used to recruit survey respondents simulating the at-risk population. Basic demographic information and family characteristics were collected. Sawtooth Software was utilized to generate relative importance values of five treatment attributes and determine subjects' ultimate treatment choice. Student's t-test or Wilcoxon rank sum test was used to compare relative importance between groups. The final analysis included 186 subjects with 147 (79%) choosing casting as their ultimate treatment choice, while 39 (21%) chose FIN. Need for second surgery had the highest overall average relative importance (42.0), followed by a chance of serious complications (24.6), time away from school (12.9), effort required by caregivers (11.0), and return to activities (9.6). Most respondents (85%) indicated the generated relative importance of attributes aligned "very well or well" with their preferences. For those who chose casting instead of FIN, the need for secondary surgery (43.9 vs. 34.8, P <0.001) and the chance of serious complications (25.9 vs. 19.6, P <0.001) were the most important factors. In addition, returning to activities, the burden to caregivers, and time away from school were all significantly more important to those choosing surgery versus casting (12.6 vs. 8.7 P <0.001, 12.6 vs. 9.8 P =0.014, 16.6 vs. 11.7 P <0.001, respectively). Our decision-making tool accurately identified subjects' treatment preferences and appropriately aligned them with a treatment decision. Given the increased emphasis on shared decision-making in health care, this tool may have the potential to improve shared decision-making and family understanding, leading to improved satisfaction rates and overall outcomes. Level-III.

Resource implications of managing paediatric femoral fractures in a major trauma centre: Analysis of 98 cases

IntroductionThe management of paediatric femoral shaft fractures is expensive and is guided by age and fracture characteristics. The primary aim of this study was to perform a cost evaluation for managing paediatric femoral shaft fractures. The secondary aim of this study was to perform and compare costs of the different techniques of managing paediatric femoral shaft fractures. MethodsNinety-eight femoral shaft fractures in children aged ≤16 were identified between 01/06/2014–30/06/2019. Retrospective data of clinical complications were obtained on infection, malunion and non-union. Data on additional intervention, reoperations for complications and routine removal of metal work were obtained. Costing analysis was performed by a bottom-up calculation, and gathering Patient Level Information and Costing System (PLICS) data. ResultsThere were 41 hip spica casting (HSC), 21 flexible intramedullary nailing (FIN), 14 submuscular plating (SMP), 19 rigid intramedullary nailing (RIN) and 3 external fixation (EF). Complications observed were HSC 3(7%); FIN 8(38%); SMP 2(14%); RIN 1(5%); EF 2(67%). The total costs for managing femoral shaft fractures were £8,955pp the costs for the different managements were; HSC £3,442pp; FIN £7,739pp; SMP £6,953pp; RIN £8,925pp; EF £19,116pp. The additional costs incurred for managing complications and routine removal of metal work for the internal fixation methods were: HSC 0.7%, FIN 23.7%, SMP 16.3%, RIN 10.9%, EF 28.1%. ConclusionThe operative management of paediatric femoral shaft fractures is associated with a high cost burden and this study demonstrates how financial data can be used to influence clinical management strategy. RIN carry a high initial implant cost however when considering the additional costs, such as treating complications it remains comparable to other modes of fixation. Our cost analysis did not demonstrate a significant difference between FIN, SMP and RIN. Due to the clinical complications observed and associated additional costs, we have discontinued the routine use of FIN for femoral shaft fractures at our centre. We recognise other centres may have a different complication and cost profile for each technique, but recommend they evaluate their practice given the potential economic benefit it has on the service provider.

TENS in Femoral Shaft Fractures of Children

Background: Pediatric femoral shaft fractures are one of the common fractures that we encounter in the orthopedics outpatient department. These fractures have various treatment options ranging from traction and early hip spica casting to elastic titanium intramedullary nails [titanium elastic nailing system (TENS)] and reamed intramedullary nails. In this study, we are evaluating the functional outcome and results following the use of flexible intramedullary nails and conservative management for femoral shaft fractures in children.&#x0D; Methods: This was a prospective observational study which was carried out in a tertiary care hospital from October 2015 to May 2017 for two groups of children who sustained traumatic femoral shaft fractures. A total of 40 patients were taken into consideration with 20 patients each in two groups.&#x0D; Results: The male-to-female ratio was 2.6:1 in our study population. The overall post-operative complication rate was more in the TENS group. Besides, we found that the TENS group of patients had a less limb length discrepancy (LLD) (P = 0.004) and a lower degree of angular deformity (P = 0.36).&#x0D; Conclusion: TENS demonstrated advantages including sufficient axial stability, early mobilization, and more rapid return to function than spica cast treatment; however, it had the drawback of possible infection and pin site irritation. Overall, TENS offers a minimally invasive method for treatment of the femoral shaft fractures in children which stands superior to traditional spica casting.&#x0D;

Rate of Refracture After Removal of Hardware in Pediatric Femur Fractures.

Both flexible intramedullary nails (FINs) and plate osteosynthesis are commonly used for the treatment of femoral shaft fractures in pediatric patients. The purpose of this study is to determine the refracture rate after hardware removal in pediatric femur fractures. This is a retrospective cohort study that utilized the Pediatric Health Information System database to determine the number of pediatric patients ages 4 to 10 who underwent surgical fixation of a femur fracture and subsequent hardware removal between the years 2015 and 2019. All patients had a minimum of a 2-year follow-up to assess for refracture. Patients with metabolic bone disease, neuromuscular conditions, bone fragility disorders, nutritional deficiencies, and pathologic fractures were excluded. Of the total, 2805 pediatric patients with 2881 femoral shaft fractures who underwent FIN (48.4%), plate fixation (36.1%), splinting/casting (14.9%), or external fixation (0.6%) were included. The mean age of patients with index fracture was 7.2 years (SD, 2.1) and 69% were males. Eight hundred eighty patients (60%) in the FIN group had their hardware removed compared with 693 patients (68%) in the plate fixation group ( P = 0.07), at an average of 287 ± 191 days versus 320 ± 203 days ( P = 0.03). Refracture occurred in 13 patients (1.5%) who had their hardware retained and in 21 patients (1.4%) who had their hardware removed ( P = 0.732). Among 65% of patients who underwent hardware removal, refracture occurred in 7 patients with FIN (0.8%) and 14 patients with plate fixation (2.2%) ( P = 0.04). Refracture occurred within 365 days from hardware removal in 1 patient with FIN (0.1%) and 7 patients with plate fixation (1%) ( P = 0.01). In logistic regression, patients with FIN fixation had lower odds of refracture after hardware removal compared with plate fixation (adjusted odds ratio: 0.39; 95% CI: 0.15-0.97). Age and payor status did not reach statistical significance in multivariate analysis. The rate of refracture after hardware removal for pediatric patients with a femoral shaft fracture was similar between patients with hardware retained and removal. However, patients with FIN had a lower rate of refracture AFTER hardware removal compared with plate fixation. This information can be helpful for advising families regarding the risks of refracture after hardware removal. Level IV-retrospective cohort study.

Canal Fill of the Forearm Bones When Placing Intramedullary Nails in the Pediatric and Adolescent Populations.

In the lower extremity, studies have suggested an optimal nail diameter to medullary canal diameter (ND/MCD) ratio to minimize postoperative complications. The goal of this study was to determine whether a correlation exists between the occurrence of complications, angulation, and range of motion and the ratio of the ND/MCD in the upper extremity. A total of 85 radius and ulna fractures treated with flexible intramedullary nails had ND/MCD ratios measured. Random-effects models were developed to determine the association between complications and ND/MCD ratio, angulation and ND/MCD ratio, and range of motion and ND/MCD ratio. The results were reported for unadjusted models and adjusted models. Of the 85 forearm fractures treated with intramedullary nailing, there were 3 complications. The average follow-up was 6 months. The ND/MCD ratios were categorized as <0.50, 0.50 to 0.59, and ≥0.60. There was not a significant association between the different ratios and angulation, or risk of complication. There was an association between the ND/MCD ratio ≥0.60 and decreased pronation of -1.58° (-2.77° to -0.38°) and supination of -2.68° (-4.91° to -0.46°) (P < .05). This study found that there was not an association between the nail to canal diameter ratio and postoperative angulation in forearm fractures treated with flexible intramedullary nails. When choosing a flexible nail for forearm fractures, there does not appear to be an optimal ratio; it is therefore reasonable to use the ND that passes more easily.

Femoral lengthening using limb reconstruction system augmented with only one antegrade flexible nail in children: early results.

Several techniques have been described for decreasing the duration of external fixator use, augmenting stability, and minimizing complications. The purpose of the present study was to evaluate the clinical results and complications of femoral lengthening procedures using the Limb Reconstruction System (LRS) in combination with a single antegrade flexible intramedullary nail (FIN). Femoral lengthening with LRS and FIN was applied to 14 patients (aged 6-16 years) between 2017 and 2021. The etiology was a congenital femoral deficiency in 12 patients and post-traumatic growth arrest in two. A single nail was inserted antegradely through the trochanteric apophysis in each patient. Radiographs and medical records of the patients were assessed retrospectively. The mean lengthening achieved was 4.8 ± 1.0 cm. The mean duration of external fixation was 181 days (range 139-248 days) and the mean healing index was 39.6 ± 12.1 days/cm. The mean values of mechanical medial proximal tibial angle, mechanical lateral distal tibial angle, mechanical lateral proximal femoral angle, and mechanical lateral distal femoral angle were within the normal range at the last follow-up. Seven of the 14 cases had a regenerate deformity that caused a displacement of more than 2 mm in the mechanical axis deviation, none of them was greater than 10 mm and considered clinically insignificant. Fracture was seen in two limbs with regenerate deformity. This study suggests that LRS in combination with only one FIN may be an effective alternative for femoral lengthening, with acceptable complication rates.

Allongement combiné des inégalités de longueur des membres inférieurs acquises : est-ce que l’utilisation de clous élastiques avec hydroxyapatite a des avantages ?

IntroductionThe aim of this multicenter prospective study was to analyze the outcomes of bone lengthening by external fixator associated with flexible intramedullary nailing (FIN) in acquired limb length discrepancy (LLD). HypothesisHydroxyapatite(HA)-coated FIN enables reduced External Fixation Index in limb lengthening for acquired leg length discrepancies in comparison to non-HA-coated FIN. Material and MethodsThis study included 54 patients (mean age, 17.9 years) operated on for femoral or tibial lengthening by combined technique (External fixator with FIN) for acquired length discrepancy. Titanium non-HA-coated FIN (29 cases) or HA-coated FIN (25 cases) were used. The factors that might influence external fixation index, complication occurrence and outcome were analyzed: age, amount of lengthening, nail diameter, HA-coating vs. non-HA-coated nails. ResultsThe mean External Fixation Indexes (EFI) of groups compared for non-HA-coated nails vs. HA-coated nails were not significantly different: 26.5 d/cm and 27.2 d/cm in femoral lengthening and 34.9 d/cm and 31.7 d/cm in tibial lengthening. Positive correlation between the “Nail diameter/inner distance between cortices at osteotomy site” ratio and EFI in tibial lengthening was revealed (p=0.034). The nail types and the “nail diameter/medullary canal diameter” ratio interact and have significant simultaneous effect on EFI in femoral lengthening (p=0.021). DiscussionThe results of this study revealed no differences with regards to EFI using HA-coated or non-HA-coated titanium FIN in lengthening for acquired leg-length discrepancies. Combined technique allowed reduced EFI and avoided major complications. Both non-HA-nail and HA-coated nail lengthening provided good and excellent outcomes. Level of EvidenceIII; (controlled trial without randomization) prospective comparative study.

Suitability of skin traction combined with braces for treating femoral shaft fractures in 3–5 years old children

BackgroundIn children aged 3–5 years, femoral fractures are common and are frequently treated using flexible intramedullary nails (FIN) or spica casting. Recently, more surgeons have been relying on FIN surgery because of the high rate of complications associated with spica casts, such as skin irritation and re-adjustment surgery. We aimed to evaluate the effect of skin traction combined with braces in 3–5 years old children at our hospital.MethodsWe retrospectively analyzed 125 children aged 3–5 years with femoral shaft fractures treated at our hospital between January 2010 and December 2020. We assigned 68 patients who underwent FIN surgery to Group A and 57 patients treated with skin traction and braces to Group B. Comparative analysis included the children’s age, sex, side of the affected limb, cause of fracture, function of the knee joint, healing time of the fracture, duration of hospitalization, cost of hospitalization, and complications. The complications evaluated included joint dysfunction, pain, infection, pressure ulcers, angular deformities, limb length differences, re-fractures, nonunion fractures, and delayed union.ResultsThere were significant differences in and hospital costs (p = 0.001). Conversely, no statistically significant differences were observed in sex (p = 0.858), injury type (p = 0.804), age (p = 0.231), hospitalization time (p = 0.071), bone healing time (p = 0.212), and complications. Pressure ulcers, nonunion fractures, and delayed union did not occur in both groups.ConclusionBoth methods had similar therapeutic effects and postoperative complications in children aged 3–5 years with femoral shaft fractures. Therefore, skin traction combined with braces is recommended for this population and for patients hospitalized in institutions where several beds are available, with a consequent possibility of prolonged hospitalization.Level of Evidence: IV.

Management of Infected Femoral Nonunion by Arched External Fixator Augmented by Flexible Intramedullary Nails

Abstract Purpose: The aim of this study is to evaluate the functional and radiological outcome of the management of infected femoral nonunion by arched frame augmented by flexible intramedullary nails. Patients and Methods: In this retrospective case series study, 20 cases were included. All patients had chronically infected nonunited fracture femur. The mean age of the included patients was 33 years. The site of the femoral fracture was midshaft in 12 patients, proximal third of femur in 6 patients, and distal third in 2 cases. Initially, the fracture was open in 17 patients and closed in 3 patients. Four of the included patients had diabetes mellitus. Ten cases were smokers and six of them were heavy smokers. All cases were managed by arched frames, augmented by flexible intramedullary nails. Functional and radiological evaluation was performed using the Association for the Study and Application of the Methods of Ilizarov (ASAMI) scoring system. Results: The mean follow-up was 18.45 months. All cases achieved union except two cases (10%). According to ASAMI bony score, 11 patients (55%) were excellent, 6 (30%) were good, 1 was fair (5%), and 2 (10%) showed poor results. According to ASAMI functional score, 3 patients were excellent, 15 (75%) were good, 3 (15%) were fair, and 2 (10%) showed poor results. Conclusion: The management of infected nonunion of the femur by arched frame and intramedullary flexible nails provides a stable fixation, with acceptable functional and radiological results. Level of Evidence: Level IV case series study.

FLEXIBLE INTRAMEDULLARY NAILS IN PEDIATRIC SUBTROCHANTERIC FEMUR FRACTURE: BIOMECHANICAL STUDY.

Evaluate the stability provided by two flexible intramedullary nails (FINs) in a simulation of fractures at the proximal levels in pediatric femur models. Two FINs were inserted in 18 synthetic models of pediatric femurs. Fractures were simulated at one of three levels, and the models were divided into the following groups (n=6): diaphysis (control), subtrochanteric and trochanteric. Flex-compression tests were performed with force up to 85 N. Relative stiffness and the average deformation was obtained. Torsion tests were performed by rotating the proximal fragment until 20°, to obtain the average torque. At flex-compression, the set's average relative stiffness and average deformations were: 54.360x103 N/m and 1.645 mm in the control group, respectively. In the subtrochanteric group, the relative stiffness was 31.415x103 N/m (-42.2%) and the deformation was 2.424 mm (+47.3%) (p<0.05). For the trochanteric group, the relative stiffness was 30.912x103 N/m (+43.1%) and the deformation was 2.508 mm (+52.4%) (p<0.05). In torsion, the average torque was 1.410 Nm in the control group; 1.116 Nm in the subtrochanteric group (-20.8%), and 2.194 Nm in the trochanteric group (+55.6%) (p<0.05). FINs do not seem to be biomechanically competent for the treatment of proximal femoral fractures. Level of Evidence I; Therapeutic Studies - Investigating the results of treatment.

Management of Diaphyseal Fractures of the Femur in Children Using Flexible Intramedullary Nails

Management of Diaphyseal Fractures of the Femur in Children Using Flexible Intramedullary Nails