Flexible Intramedullary Nailing Research Articles

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

Evaluation of Early Results of Tibial Fractures Fixation in Pediatrics by Flexible Intramedullary Nailing

Evaluation of Early Results of Tibial Fractures Fixation in Pediatrics by Flexible Intramedullary Nailing

Displaced Tibia Fractures in Adolescents: Closed Reduction and Casting Versus Flexible Intramedullary Nails.

Although there has been a recent trend towards the operative intervention of pediatric diaphyseal tibial fractures, there is sparse literature that supports this trend. This study compares the outcomes in children between 10 and 18 years of age with diaphyseal tibial fractures who undergo nonoperative treatment with closed reduction and casting (CRC) to those who undergo operative treatment with flexible intramedullary nailing. A retrospective chart review was performed of all patients between 10 and 18 years of age who underwent treatment for tibia fractures at the authors home institution between 2005 and 2018. Radiographs and medical records were reviewed for the duration of immobilization, time to fracture healing and complications including delayed union, malunion, nonunion, and surgical site infection. All statistical analysis was performed using an αof 0.05. One hundred forty one patients (81.8% males) were included in the final analysis. Patients treated with flexible nailing took an average of 7 weeks ( P <0.001) longer than patients treated with CRC to achieve radiographic healing. The average time to full weight-bearing activities was longer by 1 week in the patients treated nonoperatively with CRC ( P =0.001). There was no statistically significant difference in the malunion rates between the 2 groups ( P =0.067), but delayed union and nonunion were exclusively seen in the flexible nailing group. There was a total of 40 complications among 33 (23.4%) patients, most of whom were in the CRC cohort (60.6%, n=20), but there was no statistically significant difference in complication rates between the 2 cohorts. Most adolescents presenting with closed diaphyseal tibial fractures of moderate severity can be successfully treated both nonoperatively with CRC and operatively with flexible intramedullary nailing. However, we recommend an initial attempt at nonoperative treatment be performed in these patients due to the association of more severe complications with flexible nailing. Level III.

Treatment of Pediatric Femoral Shaft Fractures.

Diaphyseal femur fractures are common in pediatric orthopaedic settings. A patient-specific treatment plan incorporates several factors, including age, weight, fracture pattern, associated injuries, and social considerations. Nonaccidental trauma should be considered in children younger than 3 years. In general, young children are treated with noninvasive immobilization (Pavlik harness or early hip spica casting) while school-aged children are treated with internal fixation. Internal fixation options include flexible intramedullary nails, rigid locked intramedullary nails, and plate osteosynthesis. Flexible intramedullary nails have the best outcomes in children of appropriate weight, aged 5 to 11 years, with stable fracture patterns. Lateral-entry rigid intramedullary nails have been designed for use in older children. External fixation is usually reserved for complex scenarios. Regarding all treatment methods, surgeons should be aware of several technical factors necessary to optimize outcomes.

Flexible intramedullary nails or Spica casting? A meta-analysis on the treatment of femur fractures in preschool children aged 2-5 years.

The objective of this study is to conduct a meta-analysis (1) to evaluate outcomes of flexible intramedullary nails (FIN) versus Spica casting for treating femur shaft fractures in children aged 2-5 years and (2) to investigate the associated complications. The PubMed , Cochrane Library , Embase and Web of Science databases were searched to identify available studies comparing the outcomes of FIN and Spica casting for the treatment of femoral shaft fracture in preschool children. Meta-analysis was conducted with adherence to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Eight observational studies involving 4995 patients were included. Two were judged to be of moderate quality, with the remainder being high quality. There were 1573 patients treated by FIN and 3422 by Spica casting. Compared to Spica casting, FIN allowed a quicker return to normal activities (40.49 ± 13.43 vs. 46.97 ± 14.32 days; P < 0.001), had a lower incidence of malunion (0.88 vs. 4.19%; P = 0.01) and unplanned interventions (2.87 vs. 7.53%; P < 0.001), but had slightly longer hospital stay (2.01 ± 1.01 vs. 1.10 ± 0.93 days; P = 0.01) and required a second surgery to remove the nails. Compared with Spica casting, FIN has the advantages of faster returning to normal activities and lower incidence of residual deformities and unplanned reoperation, but a slightly longer time of hospitalization and needs a second surgery to remove the hardware. Existing studies on duration of care and financial burden are insufficient, so further studies are warranted on multicenter and high-level evidence studies. Level of evidence: III.

Incidence of secondary interventions after early spica casting for diaphyseal femur fractures in young children.

Background:Children aged 6 months to 5 years with diaphyseal femur fractures are typically treated with spica casting, as recommended by the American Association of Orthopaedic Surgeons clinical practice guideline. We aimed to determine the incidence of secondary interventions after early spica casting for femur fractures in children aged 6 years or less.Methods:This was a retrospective cohort study of patients aged 6 years or less with diaphyseal femur fractures treated with early spica casting at a single Canadian tertiary care, level 1 trauma pediatric centre between January 2005 and May 2015.Results:A total of 246 patients were included (190 boys [77.2%] and 56 girls [22.8%] with a mean age of 2.28 yr [standard deviation (SD) 1.35 yr]). Nine patients (3.7%) required early secondary interventions (cast wedging in 8 and flexible intramedullary nail fixation in 1). At last follow-up, 51 patients (20.7%) had clinically measurable limb length discrepancy (LLD) (mean 9.4 mm [SD 3–25 mm]), and 1 patient (0.4%) had mild clinical valgus deformity. Older, heavier patients with initial fracture shortening of 20 mm or more had a higher likelihood of developing a clinically measurable LLD. No patient required surgical intervention after fracture union to correct acquired LLD or angular deformity.Conclusion:Early spica casting for diaphyseal femoral fractures in children aged 6 years or younger had a low rate of complications and return to the operating room, Although 21% of patients had a clinically measurable LLD at last follow-up, no patient required secondary intervention after fracture union to correct acquired LLD or angular deformity. These findings have relevance for the Canadian health care system, especially during the COVID-19 pandemic.

Functional and radiological outcomes of mid-shaft clavicle fracture managed by flexible intramedullary nailing

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Clavicle fracture is a common injury accounting for 2.6-5% of all injuries. The commonest site of fracture is the midshaft. Historically clavicle fractures were managed conservatively with figure-of-eight bandage resulting in higher non-union and symptomatic malunion rates. With the advent of operative fixation of these fractures the ideal surgical technique remains elusive. Flexible intramedullary nailing stands out as a minimally invasive and effective method with excellent outcomes for fixation of these fractures.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A prospective study was carried out over 18 months. A total of 26 patients met the inclusion criteria and were operated with flexible intramedullary nailing. Regular follow up was done till 14 weeks. At each postoperative visit patients were evaluated for shoulder function using constant score and DASH score. Radiographs were taken at each visit to evaluate for fracture alignment and union.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In this prospective study a total of 26 patients with closed midshaft clavicle fracture were managed using flexible intramedullary nail. Average time to radiological union was 7.5 weeks. Average disabilities of arm, shoulder and hand (DASH) score at 14 weeks was 13 and average constant score was 95 suggesting excellent functional outcome.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Flexible intramedullary nailing is a simple, minimally invasive surgical technique with excellent functional outcomes for management of midshaft clavicle fractures.&lt;/p&gt;

Clinical and financial impacts of flexible intramedullary nailing in pediatric diaphyseal forearm fractures: A case-control study.

Purpose:Flexible intramedullary nailing is regularly applied for pediatric displaced unstable forearm fractures. When compared to closed reduction and casting (orthopedic treatment), flexible intramedullary nailing decreases malalignment, shortens immobilization time, and should decrease follow-up controls. Comparing flexible intramedullary nailing and orthopedic treatment in the clinical, radiological, and financial managements of these fractures was performed.Methods:Retrospective 5 years study of pediatric cases in two pediatric orthopedic university departments. Treatment method, post-operative course, and radiological follow-up were reviewed. Number of radiographs, follow-up controls, type and duration of immobilization, final bone angulation, and reported complications were compared. Extensive financial analysis was completed.Results:Of 73 girls and 168 boys included in the study, 150 were treated by flexible intramedullary nailing and 91 by orthopedic treatment. No difference was noted with regard to total number of radiographs (7.3 vs 7.2, respectively). Total number of follow-ups was 6.4 and 5.5, respectively. Malalignment occurred in two flexible intramedullary nailing and sixteen orthopedic treatments. The least expensive cost was ambulatory orthopedic treatment.Conclusion:Flexible intramedullary nailing treated children had similar numbers of radiographs or follow-up consultation, but less malunion when compared to orthopedic treatment. Orthopedic management was systematically cheaper than flexible intramedullary nailing. Unless post-operative management guidelines decreasing the number of radiographs and follow-ups are implemented, flexible intramedullary nailing will remain a costly procedure when compared to conventional orthopedic treatment.Level of evidence:level III case–control retrospective study.

Tibial shaft fractures in children: flexible intramedullary nailing in growing children especially weighing 50 kg (110 lbs) or more.

Currently the gold standard in surgical treatment of displaced tibial shaft fractures in children with open growth cartilage is elastic stable intramedullary nailing (ESIN). The purpose of this study is the analysis of indications, complications, and duration of treatment using intramedullary flexible nails in children who are still growing but especially weighing 50 kg or more. Hospital records from 2017 to 2020 were retrospectively reviewed to identify the children from 4 to 17 years of age with displaced tibial shaft fractures admitted to the hospital. Only children with open growth cartilage, with a minimum of 6 months of follow-up and complete clinical data, were included. Studies of 91 children xwere analyzed. The average patient age at the time of the injury was 10.88 ± 2.82 years. In the entire group, 31.9% children weighed 50 kg or more, and 68.1% of the children were below this weight. All children were treated using ESIN. The mean time to nail removal was 8.4 ± 4.09 months in the whole group of children stabilized with ESIN. There were no differences in the two groups depending on the weight ( P = 0.637). Only two adverse events were observed. This study demonstrates that the use of ESIN in displaced tibial shaft fractures in growing children weighing 50 kg or more is acceptable and safe. The discussion to be made is whether it is still an acceptable method of treatment for this type of fracture due to the progressive obesity epidemic in children and adolescents.

Outcome of diaphyseal femur fractures treated with enders nail in paediatric age group

Introduction: In children, shaft femur fracture is the most common injury sustained. Earlier these fractures were treating conservatively but with advancement of orthopaedic implants and surgical modalities now operative intervention is favourable for early mobilization with less complication. Inadequate reduction/fixation can lead to growth disturbances among children about to attain skeletal maturity closure. Variety of surgical options includes external fixators, plates and flexible intramedullary nails and has its own complications, but the choice of implant to be used as gold standard in the management of these fractures is still a matter of debate. Enders nailing among the Flexible Intramedullary Nails, being a minimal invasive procedure and tensile property of the nail along with the feasibility of early mobilization led to its popularity. Aim: Aim of the study was to evaluate the use of Enders nail in paediatric diaphyseal femur fractures in terms of union, complications, early mobility and minimally invasive technique. Materials and Methods: This interventional prospective study was conducted from May 2017- April 2019 with 32 paediatric patients with diaphyseal femur fracture in a 5-15 years age group. Retrograde Enders nailing was done in all diaphyseal femur fractures using traction table.