Retrospective Cohort Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Sep 18, 2020; 11(9): 380-390
Published online Sep 18, 2020. doi: 10.5312/wjo.v11.i9.380
Length unstable femoral fractures: A misnomer?
Eric Andrew Mussell, Achraf Jardaly, Shawn R Gilbert
Eric Andrew Mussell, Department of Orthopaedic Surgery, University of Alabama at Birmingham, and Andrews Sports Medicine and Orthopaedic Center, Birmingham, AL 35205, United States
Achraf Jardaly, Department of Orthopedic Surgery, University of Alabama at Birmingham and Lebanese American University, Gilbert and Rose-Marie Chagoury School of Medicine, Byblos 00000, Lebanon
Shawn R Gilbert, Department of Pediatric Orthopaedics, University of Alabama at Birmingham, Birmingham, AL 35233, United States
Author contributions: Mussell EA significant contribution and willingness to take public responsibility for the study design, data acquisition, and analysis and interpretation of data, actively involved in the drafting and critical revision of the manuscript, approval of the final version of the submitted manuscript; Jardaly A significant contribution and willingness to take public responsibility for the study design, data acquisition, and analysis and interpretation of data, actively involved in the drafting and critical revision of the manuscript, approval of the final version of the submitted manuscript; Gilbert SR significant contribution and willingness to take public responsibility for the study design, data acquisition, and analysis and interpretation of data; actively involved in the drafting and critical revision of the manuscript, approval of the final version of the submitted manuscript.
Institutional review board statement: The study was reviewed and approved by the University of Alabama at Birmingham School of Medicine Institutional Review Board.
Informed consent statement: Informed consent not required.
Conflict-of-interest statement: Eric Mussell, Achraf Jardaly, and Shawn Gilbert declare that they have no conflict of interest.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at srgilbert@uabmc.edu. Consent was not obtained but the presented data are anonymized, and risk of identification is low.
STROBE statement: The STROBE Statement guidelines were adopted during this manuscript’s synthesis.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Shawn R Gilbert, MD, Surgeon, Department of Pediatric Orthopaedics, University of Alabama at Birmingham, ACC Suite 316, Children’s Hospital, 1600 7th Avenue South, Birmingham, AL 35233, United States. srgilbert@uabmc.edu
Received: May 7, 2020
Peer-review started: May 7, 2020
First decision: May 15, 2020
Revised: May 28, 2020
Accepted: August 15, 2020
Article in press: August 15, 2020
Published online: September 18, 2020
Abstract
BACKGROUND

Flexible intramedullary nailing (FIMN) is relatively contraindicated for pediatric length unstable femoral fractures.

AIM

To evaluate FIMN treatment outcomes for pediatric diaphyseal length unstable femoral fractures in patients aged 5 to 13 years.

METHODS

This retrospective study includes pediatric patients (age range 5-13 years) who received operative treatment for a diaphyseal femoral fracture at a single institution between 2013 and 2019. Length unstable femur fractures treated with FIMN were compared to treatment with other fixation methods [locked intramedullary nailing (IMN), submuscular plating (SMP), and external fixation] and to length stable fractures treated with FIMN. Exclusion criteria included patients who had an underlying predisposition for fractures (e.g., pathologic fractures or osteogenesis imperfecta), polytrauma necessitating intensive care unit care and/or extensive management of other injuries, incomplete records, or no follow-up visits. Patients who had a length stable femoral fracture treated with modalities other than FIMN were excluded as well.

RESULTS

Ninety-five fractures from ninety-two patients were included in the study and consists of three groups. These three groups are length unstable fractures treated with FIMN (n = 21), length stable fractures treated with FIMN (n = 45), and length unstable fractures treated with either locked IMN, SMP, or external fixator (n = 29). P values < 0.05 were considered statistically significant. Patient characteristic differences that were statistically significant between the groups, length unstable with FIMN and length unstable with locked IMN, SMP, or external fixator, were average age (7.4 years vs 9.3 years, respectively), estimated blood loss (29.2 mL vs 98 mL, respectively) and body mass (27.8 kg vs 35.1 kg, respectively). All other patient characteristic differences were statistically insignificant. Regarding complications, length unstable with FIMN had 9 total complications while length unstable with locked IMN, SMP, or external fixator had 10. Grouping these complications into minor or major, length unstable with locked IMN, SMP, or external fixator had 6 major complication while length unstable with FIMN had 0 major complications. This difference in major complications was statistically significant. Lastly, when comparing patient characteristics between the groups, length unstable with FIMN and length stable with FIMN, all characteristics were statistically similar except time to weight bearing (39 d vs 29 d respectively). When analyzing complication differences between these two groups (9 total complications, 0 major vs 20 total complications, 4 major), the complication rates were considered statistically similar.

CONCLUSION

FIMN is effective for length unstable fractures, having a low rate of complications. FIMN is a suitable option for length stable and length unstable femur fractures alike.

Keywords: Flexible intramedullary nail, Titanium elastic mail, Elastic stable intramedullary nail, Pediatrics, Length unstable, Femoral fractures, Bone fracture, Orthopedics

Core Tip: There is debate between orthopaedic surgeons regarding proper treatment for length unstable femoral fractures in patients between the ages of 5 and 11. In our manuscript we present results demonstrating that flexible intramedullary nailing in this subset of patients is an effective form of treatment and compares well to other forms of treatment for this subset of patients. Our results also compare favorably to those from recently published literature pieces on this same subject.