Session VIII - Pediatrics

Sat, 10/9/04 Pediatrics, Paper #43, 3:00 pm

An International, Multicenter Analysis of Complications of Elastic Stable Intramedullary Nailing of Pediatric Femur Fractures

John Flynn, MD¹ (n); Franck Launay, MD² (n); Leslie Moroz¹ (n);

Steven Frick, MD³ (n); Mininder Kocher, MD⁴ (n); Peter Newton, MD⁵ (n); Paul Sponseller, MD⁶ (n);

¹The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA

²Marsailles, France;

³Carolinas Medical Center; Charlotte, North Carolina, USA;

⁴Childrens Hospital Boston, Boston, Massachusetts, USA;

⁵Childrens Hospital San Diego, California, USA;

⁶The Johns Hopkins University, Baltimore, Maryland, USA

Purpose: Elastic stable intramedullary nailing (ESIN) is a popular choice for stabilization of pediatric femoral diaphyseal fractures (OTA Classification 32) in children older than 5 years, yet little has been published on treatment complications. We documented the incidence and types of complications after use of ESIN at multiple pediatric trauma centers.

Methods: Surgeons at six major pediatric trauma centers reviewed the records of a consecutive series of patients with diaphyseal femur fractures treated with two retrograde titanium nails. Institutional Review Board approval was obtained at each center. Complications were studied and final results were classified as excellent (anatomic or near perfect anatomic alignment with no perioperative problems), satisfactory (acceptable alignment with resolved minor perioperative problems) or poor (unacceptable alignment or unresolved perioperative problems or both).

Results: Records of 229 patients with 234 femoral shaft fractures were reviewed. There were 114 complications in 87 cases. Results were classified as excellent in 150 patients (65%), satisfactory in 57 (25%), and poor in 23 patients (10%); 4 cases lacked sufficient information to be classified. We identified minor or major complications in 76 cases. A stepwise method for variable selection in logistic regression modeling was used and identified age as a significant factor (P = 0.008). Children <11years of age had 2.1 times higher odds of a better outcome. Children with poor outcomes were heavier than those with excellent/satisfactory outcomes (118 lbs vs. 85 lbs, P = 0.003). Poor outcome was five times more likely in children who weighed >108 lbs. Results were poor in 4/33 (12%) proximal-third, 15/164 (9%) mid-shaft, and 6/33 (18%) distal-third fractures, but there was no statistically significant association between fracture site and outcome adjusted for age (P = 0.71). There was also no significant association between fracture pattern (transverse, 32-A3; oblique, 32-A2; wedge, 32-B; or comminuted, 32-C) and outcome (P = 0.91). Twenty-two malunions and one failure of fixation led to poor outcomes. Three patients with asymmetric hip rotation, all less than 30°, were identified at follow-up. There were two refractures after removal of nails.

Significance: Elastic stable intramedullary nailing yielded excellent/satisfactory results in 90% of pediatric patients studied. Poor outcome was more likely in children who were heavy or older than 11 years.