Transcript Comparison of compression plate and flexible

Flexible Intramedullary Nailing
or External Fixation
for Pediatric Femoral Shaft Fractures
Soo-Sung Park M.D., Jae-Bum Park M.D.
Department of Orthopaedic Surgery,
Ulsan University College of Medicine
Asan Medical Center
Treatment of Pediatric Femoral Shaft Fracture
Conservative treatments
Immediate or delayed hip spica cast
Operative treatments
External Fixator(EF), Compression Plate,
Flexible Intramedullary Nailing(FIN),
Rigid Intramedullary Nailing
Early mobilization
Psychological, social, educational, economic advantage
Less deformity, less LLD
External fixation (EF)
Minimal invasive with little blood loss
Can be applied quickly
Allow to access to wounds and soft tissues
Allow the patient to be mobilized
However
Delayed Union
Pin tract infection
Refracture
Blasier et al, JPO 1997,17:342-346
Flexible Intramedullary Nailing (FIN)
Relatively rapid fracture stabilization
Early patient mobilization
Potentially anatomic fracture union
Small incision, minimal blood loss
Excellent results with no major complications
Heinrich et al. JPO 1994
Flynn et al. JPO 2001
Luhmann et al. JPO 2003
Purpose of this study
To compare the outcome of flexible
intramedullary nailing and external fixation for
the treatment of pediatric femoral shaft
fractures
Materials
1999. 6 ~ 2005. 4
EF or FIN with Follow-up > 1yr (37pts.)
Patients (5pts.) with concomitant fractures of L/E
were excluded
32 patients (M:F = 22:10)
Materials
No
Age (yr)
Mean follow-up (mo)
FIN
22
6.2 (1.5~12)
22.2 (13.1~56.5)
EF
10
7.5 (3.0~10)
26.1 (13.9~64.8)
FIN : 18/22 (2003~2005)
EF : 8/10 (1999~2001)
Fracture Characteristics
location
pattern
proximal
middle
distal
transverse
oblique
FIN
5
13
4
8
4
5
5
EF
1
7
2
2
4
1
3
spiral
Open fracture : 1 case (in EF group)
Multiple trauma : FIN – 4 cases (18%)
EF – 3 cases (30%)
comminution
Flexible Intramedullary Nailing
Closed reduction (mini-open : 5 cases)
Retrograde insertion
Two elastic nails
Implants
TEN : 6 cases
Khai nail : 13 cases
Steinmann pin : 3 cases
Flexible Intramedullary Nailing
Additional immobilization (3~5 wks)
Hip spica cast (one & half) : 18 cases
Knee immobilizer : 3 cases
Long leg splint : 1 case
Implants was removed routinely after bony
union
External Fixation
Closed reduction
Apposition
End to end : 5 cases
Side to side : 5 cases
Implant removal
Evaluation
Hospital stay, Operation time, Hospital costs
Time interval between OP & RI
LLD, malalignment
ROM
Complications
Wilcoxon-Mann-Whitney test
TEN outcome scoring
Excellent Result
Satisfactory Result
Poor Result
LLD
< 1.0 cm
< 2.0 cm
> 2.0 cm
Malalignment
5 degrees
Pain
none
Complications
none
10 degrees
>10 degrees
none
present
minor & resolved
major and/or
lasting morbidity
Flynn et al. JPO 2001
Results
Days of hospital stay
16
13.8
14
12
10
8
6
7.4
FIN
EF; 1 open fx
4
2
0
* P < 0.01
Operation time
120
104.7
100
80
78.7
FIN + HSC
60
EF
40
20
0
* P <0.05
Hospital Costs
Won
FIN
1,300,000 (57~310 만)
EF
2,750,000 (120~420만)
* P <0.05
Implant removal
Days (after Op)
FIN
107
EF
84
P = 0.15 (>0.05)
Leg length discrepancy
FIN
2.6mm (-12~11mm)
EF
9.3mm (2~29mm)
>20mm : 1 case
* P <0.05
Malalignment (Angular deformity)
FIN - No significant deformity
EF - 1 valgus deformity
Degloving injury
Open fracture
PO 18M
Range of motion (ROM)
Full ROM at final F/U in both groups
Complications
FIN group
Nail erosion : 4 cases
Temporary peroneal nerve palsy : 1 case
Refracture : 1 case
EF group
Deep pin tract infection : 3 cases (adm.& IV antibiotics)
Refracture : 1 case
Pin breakage : 1 case
TEN outcome scoring
Excellent Result
Satisfactory Result
Poor Result
FIN (N=22)
17
4
1
EF (N=10)
4
3
3
Poor result
: FIN – 1 refracture
: EF – 1 refracture, 1 LLD >2cm , 1 valgus DF
Summary
Flexible intramedullary nailing
Shorter hospital stay
Lower hospital cost
External fixation
Shorter operation time
High rate of pin tract infection & complication
 FIN than EF
due to incidence & severity of complication
Discussion
EF or FIN
Prospective, randomized study
20 fractures (10 fractures each)
FIN > EF (open or severely comminuted fx.)
: WB, ROM, return to school, Cx rate
Bar-on E, Sagiv S, Porat S JBJS(B) 1997
Conclusions
Recommand Flexible intramedullary nailing for most
pediatric femoral shaft fractures
Reserve external fixation for the length-unstable (sig.
comminution), open, some very proximal or distal
fractures.
Thank you for your attention!