Do demographic and perioperative parameters really affect the final outcomes of pediatric femur shaft fractures managed by elastic nails? A prospective study

Abstract

Objective: Pediatric femoral shaft fractures are more commonly treated with intramedullary titanium elastic nail system (TENS). Adhering to the principles, most studies had supported excellent results with this instrumentation and attributed the variation in age, weight, immobilization protocols, technical factors like fracture pattern, reduction and complications as reasons to poor outcomes in their individual studies. Hence, we wanted to identify the potential demographic and perioperative parameters that could affect the final outcomes in this cohort.

Methods: A prospective (level III) study done in a single center between November 2013 and January 2017 on isolated closed femoral shaft fractures in patients of age between 6 and 15 years managed with TENS. The demographic and perioperative parameters were recorded. The patients were followed up regularly with plain radiographs. The final outcomes were computed at end of one year and recorded as poor, satisfactory and excellent as defined by Flynn criteria.

Results: Among the thirty patients included, mean age was 8.2 years. 80% of the patients weighing over 40 kg had satisfactory to poor outcomes. (p = 0.005). 45% of patients with proximal and distal level fractures that were long oblique spiral or comminuted types had satisfactory outcomes; however it was not statistically significant. The mean delay to surgical fixation was 5.87 days, surgical time was between 45 and 150 min and open reduction was required in about 17 cases (57%). Patients with immobilization beyond 6 weeks had satisfactory outcomes (p = 0.001). We had 5 patients with minor complications (4 bursitis and 3 superficial infections) and one major complication (chronic osteomyelitis and deep venous thrombosis) leading to satisfactory and poor outcomes respectively. Significant osseous union was noted between 6 and 11 months with 97% of patients attaining union within 9 months.

Conclusions: Intramedullary TENS is an excellent modality to treat femoral shaft fractures in patients of school going age. However, factors like weight of the patient >40 kg, immobilization beyond 6 weeks, minor and major complications in the perioperative period could pose risks for poor to satisfactory outcomes and should be anticipated and explained accordingly.

Keywords: Demographic factors; Flynn criteria; Pediatric shaft femur fractures; Perioperative factors; Titanium elastic nail system.