Submuscular Plating Versus Elastic Intramedullary Nailing in Children with Femoral Shaft Fracture; a systematic review and meta-analysis

Abstract

Introduction: Elastic stable intramedullary nailing (ESIN) is currently the technique of choice for pediatric femoral fractures. Submuscular plating (SMP) allows reliable healing associated with an early range of motion. The following systematic review and meta-analysis was carried out to reveal the functional and surgical outcomes of SMP and ESIN for fixation of pediatric femoral fractures and to aid in the decision-making processes for those who perform these procedures.

Methods: An extensive systematic literature review was implemented from inception to 23 February 2022. All clinical studies included had patients that were younger than 18 years old with femoral shaft fractures that compared outcomes between SMP and ESIN. Studies including patients with pathological fractures, closed femoral physis, multiple fractures, or refractures were excluded.

Results: This meta-analysis included six articles encompassing 568 patients. Of them, 206 patients were treated with SMP, while 362 were subjected to ESIN procedure. There was significantly more blood loss among patients treated with SMP (MD -45.45; 95% -61.62, -29.27; p < 0.001). The risk of postoperative adverse surgical events was significantly higher among patients subjected to the ESIN (RR 2.97 19.5; 95% 1.27, 6.98; p = 0.01). The mean hospital stay was significantly shorter among patients subjected to ESIN (SMD -1.47; 95% -2.43, -0.51; p = 0.003). Patients subjected to SMP showed significantly more EFOs when comparing Flynn Scores (OR 0.24; 95% 0.09, 0.64; p = 0.004). There was no significant difference between SMP and ESIN regarding the mean operation time, limb length discrepancy, and mean time to union.

Conclusions: Children with femoral shaft fractures can be managed effectively and safely with SMP. There was a similar surgical outcome between SMP and ESIN, but SMP had more EFOs. While SMP was associated with a low risk of postoperative adverse surgical events, it was associated with a more significant blood loss and prolonged hospital stays.

Keywords: Elastic nailing; Femoral; Fracture; Intramedullary nailing; Submuscular plating.

Fig. 1

PRISMA Flow chart showing the process of the literature search, title, abstract, full-text screening, systematic review, and meta-analysis.

Fig. 2

(A) Risk of bias graph, (B) Risk of bias summary: review authors' judgments about each risk of bias item presented as percentages across all included studies.

Fig. 3

Forest plot of summary analysis and 95% CI of (A) The mean difference in surgery duration between the submuscular platting and intramedullary nailing groups (B) The mean difference in the estimated blood loss between the submuscular platting and intramedullary nailing groups (C) The mean difference in the radiation exposure time between the submuscular platting and intramedullary nailing groups. (D) The risk ratio of adverse surgical events between the submuscular platting and intramedullary nailing groups. (E) The risk ratio of superficial infection between the submuscular platting and intramedullary nailing groups. (F) The risk ratio of deep infection between the submuscular platting and intramedullary nailing groups. The size of the green and blue squares is proportional to the statistical weight of each trial. The grey diamond represents the pooled point estimate. The positioning of both diamonds and squares (along with 95% CIs) beyond the vertical line (unit value) suggests a significant outcome (IV = inverse variance).

Fig. 4

Forest plot of summary analysis and 95% CI of (A) The standardized mean difference in hospital stay between the submuscular platting and intramedullary nailing groups (B) The risk ratio of limb length discrepancy between the submuscular platting and intramedullary nailing groups. (C) The mean difference in the mean time to union between the submuscular platting and intramedullary nailing groups (D) The risk of secondary procedures for implant removal between the submuscular platting and intramedullary nailing. (E) The risk of malunion between the submuscular platting and intramedullary nailing. (F) The odds ratio of Flynn score between the submuscular platting and intramedullary nailing groups. The size of the blue or green squares is proportional to the statistical weight of each trial. The grey diamond represents the pooled point estimate. The positioning of both diamonds and squares (along with 95% CIs) beyond the vertical line (unit value) suggests a significant outcome (IV = inverse variance).