Single incision pediatric flexible intramedullary tibial nailing

Abstract

Background: There has been a trend towards flexible intramedullary nailing for unstable tibial shaft fractures in the pediatric population, traditionally, utilizing a 2-incision technique with passage of one nail medially and one nail laterally. Our study aims to compare a single incision approach for flexible nailing of unstable tibial shaft fractures in pediatric patients to the traditional 2-incision approach. Methods: Patients were selected for operative fixation if they had a length unstable tibial shaft fracture confirmed by fluoroscopy. Exclusion criteria included length stable tibial fractures that could undergo nonoperative treatment. Single incision technique utilized the medial incision only. Patients were monitored in the hospital for one postoperative day and followed up at 4 week, 8 week, and 12 week marks. Radiographic analysis was performed to evaluate for malunion or nonunion. Operative times, infection rates and complications were recorded and analyzed. Results: All patients achieved complete fracture healing at the 12-week follow up. There were no delayed unions, nonunions or malunions in either treatment group. Conclusions: Single medial incision for tibial flexible nails had equivalent outcomes with no difference in primary healing rate, malunion or nonunion rate when compared to the dual incision technique.

Length Unstable Pediatric Tibial Shaft Fracture Treated With Cerclage Augmented Elastic Intramedullary Nails: A Novel Technique

“…This technique could be used and alleviate the difficult decision in determining the borderline “too young” adolescent patient with open physis to receive a reamed intramedullary nail, where the risk of physis arrest still is uncertain 19. The technique would allow for relative stability with a load-sharing construct and minimally invasive aspects of EIN while decreasing the morbidity associated with open plating 1. Recent studies have shown that elective hardware removal risks may not outweigh the benefit but is required in pediatric patients for continued growth 20.…”

“…19 The technique would allow for relative stability with a load-sharing construct and minimally invasive aspects of EIN while decreasing the morbidity associated with open plating. 1 Recent studies have shown that elective hardware removal risks may not outweigh the benefit but is required in pediatric patients for continued growth. 20 These risks could be lessened with reopening of a smaller less invasive incisions with EIN.…”

“…However, some surgeons may not have experience or be familiar with these systems. Open reduction and internal fixation with plate and screw constructs have been used as the gold standard for definitive stabilization of length unstable tibia fractures but are associated with the longer operative times, more blood loss, wider dissection, larger scars, periosteal stripping, wound complications, and risk of refracture after removal 1,5–7. Traditional reamed interlocking intramedullary nails typically seen in adult fracture surgery are discouraged in the skeletally immature due to injury to the proximal tibia physis and growth impedance.…”

“…F or the vast majority of pediatric lower extremity long bone fractures, closed reduction with casting has been the gold standard and continues to be a workhorse treatment modality in these injuries. 1 Periodically, closed reduction of these fractures cannot be completed or maintained due to a myriad of factors. These include fracture morphology, open injuries, polytraumatized patients, compartment syndrome, or soft tissue loss.…”

“…2 Historically, unstable tibial shaft fractures failing conservative treatment have been treated with either a closed reduction and external fixator placement or open reduction with internal fixation. 1 Presently, unilateral external fixation techniques are more appropriate for temporary stabilization of a polytraumatized patient before definitive fixation, but rarely should be used as definitive treatment. 3 Definitive fixations using circular frames are very useful because of the ability to perform closed indirect reductions and providing multiplanar stability with good outcomes.…”