ORIGINAL ARTICLE
The Management of Pediatric Subtrochanteric Femur Fractures With a Statically Locked Intramedullary Nail José A. Herrera-Soto, MD,* Robert Meuret, MD,† Jonathan H. Phillips, MD,* and Daniel J. Vogel, DO‡
Objectives: To evaluate locked intramedullary (IM) fixation as an
Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
alternative treatment method for children with subtrochanteric fractures. (J Orthop Trauma 2015;29:e7–e11)
Design: Retrospective review. Setting: Level 1 trauma center in a Children’s Hospital. Patients/Participants: Pediatric patients with subtrochanteric femur fractures with open growth plates.
Intervention: All patients were treated with a lateral entry IM locking nail.
Outcome Measurements: Patients were followed until full fracture consolidation or until implant removal. Data on time to full weight bearing, return to full activity, residual pain, any form of gait abnormality, and any other complication from follow-up visits were collected. Results: There were 9 males and 1 female patient with an average age of 12 years and average follow-up of 22 months. Most of the fractures occurred secondary to high-energy trauma. Partial weight bearing was started at 24 days and full at 66 days. Implants were removed on average at 11 months after implantation. There were neither intraoperative complications nor major complications in the postoperative period recorded after removal. Two patients presented with a longer limb on the affected side, both 8 mm, and 2 presented with asymptomatic grade I heterotopic ossification. Conclusions: The use of a statically locked lateral entry IM nail for subtrochanteric femur fractures in children is a safe and efficacious method of treatment with few complications and risks and satisfactory outcomes in children over the age of 8 years. Key Words: subtrochanteric, children, femoral nail, unstable, femur, trauma Accepted for publication May 7, 2014. From the *Center for Orthopedics at the Arnold Palmer Hospital for Children, Orlando, FL; †Orthopedic Residency Program, Orlando Regional Medical Center, Orlando, FL; and ‡Department of Orthopedics, Alpena Regional Medical Center, Alpena, MI. Presented as an Electronic Poster at the 2013 Pediatric Orthopedics Society of North America Annual Meeting, May 1–4, Toronto, Ontario, Canada. J. A. Herrera-Soto receives royalties from Biomet for the femoral submuscular plate system and from Biomet spine and is part of their speakers’ bureau; J. H. Phillips receives royalties from Biomet for the Pediatric Locking nail. The remaining authors report no conflict of interest. Reprints: José A. Herrera-Soto, MD, Center for Orthopedics at the Arnold Palmer Hospital for Children, 1222 S. Orange Avenue, Orlando, FL 32806 (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
J Orthop Trauma Volume 29, Number 1, January 2015
INTRODUCTION Subtrochanteric femur fractures in children are relatively uncommon.1–4 The incidence of subtrochanteric femur fractures in pediatric patients has been reported to be 26.0 per 100,000 with a median age of 8 years.5 In the same study, the most frequent location of the fracture was the femoral shaft (62.5%), followed by the proximal femur (12.5%).5 In very proximal femoral shaft fractures, it is difficult to maintain reduction because of muscle pull on the proximal fragment into a flexed, abducted, and externally rotated position.6 Because of the low incidence of these fractures, few articles have reported on the optimal surgical treatment.1,7 Historically, several different methods of treatment have been used with good results, including traction and casting, external fixation, open reduction and plate fixation, flexible intramedullary (IM) nailing, and cast bracing.1–3,8–13 All these methods have certain limitations and potential complications.1–3,8–16 To the best of our knowledge, there are no reports on the management of subtrochanteric femur fractures in the pediatric population with locked IM nailing. The purpose of our study was to present IM fixation as an alternative for the treatment of children with subtrochanteric femur fractures.
PATIENTS AND METHODS Between 2005 and 2011, we retrospectively reviewed all operative cases at our institution fixed with a statically locked lateral entry IM nail (Pediatric Locked Nail; Biomet, Warsaw, IN). Institutional Review Board exemption was obtained. A subtrochanteric femur fracture (OTA/AO 32DD4.1/4.2)17 is defined as a fracture of the femur at the lesser trochanter up to 10% of the total femoral length below the lesser trochanter.2 We included any patient with subtrochanteric fracture fixed with an IM locked nail. We excluded any patient with pathologic subtrochanteric femur fracture (n = 2) or those who did not include the definition of subtrochanteric femur fracture as previously discussed. Medical records and radiographs were reviewed identifying subtrochanteric femur fractures.2 We identified 18 pediatric subtrochanteric femur fractures fixed using an IM nail (Fig. 1A). All the patients had open growth plates at the www.jorthotrauma.com |
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FIGURE 1. A, Patient no. 1 at 9 years of age with a left subtrochanteric femur fracture. B, Patient no. 1 at 5 months after IM fixation demonstrating full fracture healing. C, Fourteen months postinjury, the patient demonstrates full healing and no complications after removal of the implants with normal alignment.
time of injury. One of 6 different pediatric orthopedic surgeons performed the surgeries. Postoperative protocols were very similar for all surgeons.18 The intervals for follow-up were 3–6 weeks, 3 months, 6 months, 1 year, and 2 years. Weight-bearing status was predicated upon evaluation of radiographs. Partial weight bearing was allowed once there was evidence of callus formation. Full weight bearing was allowed when at least bridging callus was seen on 3 cortices.
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Sixteen patients had available information from office records for review. Patients were followed until full fracture consolidation or until nail removal. Two patients (patients 6 and 11) were lost to follow-up, one of them at 2 months and the other at 4 months postoperative with full healing and fully ambulatory at the latest follow-up. Six patients had their implants removed at less than 1 year and were lost to follow-up after removal. All were pain free and doing well at the latest Ó 2014 Lippincott Williams & Wilkins
J Orthop Trauma Volume 29, Number 1, January 2015
follow-up but were excluded as their follow-up was less than a year. The fractures were reduced in a closed method and fixed with IMs implanted percutaneously on a fracture table with the foot in external rotation to compensate for the rotation the proximal femur adopts. The surgical method has been previously described.18,19 The key points for success are to have a central entry point on the lateral film and in the central portion of the lateral aspect of the greater trochanter on the anteroposterior view. Also, it is important to bend the nail approximately 20–30 degrees proximally and distally to allow ease of entry. This will help prevent neck shaft varus malalignment proximally if the nail is not bent. Finally, initial drilling should not exceed the central portion of the canal as this will avoid the pedestal effect of overdrilling. The pedestal effect is the blocking of passage of the nail when the calcar has been partially reamed resulting in the formation of a shelf on which the nail impinges and gets hung up. The medical records were reviewed, and the patients’ date of birth, date of injury, mechanism of injury, weight and height (to calculate the body mass index), associated injuries, estimated blood loss, operative time, length of hospital stay (LOS), intraoperative complications, and date of removal were recorded. Also, we collected data on time to full weight bearing, range of motion of hip and/or knee, return to full activity, residual pain, any form of gait abnormality and alignment, or any other complication from follow-up visits.
RESULTS There were 9 males and 1 female patient with an average age of 12 years (range, 9–14.5 years). They had an average weight of 88 pounds (range, 44–112 pounds), with an average body mass index of 19 (range, 14.7–26.2). The average follow-up for the patients was 22 months (range, 12–58 months). There were 3 transverse fractures, 5 reverse oblique fractures (one with associated comminution), and 1 oblique fracture and comminuted injury.
Pediatric Subtrochanteric Fracture
Table 1 depicts the demographic data. Most of the fractures occurred secondary to high-energy trauma (motor vehicle accidents or contact sports). Two patients were hit by a car and had associated injuries, including tension pneumothorax, humerus fractures, and other long bone fractures. The average operating time was 83 minutes (range, 45–115 minutes). The average blood loss during surgery was 56 mL (range, 50–100 mL). There were no intraoperative complications recorded. The average length of stay (LOS) was 5 days (range, 2–15 days), including the multiply injured patients (n = 2). The patients with isolated subtrochanteric femur fractures had an LOS of 2.6 days (range, 2–3 days). Partial weight bearing was started on average 23 days from the day of surgery (range, 13–34 days), as most of these were unstable. Full weight bearing was initiated on average at 60 days (range, 45–100 days). The radiographic follow-up of the patients (Fig. 1B) revealed that the mean time to fracture healing was 94 days (range, 66–154 days). All 10 patients had the implants removed at an average of 11 months from the date of surgery with a range of 9–13 months. All patients followed demonstrated radiographic evidence of a healed fracture and were bearing full weight at the time of implant removal and at the latest follow-up (Fig. 1C). The average operative time for removal was 51 minutes (range, 31–74 minutes). Table 2 shows the data for each patient regarding comparison of neck shaft angles of the affected side and the nonaffected side. Both groups averaged 146 degrees. The average absolute difference between sides was 2.4 degrees (range, 25 to 4 degrees).
Complications Three patients complained postoperatively of limping after starting full weight bearing. The limp resolved in all between 3 and 5 months postoperative with physiotherapy. There were 2 patients with a limb length discrepancy of 8 mm, which was longer on the fractured side (see Table 2). There was no incidence of clinical rotational malalignments of the affected limb, when we compared prone examination of
TABLE 1. Demographic and Operative Data Patient Gender
Age
Body Mass Index
Associated Injuries
1 3 5 7 10 13 14
M M M M M M M
9 y 1 mo 14 y 11 y 2 mo 9 y 2 mo 11 y 3 mo 11 y 4 mo 14 y 4 m
14.7 20.5 14.1 22.6 16.9 26.2 17.2
15
F
10 y 4 mo
24.7
14 y 5 mo 12 y 9 mo 12 y
20.5 15.4 19.0
None None None None None None Rt open humerus and distal femur Rt distal 1/3 TF, bilateral pubic rami R prox humerus, tension pneumothorax None None
16 M 18 M Average
Type of Fracture Transverse Reverse oblique Reverse oblique Reverse oblique Reverse oblique Transverse Transverse Oblique Reverse oblique and comminuted Comminuted
Time to Removal (mo) Follow-Up 10 16 9 12 8 11.5 11
1.2 4.8 1.1 1.3 2.1 1.0 1.0
8
2.0
11 13 11
2.0 1.2 1.8
Fx, fracture; HO, heterotopic ossification; LLD, limb length discrepancy; Rt, Right; R prox, Right proximal; TF, Tibio-Fibula.
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Herrera-Soto et al
TABLE 2. Neck Shaft Angle at Latest Follow-Up Patient
Complications
1 3 5 7 10 13 14 15 16 18 Average
None Grade I HO None 8 mm LLD 8 mm LLD None None None Grade I HO None
Affected Side
Nonaffected Side
146 152 146 144 147 140 144 153 141 NA 145.7
NA 148 145 144 143 141 149 155 139 NA 145.5
HO, heterotopic ossification; LLD, limb length discrepancy; NA, Not available.
femoral version. We had 2 instances of asymptomatic grade I heterotopic ossification on the trochanteric entry site. Eight of the 10 patients had full lower extremity films at the 1- or 2-year follow-ups and did not present with mechanical malalignment or malunion. All the patients demonstrated solid fusion of the fracture site, and there was no evidence of malangulation noted on follow-up full femur films. There were no cases of avascular necrosis of the femoral head. No fixation revisions were needed. There was no refracture during healing or after nail removal.
DISCUSSION The incidence of subtrochanteric femur fractures is around 12% of all femur fractures. There are only a few publications that report the results of its management. Other methods have exhibited problems, including malunion, overgrowth of the femur, infections, and refracture.1–3,8–15 Only a small number of minor complications were seen, and they can be connected to the initial injury, including trochanteric irritation that resolved and 2 grade I asymptomatic heterotopic ossifications at the nail entry site. We only use the nail in patients older than 8 years to prevent injuring the apophyseal proximal femoral growth that may lead to coxa valga.20 With a lateral entry IM locked nail, the same benefits can be obtained as in adult fractures treated in the same manner.21,22 The locked nail controls rotation and prevents shortening while maintaining the alignment of the fracture.21,22 An added benefit of a locked nail as opposed to nonlocked flexible nails is the quicker return to full weight bearing and absence of postoperative immobilization as previously reported.19 Complications reported with fixation of these injuries include prolonged time of recovery, loss of reduction, shortening, nail irritation on the subcutaneous tissues, femoral overgrowth, scar issues, and limping.1–3,10–16,23,24 The use of titanium elastic nails has been shown to have good results. Some studies recommended a more proximal placement of the elastic nails to control rotation in subtrochanteric fractures but still had residual angulation and loss of reduction.23,25 Our patients demonstrated on average similar neck shaft angles
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with 5 degrees being the largest difference between sides. To our knowledge, there are no reports to date regarding the use of a statically locked cephalomedullary device for pediatric subtrochanteric femur fractures. There are other methods of treatment of subtrochanteric fractures in the pediatric population. Theologis and Cole7 examined 99 pediatric subtrochanteric femur fractures noting that closed reduction and hip spica cast yielded 80% satisfactory outcomes and 27% required remanipulation. They noted that satisfactory outcomes in the traction and delayed spica group approached 100% when traction pins were abandoned and skin traction was applied. Long-term traction pins showed persistent femoral overlengthening and pin site pain. When the same authors evaluated children treated with surgical means, the satisfactory radiographic outcomes were 100%. The patient-determined outcomes were only 60% satisfactory, on those studies. The average age of the patients treated surgically was 10 years. Forty percent of those patients treated with plate and screw had persistent thigh pain even after removal of the hardware. In addition, recent reports have given rise to concerns of high refracture rates26 and valgus development.27 The patients treated with closed reduction and IM fixation did not have this problem in the long run. In our series, we did not observe malalignment, infections, or refracture. More importantly, none of the patients developed osteonecrosis of the femoral head.28 We only had 2 patients with a minor limb length discrepancy (8 mm longer on the affected leg) that did not require treatment. We believe that locking the nail controlled the alignment and that the nail was mechanically strong enough to support early weight bearing, on average 23 days, without displacement of the fracture or structural failure of the implant. We saw no significant surgical complications, except 2 asymptomatic grade I heterotopic bone formation. In addition, surgical scarring from this percutaneous technique was minimal when compared with plating techniques and external fixation.8,9 Infections are rare, and most are from the use of external fixation.1,13–15 We had no refracture during healing or after nail removal. No patient developed nonunion or malunion. There were 6 different surgeons treating the patients, but there was no apparent difference in outcomes. This is probably because of adhering to similar surgical technique and postoperative treatment protocols. However, the surgical technique for use of this nail is not demanding and is reproducible.18,19 One of the limitations to our study is the number of subjects. Though subtrochanteric femur fractures are rare in children and adults, we were able to identify 18 in a 6-year period treated at our institution and we lost to follow-up 6 of them before 1 year from surgery. Office notes were only available for review for 16 as we lost 2 patients to follow-up. We also lost 2 more patients before removal of the nail; both of them showed fracture healing before being lost to followup. Another limitation of this study is the lack of a standardized method for evaluating the patients’ perceived outcome and level of happiness. Possibly using the Childhood Health Assessment Questionnaire would help better evaluate the patients’ outcomes.7 It seemed from reviewing the charts that the patients were able to participate in the activities that they desired and did not have limitations. Ó 2014 Lippincott Williams & Wilkins
J Orthop Trauma Volume 29, Number 1, January 2015
A persistent limp was noticed in 3 patients but had resolved in all by 5 months after the injury. Thigh pain and limp are also associated with other treatment methods, surgical and nonsurgical, and they are inherent of the injury sustained.7 We believe that the limp and thigh pain are related to the healing fracture and disuse of the affected extremity, as it will be in other types of treatment. It will not be surprising that there is some level of atrophy that had developed in the fractured side. In conclusion, we believe that the use of a statically locked lateral entry IM nail for subtrochanteric femur fractures in children older than 8 years is an acceptable alternative method of treatment with few complications and risks and satisfactory short-term outcomes. It is a safe and efficacious method of treating subtrochanteric femur fractures in children older than 8 years. With more patients and longer outcomes, we hope to strengthen and build on this treatment method. REFERENCES 1. Jarvis J, Davidson D, Letts M. Management of subtrochanteric fractures in skeletally immature adolescents. J Trauma. 2006;60:613–619. 2. Pombo MW, Shilt JS. The definition and treatment of pediatric subtrochanteric femur fractures with titanium elastic nails. J Pediatr Orthop. 2006;26:364–370. 3. Lascombes P, Haumont T, Journeau P. Use and abuse of flexible intramedullary nailing in children and adolescents. J Pediatr Orthop. 2006; 26:827–834. 4. Lundy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg. 2007;15:663–671. 5. Rewers A, Hedegaard H, Lezotte D, et al. Childhood femur fractures, associated injuries, and sociodemographic risk factors: a populationbased study. Pediatrics. 2005;115:e543–552. 6. Ireland DC, Fisher RL. Subtrochanteric fractures of the femur in children. Clin Orthop Relat Res. 1975;157–166. 7. Theologis TN, Cole WG. Management of subtrochanteric fractures of the femur in children. J Pediatr Orthop. 1998;18:22–25. 8. Lundy DW, Acevedo JI, Ganey TM, et al. Mechanical comparison of plates used in the treatment of unstable subtrochanteric femur fractures. J Orthop Trauma. 1999;13:534–538. 9. van Meeteren MC, van Rief YE, Roukema JA, et al. Condylar plate fixation of subtrochanteric femoral fractures. Injury. 1996;27:715–717. 10. DeLee JC, Clanton TO, Rockwood CA Jr. Closed treatment of subtrochanteric fractures of the femur in a modified cast-brace. J Bone Joint Surg Am. 1981;63:773–779. 11. El-Sayed M, Abulsaad M, El-Hadidi M, et al. Reconstruction plate fixation of subtrochanteric femoral fractures in children. Acta Orthop Belg. 2007;73:484–490.
Ó 2014 Lippincott Williams & Wilkins
Pediatric Subtrochanteric Fracture 12. Blasier RD, Aronson J, Tursky EA. External fixation of pediatric femur fractures. J Pediatr Orthop. 1997;17:342–346. 13. Miner T, Carroll KL. Outcomes of external fixation of pediatric femoral shaft fractures. J Pediatr Orthop. 2000;20:405–410. 14. Carmichael KD, Bynum J, Goucher N. Rates of refracture associated with external fixation in pediatric femur fractures. Am J Orthop (Belle Mead NJ). 2005;34:439–444; discussion 444. 15. Matzkin EG, Smith EL, Wilson A, et al. External fixation of pediatric femur fractures with cortical contact. Am J Orthop (Belle Mead NJ). 2006;35:498–501. 16. Jeng C, Sponseller PD, Yates A, et al. Subtrochanteric femoral fractures in children. Alignment after 90 degrees-90 degrees traction and cast application. Clin Orthop Relat Res. 1997;170–174. 17. Slongo TF, Audige L; Group AOPC. Fracture and dislocation classification compendium for children: the AO pediatric comprehensive classification of long bone fractures (PCCF). J Orthop Trauma. 2007;21(suppl): S135–S160. 18. Phillips JH. Operative Treatment of Femur Fractures Using a Greater Trochanteric Entry IM Nail. Vol Pediatrics. Philadelphia, PA: Lippincott Williams & Wilkins; 2008. 19. Jencikova-Celerin L, Phillips JH, Werk LN, et al. Flexible interlocked nailing of pediatric femoral fractures: experience with a new flexible interlocking intramedullary nail compared with other fixation procedures. J Pediatr Orthop. 2008;28:864–873. 20. Gage JR, Cary JM. The effects of trochanteric epiphyseodesis on growth of the proximal end of the femur following necrosis of the capital femoral epiphysis. J Bone Joint Surg Am. 1980;62:785–794. 21. Pugh KJ, Morgan RA, Gorczyca JT, et al. A mechanical comparison of subtrochanteric femur fracture fixation. J Orthop Trauma. 1998;12: 324–329. 22. Wiss DA, Brien WW. Subtrochanteric fractures of the femur. Results of treatment by interlocking nailing. Clin Orthop Relat Res. 1992;231–236. 23. Flynn JM, Luedtke L, Ganley TJ, et al. Titanium elastic nails for pediatric femur fractures: lessons from the learning curve. Am J Orthop (Belle Mead NJ). 2002;31:71–74. 24. Flynn JM, Schwend RM. Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg. 2004;12:347–359. 25. Moroz LA, Launay F, Kocher MS, et al. Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome. J Bone Joint Surg Br. 2006;88:1361–1366. 26. Becker T, Weigl D, Mercado E, et al. Fractures and refractures after femoral locking compression plate fixation in children and adolescents. J Pediatr Orthop. 2012;32:e40–46. 27. Heyworth BE, Hedequist DJ, Nasreddine AY, et al. Distal femoral valgus deformity following plate fixation of pediatric femoral shaft fractures. J Bone Joint Surg Am. Mar 20 2013;95(6):526–533. 28. Keeler KA, Dart B, Luhmann SJ, et al. Antegrade intramedullary nailing of pediatric femoral fractures using an interlocking pediatric femoral nail and a lateral trochanteric entry point. J Pediatr Orthop. 2009;29: 345–351.
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The Management of Pediatric Subtrochanteric Femur Fractures With a Statically Locked Intramedullary Nail José A. Herrera-Soto, MD,* Robert Meuret, MD,† Jonathan H. Phillips, MD,* and Daniel J. Vogel, DO‡
Objectives: To evaluate locked intramedullary (IM) fixation as an
Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
alternative treatment method for children with subtrochanteric fractures. (J Orthop Trauma 2015;29:e7–e11)
Design: Retrospective review. Setting: Level 1 trauma center in a Children’s Hospital. Patients/Participants: Pediatric patients with subtrochanteric femur fractures with open growth plates.
Intervention: All patients were treated with a lateral entry IM locking nail.
Outcome Measurements: Patients were followed until full fracture consolidation or until implant removal. Data on time to full weight bearing, return to full activity, residual pain, any form of gait abnormality, and any other complication from follow-up visits were collected. Results: There were 9 males and 1 female patient with an average age of 12 years and average follow-up of 22 months. Most of the fractures occurred secondary to high-energy trauma. Partial weight bearing was started at 24 days and full at 66 days. Implants were removed on average at 11 months after implantation. There were neither intraoperative complications nor major complications in the postoperative period recorded after removal. Two patients presented with a longer limb on the affected side, both 8 mm, and 2 presented with asymptomatic grade I heterotopic ossification. Conclusions: The use of a statically locked lateral entry IM nail for subtrochanteric femur fractures in children is a safe and efficacious method of treatment with few complications and risks and satisfactory outcomes in children over the age of 8 years. Key Words: subtrochanteric, children, femoral nail, unstable, femur, trauma Accepted for publication May 7, 2014. From the *Center for Orthopedics at the Arnold Palmer Hospital for Children, Orlando, FL; †Orthopedic Residency Program, Orlando Regional Medical Center, Orlando, FL; and ‡Department of Orthopedics, Alpena Regional Medical Center, Alpena, MI. Presented as an Electronic Poster at the 2013 Pediatric Orthopedics Society of North America Annual Meeting, May 1–4, Toronto, Ontario, Canada. J. A. Herrera-Soto receives royalties from Biomet for the femoral submuscular plate system and from Biomet spine and is part of their speakers’ bureau; J. H. Phillips receives royalties from Biomet for the Pediatric Locking nail. The remaining authors report no conflict of interest. Reprints: José A. Herrera-Soto, MD, Center for Orthopedics at the Arnold Palmer Hospital for Children, 1222 S. Orange Avenue, Orlando, FL 32806 (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
J Orthop Trauma Volume 29, Number 1, January 2015
INTRODUCTION Subtrochanteric femur fractures in children are relatively uncommon.1–4 The incidence of subtrochanteric femur fractures in pediatric patients has been reported to be 26.0 per 100,000 with a median age of 8 years.5 In the same study, the most frequent location of the fracture was the femoral shaft (62.5%), followed by the proximal femur (12.5%).5 In very proximal femoral shaft fractures, it is difficult to maintain reduction because of muscle pull on the proximal fragment into a flexed, abducted, and externally rotated position.6 Because of the low incidence of these fractures, few articles have reported on the optimal surgical treatment.1,7 Historically, several different methods of treatment have been used with good results, including traction and casting, external fixation, open reduction and plate fixation, flexible intramedullary (IM) nailing, and cast bracing.1–3,8–13 All these methods have certain limitations and potential complications.1–3,8–16 To the best of our knowledge, there are no reports on the management of subtrochanteric femur fractures in the pediatric population with locked IM nailing. The purpose of our study was to present IM fixation as an alternative for the treatment of children with subtrochanteric femur fractures.
PATIENTS AND METHODS Between 2005 and 2011, we retrospectively reviewed all operative cases at our institution fixed with a statically locked lateral entry IM nail (Pediatric Locked Nail; Biomet, Warsaw, IN). Institutional Review Board exemption was obtained. A subtrochanteric femur fracture (OTA/AO 32DD4.1/4.2)17 is defined as a fracture of the femur at the lesser trochanter up to 10% of the total femoral length below the lesser trochanter.2 We included any patient with subtrochanteric fracture fixed with an IM locked nail. We excluded any patient with pathologic subtrochanteric femur fracture (n = 2) or those who did not include the definition of subtrochanteric femur fracture as previously discussed. Medical records and radiographs were reviewed identifying subtrochanteric femur fractures.2 We identified 18 pediatric subtrochanteric femur fractures fixed using an IM nail (Fig. 1A). All the patients had open growth plates at the www.jorthotrauma.com |
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FIGURE 1. A, Patient no. 1 at 9 years of age with a left subtrochanteric femur fracture. B, Patient no. 1 at 5 months after IM fixation demonstrating full fracture healing. C, Fourteen months postinjury, the patient demonstrates full healing and no complications after removal of the implants with normal alignment.
time of injury. One of 6 different pediatric orthopedic surgeons performed the surgeries. Postoperative protocols were very similar for all surgeons.18 The intervals for follow-up were 3–6 weeks, 3 months, 6 months, 1 year, and 2 years. Weight-bearing status was predicated upon evaluation of radiographs. Partial weight bearing was allowed once there was evidence of callus formation. Full weight bearing was allowed when at least bridging callus was seen on 3 cortices.
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Sixteen patients had available information from office records for review. Patients were followed until full fracture consolidation or until nail removal. Two patients (patients 6 and 11) were lost to follow-up, one of them at 2 months and the other at 4 months postoperative with full healing and fully ambulatory at the latest follow-up. Six patients had their implants removed at less than 1 year and were lost to follow-up after removal. All were pain free and doing well at the latest Ó 2014 Lippincott Williams & Wilkins
J Orthop Trauma Volume 29, Number 1, January 2015
follow-up but were excluded as their follow-up was less than a year. The fractures were reduced in a closed method and fixed with IMs implanted percutaneously on a fracture table with the foot in external rotation to compensate for the rotation the proximal femur adopts. The surgical method has been previously described.18,19 The key points for success are to have a central entry point on the lateral film and in the central portion of the lateral aspect of the greater trochanter on the anteroposterior view. Also, it is important to bend the nail approximately 20–30 degrees proximally and distally to allow ease of entry. This will help prevent neck shaft varus malalignment proximally if the nail is not bent. Finally, initial drilling should not exceed the central portion of the canal as this will avoid the pedestal effect of overdrilling. The pedestal effect is the blocking of passage of the nail when the calcar has been partially reamed resulting in the formation of a shelf on which the nail impinges and gets hung up. The medical records were reviewed, and the patients’ date of birth, date of injury, mechanism of injury, weight and height (to calculate the body mass index), associated injuries, estimated blood loss, operative time, length of hospital stay (LOS), intraoperative complications, and date of removal were recorded. Also, we collected data on time to full weight bearing, range of motion of hip and/or knee, return to full activity, residual pain, any form of gait abnormality and alignment, or any other complication from follow-up visits.
RESULTS There were 9 males and 1 female patient with an average age of 12 years (range, 9–14.5 years). They had an average weight of 88 pounds (range, 44–112 pounds), with an average body mass index of 19 (range, 14.7–26.2). The average follow-up for the patients was 22 months (range, 12–58 months). There were 3 transverse fractures, 5 reverse oblique fractures (one with associated comminution), and 1 oblique fracture and comminuted injury.
Pediatric Subtrochanteric Fracture
Table 1 depicts the demographic data. Most of the fractures occurred secondary to high-energy trauma (motor vehicle accidents or contact sports). Two patients were hit by a car and had associated injuries, including tension pneumothorax, humerus fractures, and other long bone fractures. The average operating time was 83 minutes (range, 45–115 minutes). The average blood loss during surgery was 56 mL (range, 50–100 mL). There were no intraoperative complications recorded. The average length of stay (LOS) was 5 days (range, 2–15 days), including the multiply injured patients (n = 2). The patients with isolated subtrochanteric femur fractures had an LOS of 2.6 days (range, 2–3 days). Partial weight bearing was started on average 23 days from the day of surgery (range, 13–34 days), as most of these were unstable. Full weight bearing was initiated on average at 60 days (range, 45–100 days). The radiographic follow-up of the patients (Fig. 1B) revealed that the mean time to fracture healing was 94 days (range, 66–154 days). All 10 patients had the implants removed at an average of 11 months from the date of surgery with a range of 9–13 months. All patients followed demonstrated radiographic evidence of a healed fracture and were bearing full weight at the time of implant removal and at the latest follow-up (Fig. 1C). The average operative time for removal was 51 minutes (range, 31–74 minutes). Table 2 shows the data for each patient regarding comparison of neck shaft angles of the affected side and the nonaffected side. Both groups averaged 146 degrees. The average absolute difference between sides was 2.4 degrees (range, 25 to 4 degrees).
Complications Three patients complained postoperatively of limping after starting full weight bearing. The limp resolved in all between 3 and 5 months postoperative with physiotherapy. There were 2 patients with a limb length discrepancy of 8 mm, which was longer on the fractured side (see Table 2). There was no incidence of clinical rotational malalignments of the affected limb, when we compared prone examination of
TABLE 1. Demographic and Operative Data Patient Gender
Age
Body Mass Index
Associated Injuries
1 3 5 7 10 13 14
M M M M M M M
9 y 1 mo 14 y 11 y 2 mo 9 y 2 mo 11 y 3 mo 11 y 4 mo 14 y 4 m
14.7 20.5 14.1 22.6 16.9 26.2 17.2
15
F
10 y 4 mo
24.7
14 y 5 mo 12 y 9 mo 12 y
20.5 15.4 19.0
None None None None None None Rt open humerus and distal femur Rt distal 1/3 TF, bilateral pubic rami R prox humerus, tension pneumothorax None None
16 M 18 M Average
Type of Fracture Transverse Reverse oblique Reverse oblique Reverse oblique Reverse oblique Transverse Transverse Oblique Reverse oblique and comminuted Comminuted
Time to Removal (mo) Follow-Up 10 16 9 12 8 11.5 11
1.2 4.8 1.1 1.3 2.1 1.0 1.0
8
2.0
11 13 11
2.0 1.2 1.8
Fx, fracture; HO, heterotopic ossification; LLD, limb length discrepancy; Rt, Right; R prox, Right proximal; TF, Tibio-Fibula.
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Herrera-Soto et al
TABLE 2. Neck Shaft Angle at Latest Follow-Up Patient
Complications
1 3 5 7 10 13 14 15 16 18 Average
None Grade I HO None 8 mm LLD 8 mm LLD None None None Grade I HO None
Affected Side
Nonaffected Side
146 152 146 144 147 140 144 153 141 NA 145.7
NA 148 145 144 143 141 149 155 139 NA 145.5
HO, heterotopic ossification; LLD, limb length discrepancy; NA, Not available.
femoral version. We had 2 instances of asymptomatic grade I heterotopic ossification on the trochanteric entry site. Eight of the 10 patients had full lower extremity films at the 1- or 2-year follow-ups and did not present with mechanical malalignment or malunion. All the patients demonstrated solid fusion of the fracture site, and there was no evidence of malangulation noted on follow-up full femur films. There were no cases of avascular necrosis of the femoral head. No fixation revisions were needed. There was no refracture during healing or after nail removal.
DISCUSSION The incidence of subtrochanteric femur fractures is around 12% of all femur fractures. There are only a few publications that report the results of its management. Other methods have exhibited problems, including malunion, overgrowth of the femur, infections, and refracture.1–3,8–15 Only a small number of minor complications were seen, and they can be connected to the initial injury, including trochanteric irritation that resolved and 2 grade I asymptomatic heterotopic ossifications at the nail entry site. We only use the nail in patients older than 8 years to prevent injuring the apophyseal proximal femoral growth that may lead to coxa valga.20 With a lateral entry IM locked nail, the same benefits can be obtained as in adult fractures treated in the same manner.21,22 The locked nail controls rotation and prevents shortening while maintaining the alignment of the fracture.21,22 An added benefit of a locked nail as opposed to nonlocked flexible nails is the quicker return to full weight bearing and absence of postoperative immobilization as previously reported.19 Complications reported with fixation of these injuries include prolonged time of recovery, loss of reduction, shortening, nail irritation on the subcutaneous tissues, femoral overgrowth, scar issues, and limping.1–3,10–16,23,24 The use of titanium elastic nails has been shown to have good results. Some studies recommended a more proximal placement of the elastic nails to control rotation in subtrochanteric fractures but still had residual angulation and loss of reduction.23,25 Our patients demonstrated on average similar neck shaft angles
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with 5 degrees being the largest difference between sides. To our knowledge, there are no reports to date regarding the use of a statically locked cephalomedullary device for pediatric subtrochanteric femur fractures. There are other methods of treatment of subtrochanteric fractures in the pediatric population. Theologis and Cole7 examined 99 pediatric subtrochanteric femur fractures noting that closed reduction and hip spica cast yielded 80% satisfactory outcomes and 27% required remanipulation. They noted that satisfactory outcomes in the traction and delayed spica group approached 100% when traction pins were abandoned and skin traction was applied. Long-term traction pins showed persistent femoral overlengthening and pin site pain. When the same authors evaluated children treated with surgical means, the satisfactory radiographic outcomes were 100%. The patient-determined outcomes were only 60% satisfactory, on those studies. The average age of the patients treated surgically was 10 years. Forty percent of those patients treated with plate and screw had persistent thigh pain even after removal of the hardware. In addition, recent reports have given rise to concerns of high refracture rates26 and valgus development.27 The patients treated with closed reduction and IM fixation did not have this problem in the long run. In our series, we did not observe malalignment, infections, or refracture. More importantly, none of the patients developed osteonecrosis of the femoral head.28 We only had 2 patients with a minor limb length discrepancy (8 mm longer on the affected leg) that did not require treatment. We believe that locking the nail controlled the alignment and that the nail was mechanically strong enough to support early weight bearing, on average 23 days, without displacement of the fracture or structural failure of the implant. We saw no significant surgical complications, except 2 asymptomatic grade I heterotopic bone formation. In addition, surgical scarring from this percutaneous technique was minimal when compared with plating techniques and external fixation.8,9 Infections are rare, and most are from the use of external fixation.1,13–15 We had no refracture during healing or after nail removal. No patient developed nonunion or malunion. There were 6 different surgeons treating the patients, but there was no apparent difference in outcomes. This is probably because of adhering to similar surgical technique and postoperative treatment protocols. However, the surgical technique for use of this nail is not demanding and is reproducible.18,19 One of the limitations to our study is the number of subjects. Though subtrochanteric femur fractures are rare in children and adults, we were able to identify 18 in a 6-year period treated at our institution and we lost to follow-up 6 of them before 1 year from surgery. Office notes were only available for review for 16 as we lost 2 patients to follow-up. We also lost 2 more patients before removal of the nail; both of them showed fracture healing before being lost to followup. Another limitation of this study is the lack of a standardized method for evaluating the patients’ perceived outcome and level of happiness. Possibly using the Childhood Health Assessment Questionnaire would help better evaluate the patients’ outcomes.7 It seemed from reviewing the charts that the patients were able to participate in the activities that they desired and did not have limitations. Ó 2014 Lippincott Williams & Wilkins
J Orthop Trauma Volume 29, Number 1, January 2015
A persistent limp was noticed in 3 patients but had resolved in all by 5 months after the injury. Thigh pain and limp are also associated with other treatment methods, surgical and nonsurgical, and they are inherent of the injury sustained.7 We believe that the limp and thigh pain are related to the healing fracture and disuse of the affected extremity, as it will be in other types of treatment. It will not be surprising that there is some level of atrophy that had developed in the fractured side. In conclusion, we believe that the use of a statically locked lateral entry IM nail for subtrochanteric femur fractures in children older than 8 years is an acceptable alternative method of treatment with few complications and risks and satisfactory short-term outcomes. It is a safe and efficacious method of treating subtrochanteric femur fractures in children older than 8 years. With more patients and longer outcomes, we hope to strengthen and build on this treatment method. REFERENCES 1. Jarvis J, Davidson D, Letts M. Management of subtrochanteric fractures in skeletally immature adolescents. J Trauma. 2006;60:613–619. 2. Pombo MW, Shilt JS. The definition and treatment of pediatric subtrochanteric femur fractures with titanium elastic nails. J Pediatr Orthop. 2006;26:364–370. 3. Lascombes P, Haumont T, Journeau P. Use and abuse of flexible intramedullary nailing in children and adolescents. J Pediatr Orthop. 2006; 26:827–834. 4. Lundy DW. Subtrochanteric femoral fractures. J Am Acad Orthop Surg. 2007;15:663–671. 5. Rewers A, Hedegaard H, Lezotte D, et al. Childhood femur fractures, associated injuries, and sociodemographic risk factors: a populationbased study. Pediatrics. 2005;115:e543–552. 6. Ireland DC, Fisher RL. Subtrochanteric fractures of the femur in children. Clin Orthop Relat Res. 1975;157–166. 7. Theologis TN, Cole WG. Management of subtrochanteric fractures of the femur in children. J Pediatr Orthop. 1998;18:22–25. 8. Lundy DW, Acevedo JI, Ganey TM, et al. Mechanical comparison of plates used in the treatment of unstable subtrochanteric femur fractures. J Orthop Trauma. 1999;13:534–538. 9. van Meeteren MC, van Rief YE, Roukema JA, et al. Condylar plate fixation of subtrochanteric femoral fractures. Injury. 1996;27:715–717. 10. DeLee JC, Clanton TO, Rockwood CA Jr. Closed treatment of subtrochanteric fractures of the femur in a modified cast-brace. J Bone Joint Surg Am. 1981;63:773–779. 11. El-Sayed M, Abulsaad M, El-Hadidi M, et al. Reconstruction plate fixation of subtrochanteric femoral fractures in children. Acta Orthop Belg. 2007;73:484–490.
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Pediatric Subtrochanteric Fracture 12. Blasier RD, Aronson J, Tursky EA. External fixation of pediatric femur fractures. J Pediatr Orthop. 1997;17:342–346. 13. Miner T, Carroll KL. Outcomes of external fixation of pediatric femoral shaft fractures. J Pediatr Orthop. 2000;20:405–410. 14. Carmichael KD, Bynum J, Goucher N. Rates of refracture associated with external fixation in pediatric femur fractures. Am J Orthop (Belle Mead NJ). 2005;34:439–444; discussion 444. 15. Matzkin EG, Smith EL, Wilson A, et al. External fixation of pediatric femur fractures with cortical contact. Am J Orthop (Belle Mead NJ). 2006;35:498–501. 16. Jeng C, Sponseller PD, Yates A, et al. Subtrochanteric femoral fractures in children. Alignment after 90 degrees-90 degrees traction and cast application. Clin Orthop Relat Res. 1997;170–174. 17. Slongo TF, Audige L; Group AOPC. Fracture and dislocation classification compendium for children: the AO pediatric comprehensive classification of long bone fractures (PCCF). J Orthop Trauma. 2007;21(suppl): S135–S160. 18. Phillips JH. Operative Treatment of Femur Fractures Using a Greater Trochanteric Entry IM Nail. Vol Pediatrics. Philadelphia, PA: Lippincott Williams & Wilkins; 2008. 19. Jencikova-Celerin L, Phillips JH, Werk LN, et al. Flexible interlocked nailing of pediatric femoral fractures: experience with a new flexible interlocking intramedullary nail compared with other fixation procedures. J Pediatr Orthop. 2008;28:864–873. 20. Gage JR, Cary JM. The effects of trochanteric epiphyseodesis on growth of the proximal end of the femur following necrosis of the capital femoral epiphysis. J Bone Joint Surg Am. 1980;62:785–794. 21. Pugh KJ, Morgan RA, Gorczyca JT, et al. A mechanical comparison of subtrochanteric femur fracture fixation. J Orthop Trauma. 1998;12: 324–329. 22. Wiss DA, Brien WW. Subtrochanteric fractures of the femur. Results of treatment by interlocking nailing. Clin Orthop Relat Res. 1992;231–236. 23. Flynn JM, Luedtke L, Ganley TJ, et al. Titanium elastic nails for pediatric femur fractures: lessons from the learning curve. Am J Orthop (Belle Mead NJ). 2002;31:71–74. 24. Flynn JM, Schwend RM. Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg. 2004;12:347–359. 25. Moroz LA, Launay F, Kocher MS, et al. Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome. J Bone Joint Surg Br. 2006;88:1361–1366. 26. Becker T, Weigl D, Mercado E, et al. Fractures and refractures after femoral locking compression plate fixation in children and adolescents. J Pediatr Orthop. 2012;32:e40–46. 27. Heyworth BE, Hedequist DJ, Nasreddine AY, et al. Distal femoral valgus deformity following plate fixation of pediatric femoral shaft fractures. J Bone Joint Surg Am. Mar 20 2013;95(6):526–533. 28. Keeler KA, Dart B, Luhmann SJ, et al. Antegrade intramedullary nailing of pediatric femoral fractures using an interlocking pediatric femoral nail and a lateral trochanteric entry point. J Pediatr Orthop. 2009;29: 345–351.
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