Retrospective Cohort Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Sep 18, 2020; 11(9): 380-390
Published online Sep 18, 2020. doi: 10.5312/wjo.v11.i9.380
Length unstable femoral fractures: A misnomer?
Eric Andrew Mussell, Achraf Jardaly, Shawn R Gilbert
Eric Andrew Mussell, Department of Orthopaedic Surgery, University of Alabama at Birmingham, and Andrews Sports Medicine and Orthopaedic Center, Birmingham, AL 35205, United States
Achraf Jardaly, Department of Orthopedic Surgery, University of Alabama at Birmingham and Lebanese American University, Gilbert and Rose-Marie Chagoury School of Medicine, Byblos 00000, Lebanon
Shawn R Gilbert, Department of Pediatric Orthopaedics, University of Alabama at Birmingham, Birmingham, AL 35233, United States
Author contributions: Mussell EA significant contribution and willingness to take public responsibility for the study design, data acquisition, and analysis and interpretation of data, actively involved in the drafting and critical revision of the manuscript, approval of the final version of the submitted manuscript; Jardaly A significant contribution and willingness to take public responsibility for the study design, data acquisition, and analysis and interpretation of data, actively involved in the drafting and critical revision of the manuscript, approval of the final version of the submitted manuscript; Gilbert SR significant contribution and willingness to take public responsibility for the study design, data acquisition, and analysis and interpretation of data; actively involved in the drafting and critical revision of the manuscript, approval of the final version of the submitted manuscript.
Institutional review board statement: The study was reviewed and approved by the University of Alabama at Birmingham School of Medicine Institutional Review Board.
Informed consent statement: Informed consent not required.
Conflict-of-interest statement: Eric Mussell, Achraf Jardaly, and Shawn Gilbert declare that they have no conflict of interest.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at srgilbert@uabmc.edu. Consent was not obtained but the presented data are anonymized, and risk of identification is low.
STROBE statement: The STROBE Statement guidelines were adopted during this manuscript’s synthesis.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Shawn R Gilbert, MD, Surgeon, Department of Pediatric Orthopaedics, University of Alabama at Birmingham, ACC Suite 316, Children’s Hospital, 1600 7th Avenue South, Birmingham, AL 35233, United States. srgilbert@uabmc.edu
Received: May 7, 2020
Peer-review started: May 7, 2020
First decision: May 15, 2020
Revised: May 28, 2020
Accepted: August 15, 2020
Article in press: August 15, 2020
Published online: September 18, 2020
Processing time: 130 Days and 5.7 Hours
ARTICLE HIGHLIGHTS
Research background

While flexible intramedullary nailing (FIMN) is routinely recommended for length stable transverse diaphyseal femoral fractures in patients aged roughly 5-11 years old, there is lacking consensus amongst orthopaedists as to the recommended fixation method for length unstable femoral fractures for patients in this age range.

Research motivation

The motivation for this study is to identify the proper treatment modality for the subset of pediatric patients where there is lacking consensus amongst orthopaedists as to what the proper treatment method should be. We hope that our conclusions will streamline the decision-making process further for the patient’s designated physician and their family.

Research objectives

The objective of this study is to analyze the effectiveness of FIMN for pediatric diaphyseal length unstable femoral fractures in patients between the ages of 5 and 13. The effectiveness of FIMN for this subset of patients, named length unstable with FIMN, is then compared against 2 separate groups, one identified as length unstable with locked intramedullary nailing (IMN), submuscular plating (SMP), and external fixator, and the other being length stable with FIMN.

Research methods

This is a retrospective study of patients belonging to one of the three groups mentioned above.

Research results

The study included 95 fractures from 92 patients, the group of interest, length unstable with FIMN, had 21 fractures, while 45 fractures were of the length stable with FIMN group, and 29 were in the length unstable with locked IMN, SMP, and external fixator group.

When examining patient details of the groups, length unstable with FIMN and length unstable with locked IMN, SMP, and external fixator, the first group had less blood loss (P < 0.05). In terms of complications, length unstable with FIMN had 9 total complications while length unstable with locked IMN, SMP, and external fixator had 10. When stratifying these complications as minor or major, length unstable with locked IMN, SMP, and external fixator had 6 major complication while length unstable with FIMN had 0 major complications (P < 0.05).

Comparing length unstable with FIMN (n = 21) and length stable with FIMN (n = 45), the complication rates were similar. As mentioned, length unstable with FIMN had 9 total complications, with 0 being major, while length stable with FIMN had 20 total complications, with 4 being major.

Research conclusions

After analyzing the results from this single institution, retrospective comparative/ cohort study, we believe FIMN can be used for certain length unstable diaphyseal femoral fractures in patients between the ages of 5 and 13.

Research perspectives

Future studies pertaining to this topic should collect patient reported outcomes for greater follow-up while also achieving a greater sample size of patients. Lastly, future studies should work to define the appropriate parameters and/or algorithm(s) necessary for deciding if a pediatric length unstable femur fracture may still benefit from a more rigid fixation method than FIMN.