Thierry Haumont

Use and abuse of flexible intramedullary nailing in children and adolescents.

Abstract: Elastic stable intramedullary nailing (ESIN) has became a well-accepted method of osteosynthesis of diaphyseal fractures in children and adolescents for many reasons including the following: no need for postoperative cast, primary bone union with avoidance of growth plate injury, and minimum invasive surgery. Operative technique: The principle is to introduce 2 elastic nails, titanium or stainless steel, into the medullary canal through a metaphyseal approach. The bended nails must have their maximum of curve at the level of the fracture, and their orientation, most often face to face, is in charge of the reduction and, so far, the stabilization, of the fracture. The usual size of the nails is equal to 0.4 times the diameter of the medullary canal. As far as possible, a bigger diameter is better than a thinner one. Most fractures of the femur are treated with a bipolar retrograde ESIN when some distal fractures need an antegrade subtrochanteric approach. Forearm fractures need a combined retrograde radial and antegrade ulnar through the posterolateral part of the olecranon. Humerus and tibial diaphyseal fractures may also be treated with ESIN. Complications are mainly caused by technical errors including too-thin nails, asymmetry of the frame, and malorientation of the implants. Nonunion was never observed in fractures of the femur and the forearm; osteomyelitis rate is 2%, and mean overgrowth of the femur is less than 10 mm before the age of 10 years. Indications of ESIN are fractures of the diaphysis: all the fractures of the femur between the age of 6 years and the end of growth except for the severe open grade III fractures, all the unstable fractures of the forearm, and some unstable fractures of the humerus and the tibia during adolescence or before the end of growth. In addition, ESIN is indicated in polytraumatism and multiple injuries. Conclusions: The good results of this reliable technique are obtained when surgeons have a good knowledge of it, especially in the understanding of the principle of the correction of the fracture and its stability.

Flexible Intramedullary Nail Use in Limb Lengthening

Background The aim of this study is to evaluate the influence of the external fixation associated with flexible intramedullary nailing (FIN) on the healing index (HI) in limb lengthening. Methods We compared the healing index between 2 groups of children undergone the lengthening of upper and lower limbs carried out with the Ilizarov external fixator alone (group I, 194 cases of lengthening) or with the combination of the Ilizarov external fixator and intramedullary nailing (group II, 92 cases). Two nails of the diameter from 1.5 to 2.0 mm with the ray of curvature about 40 degrees to 50 degrees were used for the intramedullary nailing. Results The HI was less in every subgroup of Group II compared with Group I. A significant difference was noted in congenital pathologies: monofocal monosegmental lengthening at the level of femur and forearm, bifocal lengthening of the tibia, polysegmental lengthening; and in acquired discrepancy: monofocal tibial lengthening, bifocal femoral lengthening, and the forearm lengthening. The reduction of HI was between 60% and 85% in congenital pathologies: monosegmental femur and forearm, bifocal femur and tibia lengthening; and in acquired discrepancy: femur, tibia, humerus and forearm monosegmental lengthening, humerus and tibia bifocal lengthening, and polysegmental in upper and lower limbs. This difference varies from 1.9 days/cm to 19.1 days/cm. That means that the duration of the external fixator was decreased of 20% to 33% of the number of days between the Group I and the Group II. Maximum diminution of HI was noted for monofocal acquired forearm cases (51.3%) and bifocal acquired femoral lengthening cases which (59.9%). Conclusions The flexible intramedullary nailing allows adding multiple advantages to the method of limb lengthening with the external fixator. Correctly applied the FIN indeed respects the bone biology that is essential during the limb lengthening. The major effect of application of the combination of Ilizarov frame fixation with FIN is a significant decrease of duration of the external osteosynthesis. Level of Evidence II.

Hip septic arthritis in children: assessment of treatment using needle aspiration/irrigation.

INTRODUCTION This retrospective series evaluated the surgical treatment of hip arthritis in children by needle aspiration-irrigation alone. PATIENTS AND METHODS Forty-three cases of septic hip arthritis were treated by needle aspiration-irrigation under general anesthesia associated with intravenous then oral administration of antibiotics. Clinical and biological criteria at admission, during hospitalization and at final follow-up were studied to identify any criteria carrying a predictive value for unsuccessful needle aspiration-irrigation. RESULTS Thirty-eight hips had a favorable outcome in this series, while secondary open arthrotomy was required in five hips for further irrigation. Common criteria found in the group requiring open arthrotomy were a diagnosis delay of at least 6 days between initial clinical symptoms and treatment as well as markedly abnormal biological results at admission. A threshold for the predictive value of certain variables was identified including C-reactive protein above 100, white polynuclear blood count above 15000, and sedimentation rate above 25 in the first hour and 50 in the second hour. DISCUSSION Treatment modalities for septic arthritis of the hip remain controversial in children and various techniques have been shown to be effective in the literature. Needle aspiration-drainage, the least invasive of these, has been shown to have good results, even in the hip, even though this is a deep, tight, joint which is known to be difficult to drain. Prognostic criteria are difficult to identify, however all authors agree that delayed treatment makes evacuation of intra-articular debris especially difficult. CONCLUSION Needle aspiration-irrigation is effective in septic arthritis of the hip, as long as basic principles are followed. Delayed treatment and certain biological criteria should be taken into account when selecting a treatment, since negative predictive criteria identified in this series were present in the five hips requiring secondary arthrotomy.

Early complications with flexible intramedullary nailing in childhood fracture: 100 cases managed with precurved tip and shaft nails

BACKGROUND AND PURPOSE Diaphyseal and metaphyseal fractures in children are frequently treated with the flexible intramedullary nailing (FIN) method. The aim of this study was to record postoperative complications and outcome in consecutive fracture patients treated with the new precurved tip and shaft nails and dedicated ergonomic instrumentation. METHODS We report the analysis of 100 consecutive fractures followed up for a minimum of 6 months. Ninety-seven children were included, comprising 77 shaft and 23 metaphyseal fractures. Demographic data, duration of surgery, nail and medullary canal diameter, date of nail removal, clinical assessment, follow-up radiographs and all complications were recorded. RESULTS Mean age was 9.7 years, and mean body weight 35.1 kg. Twenty-one fractures had associated lesions. Mean duration of surgery was 42.4 minutes. Nail removal was at a mean 6.1 months. Twelve percent of patients had complications, with six insufficient reductions, one delayed union, one non-union, one iterative fracture, and three skin impingements. Unexpected surgical revision was required in seven cases. At follow-up, only one patient showed functional impairment, with 20° pronation loss, and three showed more than 10° axial deviation on X-ray. CONCLUSION The low rate of skin impingement compared with the literature may be due to the new dedicated instruments. We believe that other complications can be avoided if one follows the FIN principles, avoiding weak assembly due to an insufficient nail/medullary canal diameter ratio, which is a limiting factor for indications in adolescents. The surgeons reported that precurved shaft nails facilitated the FIN procedure, although this subjective judgment may be due simply to the novelty of the nails. LEVEL OF EVIDENCE Level IV. Retrospective study.

Flexible intramedullary nailing in children: nail to medullary canal diameters optimal ratio.

Background: Postoperative axial deviations and delayed unions are possible complications after flexible intramedullary nailing (FIN). The goals of this study were to determine if a correlation exists between occurrence of the above complications and the ratio of the diameter between nail and medullary canal [nail diameter (ND)/MCD ratio], to study the interobserver variability in the measurement of MCD, and to define a threshold to be respected to optimize the results. Methods: Eighty-one consecutive diaphyseal fractures treated by means of FIN were evaluated. The ND/MCD ratios were determined by 2 independent observers. Axial deviations were defined as 5-degree angulation or more observed before bone union. Absence of bone union at 3 months was considered as delayed union. Statistical analysis was made for interobserver variability of MCD, dependency between occurrence of complications and ND/MCD ratio and eventual confounding variables (age, weight, sex, and fracture location). Results: Of the 81 fractures, 14 presented with an axial deviation and 3 with a delayed union. Interobserver variability of MCD diameter was excellent (intraclass correlation: 0.96). Occurrence of the above complications was significantly associated with a low ND/MCD ratio (P=0.0002) but with none of the examined confounding variables. Receiver operating characteristic analysis showed absence of complications with a ND/MCD ratio >35% with a sensitivity of 100% and specificity of 89%. Related with the MCD measurements variability, a safe threshold of 40% can be suggested. Conclusions: In FIN, ND>40% to the MCD should be chosen to avoid complications, besides respecting the technical principles. Measuring the medullary canal diameter in order to choose correct nail size is reproducible between different observers. In adolescents with a medullary canal diameter of >10 mm in femur or tibia fractures, alternative methods of osteosynthesis than FIN should be considered. Significance: This work statistically confirms that a ND/MCD ratio of >40% must be respected to avoid some complications in FIN. Level of Evidence: Level III.

Classification of complications after progressive long bone lengthening: Proposal for a new classification

INTRODUCTION Long bone lengthening surgery using progressive surgical methods has been the source of frequent complications. Some authors have classified these complications either descriptively, according to the date of onset after the operation, or based on their severity. The Caton classification (1985) has had the virtue of contributing the notion of the treatment contract stipulating the objective to reach in treatment. Within the context of the preoperative information delivered to patients and their family, this contract can be improved by adding a notion of maximum treatment duration. The objective of this study was therefore to propose a classification that includes honoring a triple contract associating the planned gain in bone length, the duration of treatment, and the occurrence of sequelae. MATERIALS AND METHODS The classification of complications proposed includes four grades: grade I: triple contract honored, including a few treatments without general anesthesia; grade II: triple contract fulfilled, but with unplanned interventions under general anesthesia; grade III: the time stipulated was not honored because the time to obtain bone union was too long or because the program was interrupted; grade IV: sequelae are present. This classification was assessed based on a consecutive series of 34 surgical procedures in 32 patients (two patients underwent two lengthening procedures during this period) at 43 bone segments associating progressive lengthening with external fixation or with nail lengthening. The grade of each complication was determined by each of the authors according to the classification proposed and other classifications reported in the literature (Caton, Paley, Popkov, and Donnan). RESULTS Approximately one-third (10) of the 34 lengthening procedures did not present any complications. Two-thirds (24) presented 30 complications. Consensus was obtained between all the authors on the grades proposed for our classification and the Caton classification, but consensus was not reached with the other classifications in which part of the interpretation was subjective (Paley, Popkov, and Donnan). DISCUSSION The classification proposed required respecting predetermined objectives during limb lengthening surgery based on a triple contract: gain, duration, and function. It is reliable and reproducible by different operators because the criteria are objective. It can also be applied to diverse surgical techniques, whether with external fixation and/or internal osteosynthesis. LEVEL OF EVIDENCE Level IV: retrospective study or historical series.

Child calcaneonavicular coalitions: MRI diagnostic value in a 19-case series

INTRODUCTION In case of hindfoot pain, diagnosis of calcaneonavicular tarsal coalition may be missed on X-ray due to the absence of any visible synostosis. All other possible etiologies (too-long anterior process (TLAP) of the calcaneum, synchondrosis, syndesmosis) must be investigated. The literature tends to recommend imaging associating standard X-ray and CT, and possibly bone scintigraphy. MRI is, however, also worth assessing, due to the many non-osseous forms calcaneonavicular pain may take. MATERIAL AND METHODS Thirty-two cases of surgically treated calcaneonavicular tarsal coalition were studied. Nineteen cases, in 14 children, over a 10-year period, showed no visible synostosis on initial standard X-ray. In seven cases, bone scintigraphy was performed, CT in seven and MRI in 12. On the basis of the literature, our attitude was in favor of X-ray associated to CT in our early experience. Repeated diagnostic difficulties, however, led us to replace CT by MRI in case of foot pain combined to symptomatology suggestive of coalition. RESULTS The series comprised four cartilaginous forms, four fibrous forms and eight TLAPs. In 10 of the 19 feet, radiology was strictly normal, the others showing indirect osseous signs. Only three of the seven scintigraphies showed hyperfixation. CT-scan enabled diagnosis in seven cases (two synchondroses and five rudimentary forms), and missed diagnosis in four (two cartilaginous and two fibrous forms). Second intention MRI showed two synchondroses and two syndesmoses. In the light of these 11 cases, a subsequent series of eight feet was assessed by MRI in first intention, obtaining systematic diagnosis. In all the feet of the series, the symptomatic coalition was treated by surgery, allowing peroperative findings to be compared with the imaging data. DISCUSSION Given a rigid and painful foot syndrome suggestive of tarsal coalition, two diagnostic situations arise: (a) the clinical aspect is suggestive and standard X-ray enables diagnosis; (b) the clinical aspect is suggestive, but radiography proves non-contributive, in which case we recommend MRI with sagittal, frontal and axial slices in gadolinium-enhanced T1-weighted and fat-sat T2-weighted sequences, revealing direct (cartilaginous or fibrous coalition) or indirect signs (peripheral inflammation, osteomedullary edema, chondral lesion) unobtainable on CT scans. MRI is particularly effective in as much as most of the children concerned will not have reached bone maturity. CONCLUSION We consider MRI to be the most effective means of precise diagnosis (causes and consequences) of tarsal coalition, especially for calcaneonavicular locations. It entails minimal invasion and irradiation, at a lower cost than CT associated to scintigraphy. LEVEL OF EVIDENCE IV. Diagnostic study.

Is combining massive bone allograft with free vascularized fibular flap the children's reconstruction answer to lower limb defects following bone tumour resection?

PURPOSE OF THE STUDY Bone tumours are frequent conditions in children, and their surgical resection may lead to extensive defects which reconstruction is often challenging. Indeed, local conditions do not promote bone healing, and the achieved surgical result requires to be life-lasting. Capanna suggested a reconstruction technique combining massive allograft and free vascularized fibular flap. The first one is intended to withstand mechanical stress, and the second one offers biological and vascular support to improve bone healing and prevent infections. MATERIAL AND METHODS We report our experience with this technique when applied to the lower limb in a prospective study including seven children, with a mean follow-up of 44 months. RESULTS Bone healing was achieved by one single procedure in 85.7% of the cases, usually 7 months after surgery. Six out of seven patients achieved a final and long-lasting outcome, five of them following a simple surgical history. Partial weight-bearing was post-operatively allowed at about 2 months, full weight-bearing was initiated at about 5.5 months. DISCUSSION A low complication rate was reported despite the extent of the disease and the type of the surgical procedure. Capannas combined reconstructive technique appears very efficient in the management of massive bone defects following tumour resection in childrens lower limb. LEVEL OF EVIDENCE Level IV. Retrospective therapeutic study.

Ollier's disease limb lenghtening: Should intramedullary nailing be combined with circular external fixation?

INTRODUCTION During progressive lower limb lengthening in the management of Olliers disease, the mean bone-healing index usually reported in the literature stands around 35 days/cm. One of the therapeutic objectives is to reduce the duration of the external fixation. HYPOTHESIS The use of an elastic stable intramedullary nailing system (ESIN) combined with a circular external fixator significantly reduces the healing index. MATERIAL AND METHODS Two groups of patients were compared. In group I, seven patients were operated on for progressive limb lengthening using a circular external fixator associated with an ESIN system: four monosegmental femoral lengthenings, one monosegmental tibial lengthening and two polysegmental femorotibial lengthenings. Nailing was performed via two intramedullary nails already used in traumatology. The date of external fixator removal coincided with that of radiographic healing. The nails were left in place. Group II included 37 patients who underwent limb lengthening by means of an external fixator only. The healing index was calculated and complications were analysed in both groups. RESULTS The mean healing index (HI) values were: in group I: 23.3 days/cm for the femur, 22.4 days/cm for the tibia and 11.6 days/cm for polysegmental lengthenings ; in group II: 31.6 days/cm for the femur, 35.7 days/cm for the tibia and 19.9 days/cm for polysegmental lengthenings. Group I demonstrated a statistically significant decrease in the HI for monosegmental femoral lengthenings. CONCLUSION A substantially reduced duration of external fixation, limited postoperative complications and prevention of later pathologic fractures are the reported advantages of the associated use of a circular external fixator with an ESIN system in the management of Olliers disease. LEVEL OF EVIDENCE Level III, comparative retrospective study.

High failure rate of the Pavlik harness in dislocated hips: is it bilaterality?

Background: The purpose of this study was to evaluate the efficacy of Pavlik harness treatment in patients with bilaterally dislocated Graf type IV hips and compare them to cases with unilaterally dislocated hips. Methods: Twenty-one patients (42 hips) who presented with bilaterally dislocated hips with no prior treatment were studied. The comparison group consisted of 33 patients (33 hips) with unilateral hip dislocation treated with the same protocol. Successful treatment was defined as relocation of the hips within 3 weeks of Pavlik harness application. Results: Twelve of 21 patients (57%) in the bilateral group (6 failed bilaterally, 6 unilaterally) and 18/33 patients (54.5%) in the unilateral group failed harness treatment. Conclusions: The use of the Pavlik harness in dislocated hips is associated with a high failure rate. Patients presenting with bilaterally dislocated hips however, are at no greater risk for failure than patients presenting with unilateral hip dislocation. Level of Evidence: Level III.