Complications Cast Treatment Psychosocial effect on children Economoic effects on their families [Hughes 1995] ORIF with Plate Ex Fix Antegrade Nail L

Transcription

1 Introduction Cast or Traction + cast Nicol [2000] ORIF Kregor [ 93], Ward [92] Ex Fix Aronson [ 92], Tolo [93] Antegrade Nail Beaty [94], Buford [98], Galpin [ 94], Herndon [ 89] Flexible IM Pinning [00], Bourdelat [1996],Metaizeau [88], Vrsansky

2 Complications Cast Treatment Psychosocial effect on children Economoic effects on their families [Hughes 1995] ORIF with Plate Ex Fix Antegrade Nail Large scar[cosmesis], Infection, fixation failure Refracture, Malunion, Pin track infection AVN, Physeal damage, Coxa Valga Titanium i elastic Nails: Considered d to be ideal fixation device as complications are minimal

3 Flexible nail: Ideal Treatment for Pediatric Femur fractures: Check Bar-On E JBJS [Br] 1997 Flynn JM JPO 2001 Gregory Trauma 1995 Heinrich SD JPO 1994 Kregor PJ JBJS [Am] 1993 Ligier JN JBJS JS[ [Br] 1998 O Malley DE JPO 1995 Parsch KD JPO 1997 Reeves JPO 1990

4 Purpose To report complications following TEN fixation of femur in older Children [9-14 yrs] Complications: 2 Major = Requiring further fixation 2 Minor = 1. Hemarthrosis 2. Delayed union

5 Case 1: JE 13 Y M Motorbike Vs back of pick up truck Dx: Open Type I fracture femur X ray: Midshaft comminuted fracture femur

6 Post Op Rx: Debridement Retrograde 3.5 TEN X ray: Good reduction; <3* varus 3 wks Post op Post Op: Physio TWB

7 Fell off a chair O/E: Leg was shortend Deformity (varus and ER)

8 X ray Lateral pin was bent at the fracture site Varus: >20*

9 Closed locking Delta 2 Russel Taylor (8mm) Entry point: Through the tip of the Greater trochanter MUA of the knee: 40* 120* Post op period was uneventful

10 12/8/03 [3 months Post op] Asymptomatic Walks FWB Knee ROM: Full Extensive callus Back in contact sports

11 Case 2: AH 15 M Farm bike accident Comminutted midshaft femur Dec 02: TEN 4.5 Antegrade. Appeared satisfactory [Varus <5*] TWB on Crutches

12 Post op ROM brace for 6 wks

13 4 months Post op: Fully weight bearing with limp Knee: 0-30 Significant irritation from the pin Pins removal; PWB on crutches

14 2 Week later: Refracture Collapsed while walking with crutches

15 Post Op 4 months Post op Fracture healed well No AVN Back at sports

16 Asymptomatic Full knee ROM Slight gluteal lurch

17 Case 3: CF 9 F Mech Paed Vs Car, [Thrown onto bonnet] X ray: Transverse Midshaft femur 24/9/02 TEN fixation femur

18 4 Months : Fracture healed with 5* of varus Had irritation around the knee Booked for removal pins on the waiting list

19 >6 Months: A tense painful R Knee O/E All movements were painful X ray: Prominent Medial wire Anterior placement of wire Septic Screen: -ve [ESR8;CRP1;WBC9] Aspirate Frank blood; Gram Stain: -ve Rx: TEN removed and washout was given

20 Case 4: AR; 14 M Fell from a push bike Transverse # at Middle third and lower third 31/1/03: 4.5 titanium elastic nail

21 Delayed union At 5 months: good healing Pins removed 2 months later Irritation around the knee

22 Summary Chart Age/sex complication Pin Irritation Technical Case 1 13/M ImplantFailure +++ *Inadequate size of the pin *Early wt bearing Case 2 15/M Refracture +++ *Early removal *Early wt bearing Case 3 9/F Hemarthrosis +++ *Anterior Pin Case 4 14/M Delayed union ++? None *Backing off pin

23 DISCUSSION Complications in 4 patients [ age 9-15 yrs] ; Performed by 4 different surgeons and the results reflect the learning curve. Unknown factors TEN Fixation: Ideal patients : Age and weight Post-op: op: Management ie: Spica or not Weight bearing

24 Complications of Titaneum Nails 1. Flynn: JPO. 21: 4-8. [Philadelphia] 2001 Irritation of the soft tissue: 4/58 Deep infection: 2/58 Refracture 1/ * Varus 6/58 2. Scott. JPO 23: 443 [2003] St. Louis, Missouri 50% complications 2 Major: Septic arthritis Nonunion Minor Pain at the nails in 13/43 Nail erosion through the skin in 4, 1 delayed union.

25 Conclusions 1. Adolescent [9-15 yrs], TEN has a significant complication rate. 2. Technical pitfalls exist with TEN and can be improved

26 Conclusions: Cont. 3. In comminutted fracture/ low compliance Walking hip spica cast, Orthoses or Brace 4. We recommend waiting until callus is solid before nail removal.

27 Conclusions: cont. 5. Alternative fixation: Patients over 10 years of age, g, due to their larger size, may be better treated a rigid femoral nail inserted through the greater trochanter. [Momberger 2000, Galpin 1994, Gordon 2003, Green 2002]