Intramedullary Fixation for Pediatric Femoral Nonunion in Low- and Middle-Income Countries

Area of Science:

• Orthopedic surgery
• Pediatric orthopedics
• Traumatology

Background:

• Pediatric femoral shaft nonunion is uncommon in high-income countries but may be more frequent in low and middle-income countries.
• Complications can arise from both plate and intramedullary nail (IMN) fixation.
• This study focuses on outcomes in lower-resource settings.

Purpose of the Study:

• To assess union and painless weight-bearing rates after IMN fixation for pediatric femoral shaft nonunion.
• To evaluate the effectiveness of IMN fixation in lower-resource settings.
• To analyze complications associated with previous fixation methods.

Main Methods:

• A query of the Surgical Implant Generation Network (SIGN) Fracture Care International database identified 85 pediatric femoral shaft nonunions since 2003.
• Nonunion was defined by failure of initial instrumentation or lack of radiographic healing.
• Radiographic union was assessed using the Radiographic Union Scale in Tibial fractures (RUST) score, and painless weight-bearing was recorded.

Main Results:

• Fifty-seven patients from 18 countries were included, with a mean age of 13.8 years at revision surgery.
• Previous fixation failures included plate constructs (56%) and non-SIGN IMNs (40%).
• At latest follow-up, 91% achieved a RUST score of ≥10, and 89% had painless full weight-bearing, with no cases of femoral head osteonecrosis.

Conclusions:

• Pediatric femoral shaft nonunion can occur after plate and IMN fixation in low and middle-income countries.
• Intramedullary nail fixation is an effective and safe treatment option for these injuries in resource-limited environments.