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Safety of Rigid Intramedullary Nailing in Skeletally Immature Tibia Fractures-Risk of Growth Disturbance is Not Zero
Christopher D Souder1, Grant S McHorse2, James D Bomar1
1Rady Children's Hospital, San Diego, CA.
Insights
Rigid intramedullary nail (RIMN) fixation for pediatric tibia fractures is generally safe. While it can cause minor posterior slope changes, a small risk of deformity exists, necessitating careful monitoring.
Area of Science:
- Pediatric Orthopedics
- Trauma Surgery
- Skeletal Growth and Development
Background:
- Rigid intramedullary nail (RIMN) fixation is standard for adult tibial shaft fractures.
- Its use in skeletally immature patients involves violating the proximal tibial physis.
- Potential for growth disturbance and deformity after RIMN in patients with open physes is a concern.
Purpose of the Study:
- To evaluate growth disturbance and resultant deformity after RIMN treatment in skeletally immature patients with open physes.
- To assess changes in proximal tibial angles post-RIMN fixation.
- To determine the safety and potential risks of RIMN in pediatric tibial fractures.
Main Methods:
- Retrospective radiographic review of 43 skeletally immature patients with acute tibia fractures treated with RIMN.
- Analysis of medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA) pre- and post-operatively.
- Radiographic follow-up of at least 6 months to assess changes in tibial angles and identify deformities.
Main Results:
- Average change in MPTA was 1.0±0.9 degrees, with no significant changes observed.
- Average change in PPTA was 2.3±3.8 degrees (P=0.007), indicating a statistically significant increase in posterior slope.
- Two patients developed recurvatum deformity, highlighting a potential risk despite overall safety.
Conclusions:
- RIMN use in skeletally immature adolescents leads to a statistically significant, likely clinically insignificant, change in posterior tibial slope.
- While generally safe, RIMN fixation carries a risk of subsequent sagittal deformity, as evidenced by cases of recurvatum.
- Careful patient selection and monitoring are crucial when using RIMN for tibial shaft fractures in growing children.
Background:
Rigid intramedullary nail (RIMN) fixation is the standard treatment for tibial shaft fractures in adult patients. Recently, this technique has gained favor for usage in skeletally immature patients despite the required violation of the proximal tibial physis. The goal of this paper was to determine whether growth disturbance with resultant deformity could occur after RIMN treatment in patients with open physes.
Methods:
A retrospective radiographic review was performed of all patients undergoing RIMN placement for acute tibia fractures at 3 level I Pediatric Trauma Centers between January 2012 and June 2022. Patients with an open proximal tibial physis and radiographic follow-up of at least 6 months were included. Intraoperative radiographs were analyzed to determine the immediate postoperative medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA), as well as the skeletal bone age utilizing the Abbreviated Modified Fels Knee System. The final radiographs were assessed for changes in the MPTA and PPTA.
Results:
A total of 43 patients with an average chronological age of 14.5±1.3 years and skeletal age of 14.3±1.0 years met the inclusion criteria. There were a total of 37 males and 6 females with an average follow-up of 18.3±12.7 months. The average change in the MPTA was 1.0 ± 0.9 degrees ( P =0.566) with no patients having a change >3 degrees. The average change in the PPTA was a 2.3 ± 3.8 degrees ( P =0.007). Two patients progressed to a recurvatum deformity with 99 and 104 degrees of PPTA. With these 2 patients excluded, the average change in slope remained significant at 1.5 ± 1.6 degrees ( P =0.019).
Conclusion:
The use of RIMN in skeletally immature adolescents can lead to a statistically significant, but most likely clinically insignificant change in the posterior slope. Yet, cases of recurvatum deformity can occur in the setting of this procedure. Though our series confirms RIMN are generally safe in treating tibial shaft fractures in skeletally immature adolescents, 2 cases demonstrate that a true risk of a subsequent sagittal deformity does exist.
Level Of Evidence:
Level IV-retrospective case series.
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