Plate fixation versus flexible intramedullary nails for management of closed femoral shaft fractures in the pediatric population: A systematic review and meta-analysis of the adverse outcomes

Abhinav Singh; William Bierrum; Justin Wormald; Manoj Ramachandran; Gregory Firth; Deborah Eastwood

doi:10.1177/18632521231190713

Plate fixation versus flexible intramedullary nails for management of closed femoral shaft fractures in the pediatric population: A systematic review and meta-analysis of the adverse outcomes

J Child Orthop. 2023 Aug 28;17(5):442-452. doi: 10.1177/18632521231190713. eCollection 2023 Oct.

Authors

Abhinav Singh^{1

2}, William Bierrum³, Justin Wormald¹, Manoj Ramachandran⁴, Gregory Firth⁴, Deborah Eastwood^{5

6}

Affiliations

¹ Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
² Department of Orthopaedic Surgery, Imperial College NHS Healthcare Trust, London, UK.
³ Department of Acute Internal Medicine, University College London Hospital NHS Trust, London, UK.
⁴ Department of Orthopaedic Surgery, Barts Health NHS Trust, London, UK.
⁵ Department of Orthopaedic Surgery, Great Ormond Street Hospital, London, UK.
⁶ University College London, London, UK.

Abstract

Purpose: Fractures of the femoral diaphysis are associated with a risk of morbidity in children. Various fixation methods have been developed, but with only limited evidence to support their use. This systematic review assesses the evidence regarding clinical outcomes of closed femoral diaphyseal fractures in children treated with plate fixation or flexible intramedullary nails.

Methods: A PROSPERO-registered, PRISMA-compliant systematic review and meta-analysis were conducted. MEDLINE, Embase, and Web of Science (WoS) databases were searched from inception to February 2023. Inclusion criteria included clinical studies reporting adverse outcomes following surgical treatment of pediatric closed femoral diaphyseal fractures using plate fixation and flexible intramedullary nails. The ROBINS-I and RoB 2 tools evaluated the risk of bias.

Results: Thirteen papers (2 prospective randomized controlled trials and 11 retrospective cohorts) reported 805 closed diaphyseal femoral fractures in 801 children (559 males, 242 females). There were 360 plate fixations and 445 flexible intramedullary nails. Two cases of osteomyelitis and one nonunion were reported. Meta-analysis showed that plate fixation had a lower risk of soft tissue infection (relative risk 0.26 (95% confidence interval 0.07-0.92)). There was no difference in the following outcomes: malunion (relative risk 0.68 (95% confidence interval 0.32-1.44)); unplanned reoperation (relative risk 0.59 (95% confidence interval 0.31-1.14)), and leg-length difference (relative risk 1.58 (95% confidence interval 0.66-3.77)). The risk of bias was high in all studies.

Conclusions: An analysis of 805 fractures with minimal differences in meta-analyses is considered high quality even when the quality of the evidence is low. The findings are limited by important flaws in the methodology in the published literature. Well-designed multicentre prospective studies using standardized core outcomes are required to advise treatment recommendations.

Level of evidence: III.

Keywords: Children; femur fracture; intramedullary nail; meta-analysis; plate fixation.

Publication types

Review