AO Trauma Pediatrics - Elastic nailing - M Kremli 2022.pptx

Describe main characteristics of the elastic nailing technique
Explain biomechanical properties underlying the technique
Identify common indications for application of elastic nailing in children and adolescents
Recognize required precautions and possible pitfalls

1. Mamoun Kremli Saudi Arabia AO Trauma Online Course—Managing Pediatric Musculoskeletal Injuries Davos, December 2020 Principles of elastic nailing With technique tips

2. Declaration conflicts of interest I have no financial relationships with commercial entities that produce healthcare-related products.

3. Learning objectives Describe main characteristics of the elastic nailing technique Explain biomechanical properties underlying the technique Identify common indications for application of elastic nailing in children and adolescents Recognize required precautions and possible pitfalls

4. Elastic nails—many names Elastic stable intramedullary nailing (ESIN) Titanium elastic nails (TEN) Titanium elastic nails system (TENS) Métaizeau nails Nancy nails …

5. Métaizeau JP L’osteosyntheses chez l’enfant : techniques et indications Pankovich AM Flexible intramedullary nailing of long bone fractures: a review Rev Chir Orthop Reparatrice Appar Mot. 1983:69:495–511. French. J Orthop Trauma. 1987;1(1):78–95. History of elastic nails

6. Main characteristics Minimally invasive Minimally traumatic More biological Precontoured to provide some elastic properties Provides sufficient (relative) stability Allows early movement and partial weight bearing

7. Biomechanics Slongo TF Injury. 2005 Feb; 36(Suppl 1): A78–85. More extended inner contact provides better stability Axial, translation, and rotation Three-point support Far better than K-wires

8. Biomechanics Photolia More extended inner contact provides better stability Axial, translation, and rotation Three-point support Far better than K-wires Slongo TF Injury. 2005 Feb; 36(Suppl 1): A78–85.

9. Biomechanics Photolia NOT a K-wire! More extended inner contact provides better stability Axial, translation, and rotation Three-point support Far better than K-wires Slongo TF Injury. 2005 Feb; 36(Suppl 1): A78–85.

10. Results of elastic intramedullary nails Elastic nails vs plating Elastic nails: Less operation time Higher union rates Caglar O et al. J Pediatr Orthop B.  2006 May;15(3):210−214. Furlan D et al. Scand J Surg. 2011;100(3):208−215. Yi Luo et al. Orthop Surg . 2019;11(4):19.

11. Results of elastic intramedullary nails Titanium elastic nails versus spica cast in pediatric femoral shaft fractures: a systematic review and meta-analysis of 1012 patients Elastic nails superior to traction and/or hip spica for femoral fractures Earlier recovery milestones Better alignment Earlier rehabilitation Imam MA et al. Arch Bone Jt Surg. 2018;6(3):176−188.

12. Results of elastic intramedullary nails Titanium vs stainless steel Controversial Titanium elastic nails are good with equal results to titanium Stainless steel elastic nails better/equal and less expensive Wall E et al. J Bone Joint Surg Am. 2009;91(8): 2041−2041 [56 t it anium vs 47 stainless steel] Lohiya R et al . J O rthop Surg Res . 2011 Dec 22;6:64 [43 t it anium v s 30 stainless steel ] Goyal N et al. Acta Orthop Belg. 2014 Mar;80(1):69−75. [18 t it anium vs 17 stainless steel] Gyaneshwar T et al. Chin J Traum . 2016 Aug 1;19(4):213 −216. [17 t it anium v s 17 stainless steel ] Marengo L et al. Injury. 2018;9 Suppl 3.

13. Principles of application Precontour To achieve three-point fixation from inside Tension within the nail provides a “memory effect”

14. Principles of application Degree of curvature: 3× the diameter of bone 3d

15. Principles of application Apex of curvature: At level of fracture

16. Principles of application 4. Two nails: Same diameter Each 30–40% medulla (1/3) Both same size

17. Principles of application 4. Two nails: Same diameter Identically precontoured Opposite each other Identical entry points

18. Principles of application 4. Two nails: Same diameter Identically precontoured Opposite each other Identical entry points Balanced construct

19. Biomechanics Number of nails: Two nails in most cases (femur, tibia, humerus) - Same diameter - Identically precontoured - Opposite each other Balanced construct

20. Biomechanics Number of nails: Two nails in most cases (femur, tibia, humerus) - Same diameter - Identically precontoured - Opposite each other One nail: (forearm)

21. Biomechanics Number of nails: Two nails in most cases (femur, tibia, humerus) - Same diameter - Identically precontoured - Opposite each other One nail: (forearm) Three nails - Special: (proximal femur, pathological)

22. Type of configuration Both-side insertion (usual) Identical, symmetrical

23. Type of configuration Both-side insertion (usual) Identical, symmetrical Single-side insertion Distal/proximal humerus, distal femur Special S-shape configuration

24. Indications for elastic nails Children aged 3–15 years Less than 45–50 kg (100–110 lbs ) Moroz , LA, et al. ( J Bone Joint Surg .2006; 88:1361–1366) Diaphyseal fractures of long bones -Transverse, oblique, short spiral Some metaphyseal fractures - Radial neck - Proximal/distal humerus - Proximal/distal femur

25. Indications for elastic nails Femoral shaft Excellent results reported Comparable to traction and hip spica Comparable to plating Earlier rehabilitation Avoids discomfort Flynn JM et al. J Pediatr Orthop .  2001 Jan-Feb;21(1):4−8. Flynn JM et al. J Bone Joint Surg Am . 2004 Apr;86(4):770−777. Moroz LA et al. J Bone Joint Surg Br. 200 Oct;88(10):1361−1366. Siddiqui AA et al. J Pediatr Orthop . 2020 Aug;40(7):e560−e565.

26. Indications for elastic nails Forearm─ unstable fractures Better results than casting, avoids plating P Schmittenbecher Kang SN et al . J B one Joint Surg B r . 2011 Feb;93(2):262−265. Lascombes P et al. J Pediatr Orthop . 2006; 26(6):827−834. Barry M et al . J Bone Joint Surg Br. 2004 Sep;86(7):947−953. Mohammed H et al. Bahrain Medical Bulletin. 2009. Shah AS et al. J Ortho Trauma. 2010 Jul;24(7):440−447.

27. Radial head/neck Indications for elastic nails Métaizeau JP et al. Rev Chir Orthop Reparatrice Appar Mot . 1980 Jan-Feb;66(1):47−49. Métaizeau JP et al. J  Pediatr Orthop .  1993 May-Jun; 13(3):355−360. Métaizeau JP. Injury. 2005 Feb;36 Suppl 1:A75-7. Schmittenbecher P et al. J Pediatr Orthop . 2005 Jan-Feb;25(1):45 −5 0. Prathapkumar KR et al. J Bone Joint Surg Br. 2006 Mar;88(3):358 −361 . Klitscher D et al. J Pediatr Orthop . 2009 Oct-Nov;29(7):698 −703 . Al- Aubaidi Z et al. Injury. 2012 Mar;43(3):301 − 305. Pogorelić Z et al. Acta Orthop Traumatol Turc . 2020 Nov; 54(6) : 618−622.

28. Tibial shaft─ Good results, complications possible Indications for elastic nails Sankar WN. J Child Orthop . 2007 Nov;1(5):281−286. Heo J et al . Injury . 2016 Apr :47(4) :832 − 836. Swindells MG et al . J Child Orthop . 2010 Feb;4(1):45−51 [Systemic review of seven papers.] Economedes DM et al. Orthopedicsa . 2014 Jul;37(7):e619−624.   Furlan D et al. Scand J Surg. 2011;100 (3):208−215.

29. Humeral shaft Indications for elastic nails Xie F et al. J P ediatr O rthop . 2011 Dec ; 31(8) :839−846. Wang X , et al. Inter Orthop . 2013; 38 . Lascombes P et al. J Pediatr Orthop . 2006 Nov-Dec;26(6):827 − 834. P Lascombes . Europ Surg Orthop Traumat , 2014

30. Proximal humerus Indications for elastic nails Lascombes P. Eur Surg Orthop Traumat . 2014

31. Principles Remember: Three-point support More extended inner contact provides better stability Slongo TF Injury. 2005 Feb; 36(Suppl 1): A78–85. Wrong Correct

32. Problems Wrong technique Wrong nail size Wrong patient Wrong fracture

33. Problems Wrong technique Unequal nail diameter Different level of entry

34. Problems Wrong technique Unequal nail diameter Different level of entry Asymmetrical curvature

35. Problems Wrong technique Unequal nail diameter Different level of entry Asymmetrical curvature Curvature not at level of fracture Causes unequal forces and displacement

36. Problems Wrong technique Unequal nail diameter Different level of entry Asymmetrical curvature Curvature not at level of fracture No inner cortex contact

37. Problems Wrong technique Unequal nail diameter Different level of entry Asymmetrical curvature Curvature not at level of fracture No inner cortex contact Nail ends not widely separated

38. Problems Wrong technique Unequal nail diameter Different level of entry Asymmetrical curvature Curvature not at level of fracture No inner cortex contact Nail ends not widely separated Multiple nail cross-over (corkscrew effect)

39. Problems Wrong technique Unequal nail diameter Different level of entry Asymmetrical curvature Curvature not at level of fracture No inner cortex contact Nail ends not widely separated Multiple nail cross-over (corkscrew effect) Causes weak construct and displacement

40. Problems Nail too thin Several crossovers (corkscrew) Slongo TF Injury. 2005 Feb; 36(Suppl 1): A78–85.

41. Problems Nail too thin Several crossovers (corkscrew) Slongo TF Injury. 2005 Feb; 36(Suppl 1): A78–85.

42. Problems Length unstable (femoral shaft) fractures: Total 102 fractures over 8 years 89 stable, 13 unstable High major complication rate in unstable 23% lower limb discrepancy (LLD) > 2 cm in unstable 1% LLD in stable Garner MR et al. J Pediatr Orthop . 2011 Jan-Feb;43.31(1):11−16.

43. Problems Wrong fracture Thin nail

44. Problems Theddy Slongo 13-year-old, 50 kg Nails crossing at fracture site Nails too short Backed out Infected

45. Problems 13-year-old, 50 kg Nails crossing at fracture site Nails too short Backed out Infected Removed Varus malunion Theddy Slongo

46. Problems 50 kg body weight is the upper limit - Poor outcome 5× in > 49 kg body weight [n = 230] Moroz LA et al. J Bone Joint Surg Br. 2006 Oct;88(10):1361−1366.

47. Problems Wrong fracture, Theddy Slongo

48. Problems Wrong fracture, wrong patient Theddy Slongo

49. Solution─end caps? (Lock the nails) Chen YN et al. Injury. 2016 Oct;47(10): 2339−2346.

50. Solution─end caps?

51. Solution─end caps?

52. Solution─end caps? No displacement

53. Solution─end caps? End caps are equivalent to locking screws They lock the nails No displacement

54. End caps─case example 14-year-old boy: next day after nails Reoperated with end caps Nectoux E et al. J Pediatr Orthop . 2008; 24:634–637.

55. End caps─case example 14-year-old boy: next day after nails Reoperated with end caps Nectoux E et al. J Pediatr Orthop . 2008; 24:634–637.

56. Complications Theddy Slongo Irritation at nail ends (up to 16%) Skin penetration—infection

57. Complications Theddy Slongo Irritation at nail ends (up to 16%) Skin penetration—infection - Caused by bent ends of nails or

58. Complications Theddy Slongo Irritation at nail ends (up to 16%) Skin penetration—infection - Caused by bent ends of nails or - Nail ends cut too long (> 2 cm)

59. Complications Injury to epiphyseal growth plate Theddy Slongo

60. Complications Refracture after removal - We do not recommend removal of forearm plates within 12 months and nails within 6 months of implantation. Makki D et al. J Pediatr Orthop B.  2014 May; 23(3):221−226.  

61. Complications Avoid technical errors Check length at end - May need impaction Check rotation at end

62. Summary—elastic nails Minimally invasive, biological Stable biomechanical properties - Three-point fixation Slongo TF Injury. 2005 Feb; 36(Suppl 1): A78–85. Photolia