O2082: Intramedullary Fixation for Pediatric Femoral Nonunion in Low- and Middle-income Countries

Background: Pediatric femoral shaft non-unions are uncommon in the United States after plating or intramedullary nailing (IMN) but occur with greater frequency in low and middle-income countries. SIGN Fracture Care International (SIGN) offers education, instruments, and implants free-of-charge if surgical data is registered for each case for quality control. We sought to describe the efficacy of SIGN IMN treatment for pediatric femoral shaft non-union in lower resource settings.

Methods: The SIGN online database was queried to identify all 85 cases (83 patients) of pediatric femoral shaft nonunion since 2003 with a follow-up visit available. Nonunion was defined as failure of initial plate or IMN instrumentation >90 days following its placement. Patients were excluded for lack of 6-week follow-up (n=6), missing lateral view on follow-up radiographs (n=5), or otherwise inadequate records (n=1). An orthopaedic traumatologist, pediatric orthopaedic surgeon, and an orthopaedic surgery resident evaluated each patient’s final follow-up radiograph as a committee to determine a radiographic union scale in tibial fractures (RUST) score. RUST scores of ≥9 were considered treatment successes. Patients with complete healing and remodeling on AP radiographs were assumed to have complete healing on the lateral view, if absent (n=2). Demographics and rates of painless full weightbearing were recorded.

Results: Fifty-seven pediatric femoral shaft nonunion cases from 48 patients (29 males, 19 females; 17 countries) were eligible for inclusion. Average age at revision surgery was 13.8±2.9 years (range 6-17). Median follow-up was 43.4 weeks (range 6.1 weeks – 7.7 years). Initial failed instrumentation included plate constructs (74%), non-SIGN IMNs (17%), and SIGN IMNs (9%). The average RUST score at final follow-up was 11.0±1.4 (range 5-12). At final follow-up, 92% (46/50) of cases achieved RUST scores of ≥9 and 86% (43/50) of patients had painless full weightbearing.

Conclusion: Pediatric femoral shaft nonunion can occur after both plate fixation and intramedullary nailing in low- and middle-income countries. SIGN intramedullary nailing is an effective treatment for these patients.