Flynn John M, Luedtke Lael M, Ganley Theodore J, Dawson Judy, Davidson Richard S, Dormans John P, Ecker Malcolm L, Gregg John R, Horn B David, Drummond Denis S
Division of Orthopaedics, Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104-4399, USA.
J Bone Joint Surg Am. 2004 Apr;86(4):770-7. doi: 10.2106/00004623-200404000-00015.
Titanium elastic nails are commonly used to stabilize femoral fractures in school-aged children, but there have been few studies assessing the risks and benefits of this procedure compared with those of traditional traction and application of a spica cast. This prospective cohort study was designed to evaluate these two methods of treatment, with a specific focus on the first year after injury, the period when the treatment method should have the greatest impact.
Eighty-three consecutive children, six to sixteen years of age, were studied prospectively. Factors that were analyzed included clinical and radiographic data, complications, hospital charges, and outcome data. Outcome and recovery were assessed both with the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collections Instrument, version 2.0, and according to a series of important recovery milestones including the time to walking with aids, time to independent walking, time absent from school, and time until full activity was allowed.
Thirty-five children (thirty-five fractures), with a mean age of 8.7 years, were treated with traction and application of a spica cast, and forty-eight children (forty-nine fractures), with a mean age of 10.2 years, were treated with titanium elastic nails. All fractures healed, and no child sustained a complication that was expected to cause permanent disability. At one year after the fracture, eighty of the children had acceptable alignment and no inequality between the lengths of the lower extremities. The remaining three children, who had an unsatisfactory result, had been treated with traction and a spica cast. Twelve patients (34%) treated with traction and a cast had a complication compared with ten patients (21%) treated with titanium elastic nails. Compared with the children treated with traction and a cast, those treated with titanium elastic nails had shorter hospitalization, walked with support sooner, walked independently sooner, and returned to school earlier. These differences were significant (p < 0.0001). We could detect no difference in total hospital charges between the two groups.
The results of this prospective study support the recent empiric observations and published results of retrospective series indicating that a child in whom a femoral fracture is treated with titanium elastic nails achieves recovery milestones significantly faster than a child treated with traction and a spica cast. Hospital charges for the two treatment methods are similar. The complication rate associated with nailing compares favorably with that associated with traction and application of a spica cast.
钛弹性髓内钉常用于稳定学龄儿童的股骨骨折，但与传统牵引及髋人字石膏固定相比，评估该手术风险和益处的研究较少。这项前瞻性队列研究旨在评估这两种治疗方法，特别关注受伤后的第一年，这是治疗方法应产生最大影响的时期。
对83名6至16岁的连续儿童进行前瞻性研究。分析的因素包括临床和影像学数据、并发症、住院费用及预后数据。使用美国矫形外科医师学会小儿预后数据收集工具2.0版以及一系列重要的恢复里程碑来评估预后和恢复情况，这些里程碑包括借助辅助器具行走的时间、独立行走的时间、缺课时间以及允许进行完全活动的时间。
35名儿童（35处骨折），平均年龄8.7岁，接受了牵引及髋人字石膏固定治疗；48名儿童（49处骨折），平均年龄10.2岁，接受了钛弹性髓内钉治疗。所有骨折均愈合，且没有儿童出现预期会导致永久性残疾的并发症。骨折后一年，80名儿童的骨折对位良好，下肢长度无差异。其余三名预后不佳的儿童接受的是牵引及髋人字石膏固定治疗。接受牵引及石膏固定治疗的12名患者（34%）出现了并发症，而接受钛弹性髓内钉治疗的10名患者（21%）出现了并发症。与接受牵引及石膏固定治疗的儿童相比，接受钛弹性髓内钉治疗的儿童住院时间更短，更早能够借助辅助器具行走，更早能够独立行走，更早返回学校。这些差异具有统计学意义（p < 0.0001）。我们未发现两组之间的总住院费用存在差异。
这项前瞻性研究的结果支持了近期的经验性观察以及回顾性系列研究发表的结果，即与接受牵引及髋人字石膏固定治疗的儿童相比，接受钛弹性髓内钉治疗股骨骨折的儿童实现恢复里程碑的速度明显更快。两种治疗方法的住院费用相似。与髓内钉固定相关的并发症发生率优于牵引及髋人字石膏固定。
