The Journal of Bone and Joint Surgery (American). 2008;90:1305-1313.
doi:10.2106/JBJS.G.00328
© 2008 The Journal of Bone and Joint Surgery, Inc.
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Complications of Titanium and Stainless Steel Elastic Nail Fixation of Pediatric Femoral Fractures

Eric J. Wall, MD1, Viral Jain, MD1, Vagmin Vora, MD2, Charles T. Mehlman, DO, MPH1 and Alvin H. Crawford, MD1

1 Division of Pediatric Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-3039
2 Department of Orthopaedics and Rehabilitation, Penn State Hershey Medical Center, Penn State Hershey College of Medicine, Mail Code EC 089, 30 Hope Drive, Building A, Hershey, PA 17033

Investigation performed at the Division of Pediatric Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. Commercial entities (DePuy Spine, Synthes Spine, Medtronic) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.

Background: In vitro mechanical studies have demonstrated equal or superior fixation of pediatric femoral fractures with use of titanium elastic nails as compared with stainless steel elastic nails, and the biomechanical properties of titanium are often considered to be superior to those of stainless steel for intramedullary fracture fixation. We are not aware of any clinical studies in the literature that have directly compared stainless steel and titanium elastic nails for the fixation of pediatric femoral fractures. The purpose of the present study was to compare the complications associated with the use of similarly designed titanium and stainless steel elastic nails for the fixation of pediatric femoral fractures.

Methods: A group of fifty-six children with femoral fractures that were treated with titanium elastic nails was compared with another group of forty-eight children with femoral fractures that were treated with stainless steel elastic nails. Both nail types were of similar design, and a similar retrograde insertion technique was used. The groups were compared with regard to complications as well as insertion and extraction time. Major complications were defined as malunion with sagittal angulation of >15° and coronal angulation of >10°, nail irritation requiring revision surgery, infection, delayed union, and rod breakage. Minor complications were defined as nail irritation or superficial infection not requiring surgery.

Results: The malunion rate was nearly four times higher in association with the titanium nails (23.2%; thirteen of fifty-six) as compared with the stainless steel nails (6.3%; three of forty-eight) (p = 0.017, chi-square test; odds ratio = 4.535 [95% confidence interval, 1.208 to 17.029]). The rate of major complications was 35.7% (twenty of fifty-six) for titanium nails and 16.7% (eight of forty-eight) for stainless steel nails. The rates of minor complications were similar for the two groups, as were the insertion times and extraction times. The supplier price of one titanium nail ranges from $259 to $328, depending on size, whereas the price of one stainless steel nail would be $78 in current United States dollars.

Conclusions: Our results indicate that the less expensive stainless steel elastic nails are clinically superior to titanium nails for pediatric femoral fixation primarily because of a much lower rate of malunion.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.


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Letters to the Editor:

Read all Letters to the Editor

Complications of Elastic Nail Fixation of Pediatric Femoral Fractures
Divesh Gulati, et al.
JBJS Online, 5 Feb 2009 [Full text]
Dr. Wall and colleagues respond to Dr. Gulati and colleagues
Eric J. Wall, MD, et al.
JBJS Online, 5 Feb 2009 [Full text]
Complication Comparison of Titanium and Stainless Steel Elastic Nails
Navin N. Thakkar
JBJS Online, 3 Nov 2009 [Full text]
Dr. Wall and colleagues respond to Dr. Thakkar
Eric J. Wall, MD, et al.
JBJS Online, 3 Nov 2009 [Full text]