To the Editor:
Flynn and his coauthors have presented an important prospective
evaluation of their femoral shaft fracture patients and used a validated
outcomes questionnaire (PODCI)to help gauge treatment effect. Their paper
further establishes the effectiveness of an elastic stable intramedullary
nailing approach to many of these fractures in this particular age group
(6-16 y/o). It is gratifying to see that the excellent results that have
been enjoyed by Jean-Paul Metaizeau (from Nancy, France)and others are now
being replicated in large series at other centers (1,2).
I do have three concerns
regarding the overall message of the article. First, the authors have given us important information regarding certain
milestones (walking independently etc), but they have not given us important
details such as fracture pattern, degree of comminution, or
patient weight. These data might help readers decide how similar their
own patients are to those of Flynn et al. We have extensive experience
with this nailing technique at our center and it is becoming clear that
some of the older and heavier patients may not be best served by flexible
nails (1). Luhman and coworkers
have raised similar concerns about patient size(3).
Second, certain complications such as pin site pain may have been
overstated in the flexible nailing group, as it did not seem that the pin
site pain that children with distal femoral traction pins experience
(including pin site care) was tracked aggressively. Just like a traction
pin is a temporary tool, elastic stable nails (aka Nancy Nails) are also
temporary - as by design they are removed following adequate fracture
healing(2).
Third, the CHARGE DATA that Flynn et al have reported are of
concern because they might mislead hospital administrators and/or policy
makers to believe that the price tag of these two treatment approaches
(traction & casting versus flexible nailing) is "a wash". To Flynn's
credit, he acknowledged that charges are at times a rather poor proxy
for costs. When we studied these same two treatments at our center, we found elastic stable intramedullary nailing to be a (approximately)
$3,000.00 bargain per patient as compared to traction & casting(1).
These cost savings were accompanied by
equvalent or superior clincial outcomes, and earlier return to home and
school environments make the Nancy Nail treatment approach very, very
attractive indeed.
References:
1. Buechsenschuetz KE, Mehlman CT, Shaw KJ, et al. Femoral Shaft
Fractures in Children: Traction and Casting Versus Elastic Stable
Intramedullary Nailing. J Trauma 2002;53:914-921.
2. Ligier JN, Metaizeau JP, Prevot J, et al. Elastic Stable
Intramedullary Nailing of Femoral Shaft Fractures in Children. J Bone
Joint Surg (Br) 1988;70-B:74-77.
3. Luhmann SJ, Schootman M, Schoenecker PL, et al. Complications of
Titanium Elastic Nails for Pediatric Femoral Shaft Fractures. J Pediatr
Orthop 2003;23:443-447.
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