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Nancy nailing: a pediatric innovation for contemporary society

Elastic stable intramedullary nails provide easier management for fractures, less strain for families.

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issue : August 2005


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Innovations in orthopedics Using rubber band stable intramedullary nails for pediatric upper and lower extremity fractures has markedly changed the state of fault fixation in the past two decades. A key change has been shorter immobilization time and hospital stays while still achieving and maintaining anatomic decrease. however, like many new developments in the orthopedic community, these advances have not been without controversy and cost. rubber band stable intramedullary breeze through ( ESIN ) is besides known as Nancy nailing in citation to the work of Jean-Paul Metaizeau in the pediatric hospital in Nancy, France. Using the ESIN concepts of the romanian surgeon Firica, Metaizeau demonstrated inserting two flexible curved rods into the relatively directly intramedullary canal produced opposing forces, which would both reduce and stabilize mid-shaft femoral fractures in children. Along with Ligier and Prevot, Metaizeau published his findings in the early 1980s .

Long hospitalizations

Surgeons had few treatment options for femoral fractures in children prior to the developments of the ESIN concept.

For years, the standard of worry for pediatric femur fractures involved long weeks of traction followed by more weeks of spica cast. According to Alvin H. Crawford, MD, conductor of pediatric orthopedics at Cincinnati Children ’ s Hospital Medical Center, “ It was a long hospitalization period followed by a long at-home period, which required a lot of care. ” Crawford, a extremity of the Orthopedics Today editorial board, said it was a very effective treatment, with few complications. however, it produced a long separation with psychological distress. private detective fixation with plate became popular and still is the standard of worry in some areas. however, some surgeons believe that plating is a big operation with bombastic incisions. late, the plate femur may be susceptible to fracture above or below the plate .

  courtesy of Dennis R. Wenger

external fixators are besides popular, but if not used properly, they could lead to refractures .

Innovative on many fronts

The concept of ESIN came to the pediatric orthopedic residential district at a time that was good for variety. As the medical community was evolving toward more expeditious and cost-efficient treatments, society itself was changing. “ In the old days there was always person at home to care for the child that you sent home in a hurl, ” said Carl L. Stanitski, MD, professor of orthopedic surgery at the Medical University of South Carolina. “ These days for individual parents, or where both parents work, or for families that do not have extended members nearby, it is very unmanageable to care for one of these children in a spica hurl — it has a huge social impact on the syndicate. ” Dennis Wenger, MD, of Children ’ s Hospital — San Diego, said ESIN developed in an era when it became clear that children ’ randomness fractures needed a more arrant reduction. “ Papers by people like Blount from Milwaukee, suggested that children ’ sulfur fractures didn ’ t need to be very accurately reduced because they would normally remodel and straighten themselves. There was a slow recognition that that would not always be true, particularly in older children. In many cases orthopedists were overplaying their cards, by putting them in a bare hurl and then in the end, the bone wasn ’ t arsenic square as they thought it would be. ” Wenger is a extremity of the Orthopedics Today editorial advisory board .

Cost effective?

Although ESIN results in reduce costs because of shorter hospitalization, the surgical costs can be high, specially if the nails are removed. besides, there may be other sociological costs. “ It is sort of good news/bad news program position, ” Crawford said. “ The kid is home in three days ; however, in a marginal or a single rear family with a few children that is barely making it, that is not a set of time for a parent to mobilize some forces, get a support network together. If the rear has no one, a fringy speculate will credibly be history. ” The routine, which is cursorily becoming the criterion of care in the United States for femur and forearm fractures, is most effective when used on the allow patients. Most orthopedists agree that patients aged 6 to 12 years, who are a moment on the lean side and have mid-shaft fractures are the best candidates. Comminuted or spiral fractures or those that are besides proximal or distal besides are well suited for the Nancy nail. By far, the largest controversy surrounding ESIN is whether or not to remove the nails following fracture healing. The nails are designed with erupt tips, which aid in removal. “ In the erstwhile days [ the patients ] would get irritation around the edges of the rods, particularly around the knee, but now we have newer techniques where we don ’ metric ton bend them at such an lean, ” Stanitski said. “ I think the fears and concerns about the metallurgy of the old days are much less now than they were earlier. ” Wenger believes they should be removed. “ I don ’ thyroxine believe that there is enough evidence for a surgeon to say ‘ I know they do not need to be removed. ’ From my view decimal point, if you are pounding them all the means in and telling the parents that they don ’ t have to come out, … you are providing advice which is not yet documented by checkup literature. Particularly in a younger child with a femur fracture, growth can make the perch end more outstanding, with risk for fracture. The people in France who started it say take them out, and we agree. ” Scott Hoffinger, MD, film director of orthopedics at Children ’ s Hospital in Oakland, Calif., believes the nails can, in most cases, be retained. “ We found several years ago that orthopedists were not having their own hardware removed. We take it out of our patients, but we leave it in ourselves, ” he said. “ We besides saw a couple of papers that showed taking out the hardware led to a higher refracture rate and we found that there was no documented downside to leaving them in. Our data show that 75 % of patients followed for up to five years had no symptoms and did not require removal. ”

Hoffinger said he has found that the rod tips annoy about 25 % of his patient ’ second with the nails. “ So you take it out of them, and leave them in the others and they are fine. ” He said surgeons are caught in a Catch-22 position based on their beliefs. “ If you decide you are going to take them out, you leave them big and they hurt the child so you have to take them out. If your desire is to retain them, you cut them short and you drive them in and they are harder to get out, so you leave them in. ”

Crawford said if you leave the nails in, as the child grows the nails might migrate up and possibly stick out of the femur and produce a stress riser. “ That is something to be concerned with, ” he said. “ We like to take them out, it is merely what we do, and it does not mean that it is right or improper. ” future generations of the devices may make the removal discussion a moot period. “ It would be fantastic to have a bioabsorbable or biodegradable implant that would not create an excessive weave reaction and response to the abasement procedure. Whether that will come to pass one doesn ’ t know, ” Stanitski said .

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