title: Retention of flexible intramedullary nails following treatment of pediatric femur fractures.
abstract: BACKGROUND
  Flexible intramedullary nails are commonly used for the treatment of diaphyseal femur fractures in children. Although, their removal after fracture healing is advocated by some, there are no definitive studies to support the routine removal of these implants. The purpose of this study is to determine the natural history of children with diaphyseal fractures of the femur treated with flexible intramedullary nails and no scheduled nail removal.
  
  
  METHODS
  We performed a retrospective case series of 24 consecutive children treated at our tertiary pediatric referral center for closed diaphyseal femur fractures. All children had intramedullary fixation with flexible titanium nails. The main outcomes measured are fracture healing, incidence of hardware removal, and pain assessment with the use of a follow-up telephone questionnaire.
  
  
  RESULTS
  All the patients healed their fractures. The average follow-up time was 3.6 years. A total of six patients had removal of nails for any reason at an average of 15 months post-injury. The survivorship free of revision due to persistent pain was 72% at 5 years of follow-up. Twenty-two patients were reached by phone for a final follow-up questionnaire. There was no difference in reports of residual symptoms of pain among those who did have nails removed and those who did not (P = 0.626).
  
  
  CONCLUSIONS
  Among children with femur fractures treated with flexible intramedullary nailing without scheduled implant removal, about a quarter may ultimately require a second procedure for nail removal due to persistent discomfort. Moreover, up to half of patients can have residual non-debilitating pain at 2-5 years post-injury regardless of presence or absence of the implant. Whether this is a previously unrecognized adverse outcome of this injury or treatment approach, or due to routinely leaving nails in will have to be assessed in future controlled trials.
authors.affiliation: Department of Orthopaedic Surgery, University of California, San Francisco School of Medicine, 500 Parnassus Avenue, MU-320W, San Francisco, CA 94143, USA. morsheds@orthosurg.ucsf.edu
authors.forename: Saam
authors.initials: S
authors.lastname: Morshed
authors.forename: Marcie
authors.initials: M
authors.lastname: Humphrey
authors.forename: Luis A
authors.initials: LA
authors.lastname: Corrales
authors.forename: Meredith
authors.initials: M
authors.lastname: Millett
authors.forename: Scott A
authors.initials: SA
authors.lastname: Hoffinger
mesh_terms: D000293:Adolescent; D001858:Bone Nails; D002648:Child; D002675:Child, Preschool; D020878:Device Removal; D018483:Diaphyses / Q000293:injuries; D005260:Female; D005264:Femoral Fractures / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D005500:Follow-Up Studies; D005594:Fracture Fixation, Intramedullary / Q000295:instrumentation / Q000379:methods; D017102:Fracture Healing; D006801:Humans; D016268:Internal Fixators; D008297:Male; D010147:Pain Measurement; D011859:Radiography; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D016896:Treatment Outcome