Complications of Titanium and Stainless Steel Elastic Nail Fixation of Pediatric Femoral Fractures

Gulati, Divesh MS(Orth); Aggarwal, Aditya MS(Orth); Singh, Arun P. MS(Orth)

Journal of Bone & Joint Surgery - American Volume:
Letters to the editor
Author Information

Corresponding author: Divesh Gulati, MS(Orth), Department of Orthopaedics, University College of Medical Sciences, Shahadara, New Delhi 110095, India, e-mail address:

Article Outline

To The Editor:

We read with interest the article “Complications of Titanium and Stainless Steel Elastic Nail Fixation of Pediatric Femoral Fractures” (2008;90:1305-13), in which Wall et al. report a 23.2% rate of malunion with use of titanium elastic nails in pediatric femoral fractures. This rate is unusually high when compared with the malunion rates of approximately 10% in similar published studies on the use of this device1-7.

The average time of recommended implant removal is between six months and one year, when circumferential callus appears to be solid and the fracture line is no longer visible3,6,7. However, Wall et al. extracted the implant at an average of 4.5 months following insertion. Early removal of the implant could be responsible for the higher rates of malunion in this study.

Wall et al. also reported an increase in the angle of malunion between the immediate postoperative evaluation and the time of final follow-up. This finding could be attributable to early implant removal as well. In addition, the authors did not report when they allowed patients to begin weight-bearing in the two groups; early weight-bearing could contribute to these problems.

Finally, the authors favored the use of stainless steel over titanium elastic nails but did not compare the average time to fracture union or look for any other significant differences between the groups.

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.

1. Flynn JM, Luedtke LM, Ganley TJ, Dawson J, Davidson RS, Dormans JP, Ecker ML, Gregg JR, Horn BD, Drummond DS. Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children. J Bone Joint Surg Am. 2004;86:770-7.
2. Ho CA, Skaggs DL, Tang CW, Kay RM. Use of flexible intramedullary nails in pediatric femur fractures. J Pediatr Orthop. 2006;26:497-504.
3. Heybeli M, Muratli HH, Celebi L, Gülçek S, Bicimoğlu A. [The results of intramedullary fixation with titanium elastic nails in children with femoral fractures]. Acta Orthop Traumatol Turc. 2004;38:178-87. Turkish.
4. Luhmann SJ, Schootman M, Schoenecker PL, Dobbs MB, Gordon JE. Complications of titanium elastic nails for pediatric femoral shaft fractures. J Pediatr Orthop. 2003;23:443-7.
5. Ligier JN, Metaizeau JP, Prévot J, Lascombes P. Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br. 1988;70:74-7.
6. Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, Kasser J. Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop. 2001;21:4-8.
7. Narayanan UG, Hyman JE, Wainwright AM, Rang M, Alman BA. Complications of elastic stable intramedullary nail fixation of pediatric femoral fractures, and how to avoid them. J Pediatr Orthop. 2004;24:363-9.
Copyright 2009 by The Journal of Bone and Joint Surgery, Incorporated