Bioabsorbable implants in paediatric supracondylar fractures of the elbow
Mackenzie, Samuel Peter
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Background. Operative stabilisation of paediatric supracondylar elbow fractures is most commonly achieved through the use of percutaneous Kirschner wires. These implants are inert, cheap and simple to use. However, the requirement for removal and the possibility of pin site infection provides opportunity for the development of new techniques that eliminate these drawbacks. Bioabsorbable pins that remain in situ and allow definitive closure of skin at the time of surgery could provide such advantages. However, their ability to maintain fracture reduction and their effect on the growth plate has not been adequately evaluated. Hypotheses. The Acumed® Biotrak Helical Nail (a bioabsorbable fixation implant) has comparable strength to Kirschner wires and does not result in significant disruption of the growth plate or subsequent growth. Studies. Three complementary studies were performed. (1) A retrospective cohort analysis was performed to establish the prevalence of complications related to Kirschner wire fixation of paediatric supracondylar elbow fractures. (2) A saw-bone model was designed to compare the mechanical performance of the Helical Nail and Kirschner wires. (3) An ovine model was designed to assess the in vivo effects of the Helical Nail on limb growth and physeal morphology. The surgical practicalities of the device and its potential for use in the paediatric setting were evaluated. The primary outcome was femoral length six months after Helical Nail insertion. Micro-CT evaluation of growth plate thickness, percentage disruption and bony infiltration was undertaken – the first time this technique has been used in a large animal study. Traditional histopathological techniques complimented the Micro-CT analysis and offered comment on the microscopic appearance of the growth plate immediately adjacent to the bioabsorbable nails. Results. The infection rate within a large tertiary referral centre was 9.6%, which was marginally higher than previous cohort studies. Mechanical testing demonstrated that the Helical Nail had comparable strength in rotation, but inferior resistance to posterior translation, when compared to Kirschner wires. In the ovine model, the Helical Nail disrupted 3.4% of the physis. The nails had no effect on femoral growth during the six month study period. Micro-CT analysis of both the helical nail and Kirschner wire groups demonstrated multiple bony bridges, with two cases of physeal tethering in the Helical Nail group. There was no difference in physeal thickness or bony infiltration of the physis. Histopathology did not reveal any significant inflammatory or foreign body reaction adjacent to the nails. Conclusion. The Helical Nail demonstrated a number of encouraging attributes which indicate its potential. However, in its current state the device is not suitable for use in the stabilisation of paediatric supracondylar elbow fractures.