Flexible intramedullary nailing in the treatment of paediatric forearm fractures: 15-years' experience at a level one trauma centre, comparison of implant retention versus removal and cost-effectiveness analysis.

INTRODUCTION: Flexible intramedullary nailing (FIN) is a common treatment method for paediatric forearm fractures. They are routinely removed after fracture healing. This study aims to assess the 15-years' experience of managing paediatric forearm fractures with FIN, with comparison between the outcomes of implant retention versus removal and cost analysis. This is the first study on FIN retention in paediatric forearm fractures.

METHODS: This was retrospective cohort study for paediatric forearm fractures treated with FIN between 2009 and 2024 at Leeds General Infirmary, a level one trauma centre in the United Kingdom. We noted a significant decline in scheduled elective removal of forearm FIN following the Coronavirus pandemic (COVID-19). The cohort was therefore divided into two comparative groups: pre-COVID (routine implant "removal") and post-COVID (routine implant "retention"). Primary outcome measured was incidence of secondary (unplanned) surgery. Secondary outcomes measured were indications for surgery, time from index procedure to FIN removal and subjective patient/parents' satisfaction.

RESULTS: A total of 268 patients were included in the study. The pre-COVID group comprised of 212 patients, and the post-COVID group 56 patients. Elective implant removal was performed in 68.9% (n = 146) of patients in the earlier group and 3.6% (n = 2) in the latter. Secondary surgery was required in 14.2% (n = 30) of patients in the pre-COVID group, with mean time to removal of 12 months, and 12.5% (n = 7) in the post-COVID group, with mean time of 28 months. Irritation and discomfort were the most common causes for secondary surgery across both groups (73.3% and 85.7%, respectively). Patients/parents were satisfied with the results in 98.5% of cases. The post-COVID group was more cost-effective (saving £131,119 per 100 patient).

CONCLUSION: FIN retention after paediatric forearm fracture fixation is a safe and reasonable option, as it does not carry a higher risk of secondary surgery when compared to routine nail removal.