Lateral-Only Flexible Intramedullary Nailing for Pediatric Tibial Shaft Fractures: An Early Comparative Experience With a Novel Technique to Reduce Symptomatic Implant Prominence
- 1University of California San Francisco School of Medicine, San Francisco, CA, USA; Department of Orthopaedic Surgery at the University of California San Francisco, San Francisco, CA, USA; Corresponding author: 1500 Owens St, San Francisco, CA, 94158, USA.
- 2University of California San Francisco School of Medicine, San Francisco, CA, USA; Department of Orthopaedic Surgery at the University of California San Francisco, San Francisco, CA, USA
- 3The Steadman Philippon Research Institute, Vail, CO, USA
Abstract
Background: Standard medial-lateral (ML) flexible intramedullary nailing (FMN) for pediatric tibial shaft fractures is associated with high rates of symptomatic hardware prominence along the subcutaneous medial border. A lateral-only (LO) technique may reduce these symptoms by avoiding medial subcutaneous hardware. Methods: We conducted a retrospective two-cohort comparison (2015-2024) at two tertiary children’s hospitals within a single health system, evaluating 42 patients (aged 5-16 years) treated with FMN for tibial shaft fractures: 13 who underwent LO fixation and 29 who underwent ML fixation. One additional patient treated with a single lateral-entry nail was excluded from the comparative analysis and is described separately; a sensitivity analysis including this patient yielded unchanged results. The primary outcome was symptomatic implant prominence, defined as implant-related complaints or clinician-documented soft-tissue findings. Secondary outcomes included operative time for the index procedure, implant removal at the last follow-up, and the incidence of complications other than implant prominence (malunion, nonunion requiring surgery, refracture, delayed union, wound complications, or growth disturbance). Given the modest sample, secondary outcomes were regarded as exploratory. Group comparisons were performed using Fisher’s exact tests and t-tests. Results: LO fixation was associated with markedly less symptomatic implant prominence than ML fixation (8% vs 66%; P < .001). No secondary outcome reached statistical significance. Implant removal at the last follow-up occurred in 31% of LO cases versus 55% of ML cases ( P = .19). Among cases with a recorded surgical case time, mean operative time was 26 min shorter with LO fixation (97 vs 123 min; 95% confidence interval: −2 to 53; P = .063). Complications other than implant prominence were more frequent in the LO cohort (3 of 13 [23%] vs 1 of 29 [3%]) but did not differ significantly ( P = .08) and lacked a consistent technique-specific mechanism. Conclusions: In this early comparative experience, LO FMN was associated with markedly less symptomatic implant prominence than conventional ML fixation. The secondary findings of a lower removal rate and shorter operative time are hypothesis-generating and require cautious interpretation given confounding by surgeon, era, and follow-up duration. The technique appears viable in appropriately selected patients, but prospective, adequately powered studies incorporating patient-reported outcomes are needed before comparative superiority can be established. Key Concepts: (1) Lateral-only (LO) flexible intramedullary nailing significantly reduces symptomatic implant prominence compared with conventional medial-lateral fixation for pediatric tibial shaft fractures. (2) The lateral approach leverages anterior compartment muscle coverage at the proximal entry site to eliminate medial subcutaneous hardware and reduce implant-related morbidity. (3) No secondary outcome reached statistical significance. The removal, operative-time, and complication comparisons are exploratory and confounded by surgeon, era, and follow-up duration. (4) Complications other than implant prominence were numerically more frequent in the LO group, so any reduction in symptomatic prominence must be weighed against that trade-off. (5) Flexible nailing by either entry strategy should be applied cautiously in heavier or near-mature adolescents, in whom rigid implants may be more appropriate. Level of Evidence: III
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BibTeX
@article{alandvillegasmeza2026lateralonly,
title = {{Lateral-Only Flexible Intramedullary Nailing for Pediatric Tibial Shaft Fractures: An Early Comparative Experience With a Novel Technique to Reduce Symptomatic Implant Prominence}},
author = {Alan D. Villegas Meza, BA and Matthew Allen, BA and Brendon C. Mitchell, MD and Mohammad Diab, MD and Jaclyn Hill, MD},
journal = {Journal of the Pediatric Orthopaedic Society of North America},
year = {2026},
month = sep,
doi = {10.1016/j.jposna.2026.100440},
url = {https://doi.org/10.1016/j.jposna.2026.100440},
note = {CC BY},
}
RIS
TY - JOUR
TI - Lateral-Only Flexible Intramedullary Nailing for Pediatric Tibial Shaft Fractures: An Early Comparative Experience With a Novel Technique to Reduce Symptomatic Implant Prominence
AU - Alan D. Villegas Meza, BA
AU - Matthew Allen, BA
AU - Brendon C. Mitchell, MD
AU - Mohammad Diab, MD
AU - Jaclyn Hill, MD
PY - 2026
DA - 2026/09/01
JO - Journal of the Pediatric Orthopaedic Society of North America
DO - 10.1016/j.jposna.2026.100440
UR - https://doi.org/10.1016/j.jposna.2026.100440
AB - Background: Standard medial-lateral (ML) flexible intramedullary nailing (FMN) for pediatric tibial shaft fractures is associated with high rates of symptomatic hardware prominence along the subcutaneous medial border. A lateral-only (LO) technique may reduce these symptoms by avoiding medial subcutaneous hardware. Methods: We conducted a retrospective two-cohort comparison (2015-2024) at two tertiary children’s hospitals within a single health system, evaluating 42 patients (aged 5-16 years) treated with FMN for tibial shaft fractures: 13 who underwent LO fixation and 29 who underwent ML fixation. One additional patient treated with a single lateral-entry nail was excluded from the comparative analysis and is described separately; a sensitivity analysis including this patient yielded unchanged results. The primary outcome was symptomatic implant prominence, defined as implant-related complaints or clinician-documented soft-tissue findings. Secondary outcomes included operative time for the index procedure, implant removal at the last follow-up, and the incidence of complications other than implant prominence (malunion, nonunion requiring surgery, refracture, delayed union, wound complications, or growth disturbance). Given the modest sample, secondary outcomes were regarded as exploratory. Group comparisons were performed using Fisher’s exact tests and t-tests. Results: LO fixation was associated with markedly less symptomatic implant prominence than ML fixation (8% vs 66%; P < .001). No secondary outcome reached statistical significance. Implant removal at the last follow-up occurred in 31% of LO cases versus 55% of ML cases ( P = .19). Among cases with a recorded surgical case time, mean operative time was 26 min shorter with LO fixation (97 vs 123 min; 95% confidence interval: −2 to 53; P = .063). Complications other than implant prominence were more frequent in the LO cohort (3 of 13 [23%] vs 1 of 29 [3%]) but did not differ significantly ( P = .08) and lacked a consistent technique-specific mechanism. Conclusions: In this early comparative experience, LO FMN was associated with markedly less symptomatic implant prominence than conventional ML fixation. The secondary findings of a lower removal rate and shorter operative time are hypothesis-generating and require cautious interpretation given confounding by surgeon, era, and follow-up duration. The technique appears viable in appropriately selected patients, but prospective, adequately powered studies incorporating patient-reported outcomes are needed before comparative superiority can be established. Key Concepts: (1) Lateral-only (LO) flexible intramedullary nailing significantly reduces symptomatic implant prominence compared with conventional medial-lateral fixation for pediatric tibial shaft fractures. (2) The lateral approach leverages anterior compartment muscle coverage at the proximal entry site to eliminate medial subcutaneous hardware and reduce implant-related morbidity. (3) No secondary outcome reached statistical significance. The removal, operative-time, and complication comparisons are exploratory and confounded by surgeon, era, and follow-up duration. (4) Complications other than implant prominence were numerically more frequent in the LO group, so any reduction in symptomatic prominence must be weighed against that trade-off. (5) Flexible nailing by either entry strategy should be applied cautiously in heavier or near-mature adolescents, in whom rigid implants may be more appropriate. Level of Evidence: III
SN - 2768-2765
ER -