Title : Elastic Stable Intramedullary Nailing (ESIN) vs. casting for pediatric tibial shaft fractures: A systematic review and meta-analysis
Abstract:
Objectives: Tibial shaft fractures are among the most common long bone injuries in the pediatric population. While conservative treatment with casting remains standard in many centres, surgical intervention with Elastic Stable Intramedullary Naili ng (ESIN) has gained popularity, particularly in adolescents. However, the comparative outcomes between these two approaches remain debated. This systematic review and meta- analysis aimed to compare the clinical outcomes of ESIN versus casting for pediatric diaphyseal tibial fractures, focusing on time to union, complication rates (malunion, infection, reoperation), functional recovery, and time to weight-bearing and return to activity.
Methods: A systematic search was conducted in accordance with PRISMA 2020 guidelines ano registered on PROSPERO (CRD42024514733). Studies were eligible if they included pediatric patients (118 years) with tibial shaft fractures treated with either ESIN or closed reduction and casting. Both randomized and nonrandomized comparative studies were included. Key outcomes extracted were time to union, malunion rate, infection rate, reoperation rate, time to weight-bearing, and time to return to activity. Five studies with a total of 511 patients were included in the final analysis. Articles were searched using CENTRAL - Cochrane Central Register of Controlled Trials, Embase - Embase via Ovid, Embase.ccrn, PubMed and Scopus. Studies were screened independently by two reviewers using our eligibility criteria, and a third reviewer resolved any differences. Data extraction was performed independently by two reviewers using a predesigned template. Risk of bias was assessed for cohort studies using the Newcastle-Ottawa Scale.
Results: Across the five included studies, ESIN was associated with a longer time to union compared to casting (mean: 14.4 vs 10.6 weeks). However, patients treated with ESIN achieved earlier weight-bearing (mean' 6.6 vs 8.6 weeks). Malunion rates were generally higher in the casting group, with reported ranges of 8.7% to 33.3%, compared to 0% to 19.4% in the ESIN group. Infection rates were low across all studies, with superficial infections reported in the ESIN group only (range: 0—6.9%). Reoperation was more frequent in casting groups, with up to 40.3% requiring later surgical intervention due to failure of conservative management, compared to reoperation rates of 0—10% in ESIN groups. Functional outcomes such as return to sport and activity were inconsistently reported but showed no major long-term differences. One study reported patient-reported outcomes, with improved early function in the ESIN group.
Conclusions: Preliminary findings from this review demonstrates that while ESIN is associated with a longer till to radiographic union, it enables earlier mobilization and is associated with lower rates of malunion and need for secondary procedures compared to casting. However, ESIN carries a small risk of superficial infection and operative complications. Overall, ESIN appears to be a favourable option in older children and adolescents with displaced tibial shaft fractures, particularly when early mobilization is a priority. Nevertheless, careful patient selection is essential, and fuFther high-quality prospective trials are warranted to confirm these findings and assess long-term functional outcomes.
