The Bisaccia and Meccariello technique in pediatric femoral shaft fractures with intramedullary titanium nail osteosynthesis linked external-fixator (IOLE): validity and reliability

The Bisaccia and Meccariello technique in pediatric femoral shaft fractures with intramedullary titanium nail osteosynthesis linked external-fixator (IOLE): validity and reliability


  • Michele Bisaccia 1 Division of Orthopedics and Trauma Surgery, University of Perugia, “S. Maria della Misericordia” Hospital, Perugia, Italy
  • Giuseppe Rollo Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
  • Auro Caraffa Division of Orthopedics and Trauma Surgery, University of Perugia, “S. Maria della Misericordia” Hospital, Perugia, Italy
  • David Gomez-Garrido 3 Department of Orthopaedics and Traumatology, Orthopaedic and Traumatology Unit, Hospital Quirón Salud Toledo and Hospital Solimat Toledo, Toledo, Spain
  • Dmitry Popkov 4 Russian Ilizarov Scientific Center “Reconstructive Traumatology and Orthopaedics”, Kurgan, Russia
  • Giuseppe Rinonapoli Division of Orthopedics and Trauma Surgery, University of Perugia, “S. Maria della Misericordia” Hospital, Perugia, Italy
  • Cristina Ibáñez-Vicente Department of General Medicine, "Hospital de Getafe", Madrid, Spain
  • Juan Antonio Herrera-Molpeceres 6 Department of Orthopaedics and Traumatology, Hospital Universitario “Virgen de la Salud”, Toledo, Spain
  • Niki Cazzella Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
  • Luigi Meccariello 7 Department of Orthopedics and Traumatology, AORN San Pio Hospital, Benevento, Italy


External fixator; Femoral fractures; Pediatric fractures; TEN


BACKGROUND: Over the last 20 years, the incidence of pediatric femoral shaft fractures was increased, due to changes in the children's daily activities. The healing times are different according to the chosen treatment and to other factors such as age, type of fracture, the involvement of the soft tissues, and concomitance with other injuries. The Bisaccia and Meccariello technique ( Intramedullary titanium nail Osteosynthesis Linked External-fixator -IOLE) was born to prevent rotationally and lengthening malunion or nonunion in the treatment of pediatric femoral shaft fractures. The aim or the objective of this paper is to compare the IOLE with the two most used methods for the treatment of femoral fractures in children.

METHODS: From 2000 to 2016, 58 pediatric patients with femoral shaft fractures were surgically treated and enrolled in the study. The ranged age of the patients was between 3 and 15 years. Twenty-two patients were treated with endomedullary titanium nails (TEN), 16 with external axial or modular external fixators and 14 patients treated with IOLE technique. The IOLE technique is the hybridization of titanium intramedullary nails with a modular external fixator. It is divided into three phases, the first revenue given the length of the femur with the external fixator; the second, the rotations are dominated by the elastic nails; and the third finally they are hybridized on the external fixator. Comparing the three groups, radiographic images were taken to assess fracture reduction and consolidation. 

RESULTS: At the final follow-up, there were no differences between three groups in terms of significant rotation defects, angulation, growth, and/or nonunion but there was a statistical in IOLE groups for the early weight-bearing.

CONCLUSIONS: The Bisaccia- Meccariello technique (IOLE) showed to lead to healing the pediatric femoral shaft fracture of the femur but allows an early weight-bearing to these patients and normal life like that.


1. Flynn John M, Schwend Richard M (2004) Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg 12:347–359
2. Petković L, Djan I, Gajdobranski D, Marić D, Petković M (2011) Pediatric femur fractures, epidemiology and treatment. Vojnosanit Pregl 68(1):9–14
3. Rollo G, Guida P, Bisaccia M, Pichierri P, Filipponi M, Lanzetti RM, Caraffa A, Stasi A, Russi V, Lupariello D, Meccariello L. TEN versus external fixator in the management of pediatric diaphyseal femoral fractures: evaluation of the outcomes. Eur J Orthop Surg Traumatol. 2018;28(7):1421-1428. doi: 10.1007/s00590-018-2201-3
4. Kong H, Sabharwal S (2014) External fixation for closed pedi- atric femoral shaft fractures: where are we now? Clin Orthop Relat Res 472(12):3814–3822
5. Berne D, Mary P, Damsin JP, Filipe G (2003) Femoral shaft fracture in children: treatment with early spica cast. Rev Chir Orthop Reparatrice Appar Mot 89(7):599–604
6. Kosuge D, Barry M (2015) Changing trends in the management of children’s fractures. Bone Joint J 97-B(4):442–448
7. Dey S, Mishra K, Nagda TV, Dhamele J, Rathod C, Dey D. Titanium Elastic Nailing with Temporary External Fixator versus Bridge Plating in Comminuted Pediatric Femoral Shaft Fractures: A Comparative Study. Indian J Orthop. 2018;52(5):507-512. doi: 10.4103/ortho.IJOrtho_304_17.
8. Slongo TF, Audigé L, AO Pediatric Classification Group. Fracture and dislocation classification compendium for children: the AO pediatric comprehensive classification of long bone fractures (PCCF). J Orthop Trauma. 2007;21(10 Suppl):S135-60.
9. Calori GM, Colombo M, Mazza EL, Mazzola S, Malagoli E, Marelli N, Corradi A.Validation of the Non-Union Scoring System in 300 long bone non-unions. Injury. 2014;45 Suppl 6:S93-7. doi: 10.1016/j.injury.2014.10.030.
10. Maiettini D, Bisaccia M, Caraffa A, Rinonapoli G, Piscitelli L, Bisaccia O, Rollo G, Meccariello L, Ceccarini P, Rebonato A. Feasibility and Value of Radiographic Union Score Hip Fracture after Treatment with Intramedullary Nail of Stable Hip Fractures. Acta Inform Med. 2016;24(6):394-396. doi: 10.5455/aim.2016.24.394-396.
11. d'Entremont AG, Cooper AP, Johari A, Mulpuri K. What clinimetric evidence exists for using hip-specific patient-reported outcome measures in pediatric hip impingement? Clin Orthop Relat Res. 2015;473(4):1361-7. doi: 10.1007/s11999-014-4027-6.
12. Su Y, Nan G. ORIF with percutaneous cross pinning via the posterior approach for paediatric widely displaced supracondylar femoral fractures. Injury. 2016;47(6):1242-7. doi: 10.1016/j.injury.2016.02.024.
13. Hullmann SE, Ryan JL, Ramsey RR, Chaney JM, Mullins LL. Measures of general pediatric quality of life: Child Health Questionnaire (CHQ), DISABKIDS Chronic Generic Measure (DCGM), KINDL-R, Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales, and Quality of My Life Questionnaire (QoML).Arthritis Care Res (Hoboken). 2011;63 Suppl 11:S420-30. doi: 10.1002/acr.20637.
14. Litrenta J, Tornetta P 3rd, Mehta S, Jones C, OʼToole RV, Bhandari M, Kottmeier S, Ostrum R, Egol K, Ricci W, Schemitsch E, Horwitz D. Determination of radiographic healing: an assessment of consistency using RUST and modified RUST in metadiaphyseal fractures. J Orthop Trauma. 2015;29(11):516–20. doi:10.1097/BOT.0000000000000390
15. Naranje SM, Stewart MG, Kelly DM, Jones TL, Spence DD, Warner WC Jr, Beaty JH, Sawyer JR. Changes in the Treatment of Pediatric Femoral Fractures: 15-Year Trends From United States Kids' Inpatient Database (KID) 1997 to 2012. J Pediatr Orthop. 2016 Oct-Nov;36(7):e81-5. doi: 10.1097/BPO.0000000000000633.
16. Sigrist EJ, George NE, Koder AM, Gwam CU, Etcheson JI, Herman MJ. Treatment of Closed Femoral Shaft Fractures in Children Aged 6 to 10. J Pediatr Orthop. 2018 Dec 8. doi: 10.1097/BPO.0000000000001310
17. 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 Apr;86-A(4):770-7.
18. Sargent MC. Single-Leg Spica Cast Application for Treatment of Pediatric Femoral Fracture. JBJS Essent Surg Tech. 2017 Sep 13;7(3):e26. doi: 10.2106/JBJS.ST.15.00070
19. Alluri RK, Sabour A, Heckmann N, Hatch GF, VandenBerg C. Increasing Rate of Surgical Fixation in Four- and Five-year-old Children With Femoral Shaft Fractures. J Am Acad Orthop Surg. 2019 Jan 1;27(1):e24-e32. doi: 10.5435/JAAOS-D-17-00064
20. Rickert KD, Hosseinzadeh P, Edmonds EW. What's New in Pediatric Orthopaedic Trauma: The Lower Extremity. J Pediatr Orthop. 2018 Sep;38(8):e434-e439. doi: 10.1097/BPO.0000000000001209
21. Ligier JN, Metaizeau JP, Prévot J, Lascombes P. Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br. 1988 Jan;70(1):74-7.
22. Imam MA, Negida AS, Elgebaly A, Hussain AS, Ernstbrunner L, Javed S, Jacob J, Churchill M, Trikha P, Newman K, Elliott D, Khaleel A. Titanium Elastic Nails Versus Spica Cast in Pediatric Femoral Shaft Fractures: A Systematic Review and Meta-analysis of 1012 Patients. Arch Bone Jt Surg. 2018 May;6(3):176-188. Review.
23. Rapp M, Kaiser MM, Grauel F, Gielok C, Illing P. Femoral shaft fractures in young children (<5 years of age): operative and non-operative treatments in clinical practice. Eur J Trauma Emerg Surg. 2016 Dec;42(6):719-724
24. Sink EL, Gralla J, Repine M. Complications of pediatric femur fractures treated with titanium elastic nails: a comparison of fracture types. J Pediatr Orthop. 2005 Sep-Oct;25(5):577-80.
25. Brousil J, Hunter JB. Femoral fractures in children. Curr Opin Pediatr. 2013 Feb;25(1):52-7. doi: 10.1097/MOP.0b013e32835c20e0.
26. Caird MS, Mueller KA, Puryear A, Farley FA. Compression plating of pediatric femoral shaft fractures. J Pediatr Orthop. 2003 Jul-Aug;23(4):448-52.
27. de Sanctis N, Gambardella A, Pempinello C, Mallano P, Della Corte S. The use of external fixators in femur fractures in children. J Pediatr Orthop. 1996 Sep-Oct;16(5):613-20.
28. Blasier RD, Aronson J, Tursky EA. External fixation of pediatric femur fractures. J Pediatr Orthop. 1997 May-Jun;17(3):342-6.
29. Hinton RY, Lincoln A, Crockett MM, Sponseller P, Smith G. Fractures of the femoral shaft in children. Incidence, mechanisms, and sociodemographic risk factors. J Bone Joint Surg Am. 1999 Apr;81(4):500-9.
30. Sabharwal S1, Kishan S, Behrens F. Principles of external fixation of the femur. Am J Orthop (Belle Mead NJ). 2005 May;34(5):218-23.
31. Zhang YT, Jin D, Niu J, Li ZJ, Fu S, Zou ZL. A meta-analysis of external fixation andflexible intramedullary nails for femoral fractures in children. Acta Orthop Belg. 2016 Dec;82(4):673-680. Review.
32. Guo YC, Feng GM, Xing GW, Yin JN, Xia B, Dong YZ, Niu XQ, He Q, Hu P. A meta-analysis of flexible intramedullary nailing versus external fixation for pediatric femoral shaft fractures. J Pediatr Orthop B. 2016 Sep;25(5):466-70. doi: 10.1097/BPB.0000000000000336.
33. Wani MM, Rashid M, Dar RA, Bashir A, Sultan A, Wani I, Rashid S, O'Sullivan M. Use of external fixator versus flexible intramedullary nailing in closed pediatric femur fractures: comparing results using data from two cohort studies. Eur J Orthop Surg Traumatol. 2016 Feb;26(2):223-30. doi: 10.1007/s00590-015-1737-8







How to Cite

Bisaccia M, Rollo G, Caraffa A, Gomez-Garrido D, Popkov D, Rinonapoli G, et al. The Bisaccia and Meccariello technique in pediatric femoral shaft fractures with intramedullary titanium nail osteosynthesis linked external-fixator (IOLE): validity and reliability. Acta Biomed [Internet]. 2021 Sep. 2 [cited 2024 Jul. 24];92(4):e2021249. Available from: