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Taşcı M, Başak F, Kemah B, Söylemez MS. Analysis of influential factors on surgical outcomes in pediatric femur neck fractures: a single-institution retrospective study. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02584-x. [PMID: 38951157 DOI: 10.1007/s00068-024-02584-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 06/14/2024] [Indexed: 07/03/2024]
Abstract
AIM This retrospective study aimed to evaluate surgical outcomes and identify influential factors in pediatric femoral neck fractures. MATERIALS AND METHODS A total of 25 hips from 23 pediatric patients who underwent surgical intervention for femoral neck fractures were included. Data encompassing patient demographics, fracture types, surgical techniques, complications, and follow-up outcomes were analyzed retrospectively. Factors such as fracture displacement, timing of surgery, fixation methods, and reduction quality were assessed concerning postoperative complications. RESULTS Falling from a height accounted for 48% of the trauma mechanisms, and avascular necrosis (AVN) was the most prevalent complication (4 hips). Although fracture displacement, bad reduction quality, and delayed surgery were more common among complicated cases, statistical significance was not attained. The study noted an association between presence of avascular necrosis and worse clinical results(rho: 0.428, p: 0.05, CI: 95%). CONCLUSION Surgical treatment yielded favorable clinical outcomes; however, limitations due to the study's retrospective design, limited sample size, and single-center approach underscore the necessity for larger multicenter studies. Our findings emphasize the need for comprehensive investigations to better understand and manage pediatric femoral neck fractures, especially regarding factors influencing AVN and long-term outcomes.
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Affiliation(s)
- Murat Taşcı
- Department of Orthopaedics and Traumatology, Umraniye Training and Research Hospital, Istanbul, Türkiye.
| | - Furkan Başak
- Department of Orthopaedics and Traumatology, Umraniye Training and Research Hospital, Istanbul, Türkiye
| | - Bahattin Kemah
- Department of Orthopaedics and Traumatology, Umraniye Training and Research Hospital, Istanbul, Türkiye
| | - Mehmet Salih Söylemez
- Department of Orthopaedics and Traumatology, Umraniye Training and Research Hospital, Istanbul, Türkiye
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Xin P, Li Z, Pei S, Shi Q, Xiao L. The incidence and risk factors for femoral head necrosis after femoral neck fracture in pediatric patients: a systematic review and meta-analysis. J Orthop Surg Res 2023; 18:22. [PMID: 36624532 PMCID: PMC9830722 DOI: 10.1186/s13018-023-03502-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/02/2023] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The incidence of avascular necrosis (AVN) after pediatric femoral neck fracture (PFNF) in the literature varies widely, and the risk factors associated with AVN after PFNF are controversial. Therefore, this study aimed to accurately investigate the incidence of AVN after PFNF and systematically evaluate and meta-classify their risk factors. METHODS A comprehensive search was performed of PubMed, Web of Science, and Embase. The pooled rate and 95% confidence interval (CI) were used to assess the incidence of AVN after PFNF, and pooled odds ratio (OR) were calculated to measure the effect sizes. In addition, we performed subgroup, stratified, and publication bias analyses. RESULTS A total of 30 articles were included in our meta-analysis, with 303 AVN cases among 1185 patients. The pooled incidence of AVN after PFNF was 22% (95% CI 18%, 27%). Subgroup analyses indicated Delbet type I-IV fracture incidences with AVN of 45%, 32%, 17%, and 12%, respectively. The incidence of AVN after PFNF in Asia was 19%, lower than in Africa at 36%, Europe at 26%, and North America at 23%. In addition, the larger sample size group and the earlier published literature group showed a higher incidence of necrosis. Stratified analyses showed that patient age and Delbet fracture classification were both important factors affecting AVN after PFNF (OR = 1.61, p = 0.02 and OR = 3.02, p < 0.001, respectively), while the time to treatment was not (OR = 0.9, p = 0.71). CONCLUSION The pooled incidence of AVN after PFNF was ~ 22%; furthermore, the available evidence demonstrates that patient age and Delbet type of fracture were important influencing factors of AVN after PFNF.
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Affiliation(s)
- Pengfei Xin
- Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ziqi Li
- The Third Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shaoqiang Pei
- Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Qi Shi
- Shanghai University of Traditional Chinese Medicine, Shanghai, China.
- Arthritis Research Institute of Integrated Traditional Chinese and Western Medicine, Shanghai Academy of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
| | - Lianbo Xiao
- Arthritis Research Institute of Integrated Traditional Chinese and Western Medicine, Shanghai Academy of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China.
- Department of Orthopedics, Guanghua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, 20000, China.
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Jian C, Qi B, Yu A. Corticoperiosteal Pedicle Flap of Greater Trochanter for Salvage of Old Femoral Neck Fracture in Children: Outcomes After a Minimum 5 Years Follow-up. J Bone Joint Surg Am 2022; 104:61-67. [PMID: 34662320 DOI: 10.2106/jbjs.20.00484] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Old femoral neck fracture (OFNF) generally refers to fractures for more than 3 weeks. Corticoperiosteal pedicle flap of greater trochanter (CPPF-GT) was designed to restore blood supply and donor bone for OFNF. This study aimed to assess the efficacy and radiographic results of CPPF-GT for treatment of OFNF in children after a minimum 5 years follow-up. METHODS Twenty-three patients with OFNFs, age from 8 to 16 years old, who underwent open reductions, fracture fixations, and transpositions of CPPF-GTs were retrospectively reviewed. Clinical and radiological outcomes, including union, nonunion, avascular necrosis of femoral head, limb shortening, coxa vara, premature epiphyseal closure and Ratliff's assessment, were investigated in the postoperative follow-up. The results were compared with previously published joint-salvage study of OFNFs. RESULTS All patients were followed for an average of 5.9 years (range: 5 to 10 years). All cases (100%) achieved hip unions at an average duration of 3.5 months (range: 2.5 to 5 months). No nonunion hip was observed. Three hips (13.0%) progressed to avascular necrosis of femoral head after 1.5 to 3 years of operation, respectively, and the revision surgeries to hip replacements were conducted. Premature epiphyseal closures were observed in 3 hips. Three hips visibly presented an average 2 cm shortening of the femoral neck. Coxa vara deformities were observed in 2 hips. According to the Ratliff's criteria, there were 20 cases (87.0%) with satisfactory union, good results were achieved in 17 cases, fair results in 3 cases, and poor result in 3 cases. CONCLUSIONS Corticoperiosteal pedicle flap of greater trochanter is an effective and desirable option for treating old femoral neck fractures in children with a low rate of avascular necrosis and without nonunion. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Chao Jian
- Department of Orthopaedic Trauma and Microsurgery, Zhongnan Hospital of Wuhan University
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Barrera-Ochoa S, Sapage R, Alabau-Rodriguez S, Muñoz-Perdomo T, Knörr J, Soldado F. Vascularized ulnar periosteal pedicled flap for forearm nonunion in children. J Hand Surg Eur Vol 2022; 47:157-163. [PMID: 34225526 DOI: 10.1177/17531934211026399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We report our experience with the use of a vascularized ulnar periosteal pedicled flap to treat forearm nonunion in children. Seven children underwent surgical treatment of radial diaphysis nonunion with this technique. The mean duration of nonunion prior to the flap was 9 months. Significant postoperative improvements were observed in pain severity (mean visual analogue scale score of 0.6), Quick Disabilities of the Arm, Shoulder, and Hand (mean score of 7.1) and grip strength (89% higher than preoperative status). Union was achieved in all patients, with a mean time to union of 3 months. One patient developed distal radioulnar synostosis as a postoperative complication. A vascularized ulnar periosteal pedicled flap is a reliable and versatile technique for treating forearm nonunion in children, associated with both good outcomes and low donor morbidity.Level of evidence: IV.
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Affiliation(s)
- Sergi Barrera-Ochoa
- Hand, Elbow and Microsurgery Unity (icatMA), Institut Català de Traumatología i Medicina de l'Esport (ICATME), Barcelona, Spain
| | - Rita Sapage
- Hand, Elbow and Microsurgery Unity (icatMA), Institut Català de Traumatología i Medicina de l'Esport (ICATME), Barcelona, Spain.,Orthopedic and Traumatology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - Sergi Alabau-Rodriguez
- Hand, Elbow and Microsurgery Unity (icatMA), Institut Català de Traumatología i Medicina de l'Esport (ICATME), Barcelona, Spain
| | - Tryno Muñoz-Perdomo
- Hand, Elbow and Microsurgery Unity (icatMA), Institut Català de Traumatología i Medicina de l'Esport (ICATME), Barcelona, Spain
| | - Jorge Knörr
- Hand, Elbow and Microsurgery Unity (icatMA), Institut Català de Traumatología i Medicina de l'Esport (ICATME), Barcelona, Spain
| | - Francisco Soldado
- Pediatric Hand Surgery and Microsurgery Unit, Hospital Vall d'Hebron, Barcelona, Spain.,Arthroscopic Surgery Unit, Hospital Vithas San José, Vitoria-Gasteiz, Spain.,Orthopedic and Traumatology Department, Hospital HM Nens, Barcelona, Spain
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Barrera-Ochoa S, Sapage R, Alabau-Rodriguez S, Mendez-Sanchez G, Mir-Bullo X, Soldado F. Vascularized Ulnar Periosteal Pedicled Flap for Upper Extremity Reconstruction in Adults: A Prospective Case Series of 11 Patients. J Hand Surg Am 2022; 47:86.e1-86.e11. [PMID: 34016492 DOI: 10.1016/j.jhsa.2021.02.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE We hypothesized that a vascularized ulnar periosteal pedicled flap (VUPPF) is a versatile graft applicable in adult patients that yields good outcomes and is a reliable alternative to other vascularized bone grafts to reduce both the technical demands and donor site morbidity of other options. METHODS We reviewed 11 adult patients who underwent surgical treatment of forearm atrophic nonunion with a VUPPF. Patients' demographics, outcomes (measured by pain on the visual analog scale; Quick Disabilities of the Arm, Shoulder, and Hand score; range of motion; and grip strength), and associated complications were reported. RESULTS Of the 11 patients, 5 had previous surgery in an attempt to treat the nonunion with an autologous cancellous bone graft from the iliac crest or olecranon. The average time from nonunion until the VUPPF was 9 months (SD, ±3 months; range, 6-14 months). The mean visual analog scale score improved considerably after surgery (8.7 vs 0.6), and considerable improvement was also noted in the Quick Disabilities of the Arm, Shoulder, and Hand score (50 vs 6). A notable improvement was seen in grip strength after surgery. Pronation/supination also improved considerably between the preoperative assessment and the final postoperative follow-up. CONCLUSIONS A vascularized ulnar periosteal pedicled flap seems to be a useful and versatile option for a variety of bone union failures of the upper extremity in adults, either at initial presentation or as a salvage technique. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Sergi Barrera-Ochoa
- Hand, Elbow, and Microsurgery Unity (icatMA), Institut Català de Traumatología i Medicina de l'Esport (ICATME), Hospital Universitario Dexeus, Barcelona, Spain
| | - Rita Sapage
- Hand, Elbow, and Microsurgery Unity (icatMA), Institut Català de Traumatología i Medicina de l'Esport (ICATME), Hospital Universitario Dexeus, Barcelona, Spain; Orthopedic and Traumatology Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal.
| | - Sergi Alabau-Rodriguez
- Hand, Elbow, and Microsurgery Unity (icatMA), Institut Català de Traumatología i Medicina de l'Esport (ICATME), Hospital Universitario Dexeus, Barcelona, Spain
| | - Gerardo Mendez-Sanchez
- Hand, Elbow, and Microsurgery Unity (icatMA), Institut Català de Traumatología i Medicina de l'Esport (ICATME), Hospital Universitario Dexeus, Barcelona, Spain
| | - Xavier Mir-Bullo
- Hand, Elbow, and Microsurgery Unity (icatMA), Institut Català de Traumatología i Medicina de l'Esport (ICATME), Hospital Universitario Dexeus, Barcelona, Spain
| | - Francisco Soldado
- Pediatric Hand Surgery and Microsurgery Unit, Hospital Vall d'Hebron, Barcelona, Spain; Hospital Vithas San José, Vitoria-Gasteiz, Spain
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Wu C, Ning B, Xu P, Song J, Wang D. Efficacy and complications after delayed fixation of femoral neck fractures in children. J Orthop Surg (Hong Kong) 2020; 28:2309499019889682. [PMID: 31833450 DOI: 10.1177/2309499019889682] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE This study evaluated the efficacy of surgery for femoral neck fractures in children after a 24-h delay and the factors affecting the risk of complications. METHODS The study included 16 children who underwent surgery after the first 24 h for femoral neck fractures. According to Delbet's classification, there were 2 type I, 11 type II, and 3 (four hips) type III cases. The mean time from injury to surgery was 85 h (range 27-240 h). According to Garden's classification, there were 1 type II, 14 type III, and 1 type IV (two hips) cases. Initial surgery consisted of closed reduction and hematocele drainage with a 20-mL needle tube. If the procedure failed, open reduction was performed. Internal fixation (K-wire pinning, screw) was performed after closed (n = 9) or open (n = 8) reduction. The results were assessed using the Ratliff criteria after a mean follow-up of 23.2 months. Patient age, type of fracture, complications, treatment, and avascular necrosis (AVN) were evaluated. RESULTS The results were good in 15 hips (88.2%) and fair in 2 hips (11.8%, one type II case with closed reduction and one type I case with open reduction). The most frequent complication was AVN (4 of 17; 23.5%; three Ratliff good and one fair), which was significantly related to poor outcomes. AVN occurred in one hip in the closed reduction group (Delbet's type II, 12.5%) and in three in the open reduction group (one Delbet's type I, 50%; two Delbet's type II, 66.7%). There were no significant differences in the time from injury to operation (27, 54, 64, and 116 h) and AVN incidence or Ratliff criteria. CONCLUSIONS The efficacy of delayed reduction fixation of the femoral neck was better in the closed reduction group than in the open reduction group. Fracture location closer to the femoral head and older age affected the incidence of AVN.
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Affiliation(s)
- Chunxing Wu
- Department of Pediatric Orthopedics, Children's Hospital of Fudan University, Shanghai, China
| | - Bo Ning
- Department of Pediatric Orthopedics, Children's Hospital of Fudan University, Shanghai, China
| | - Ping Xu
- Department of Pediatric Orthopedics, Children's Hospital of Fudan University, Shanghai, China
| | - Jun Song
- Department of Pediatric Orthopedics, Children's Hospital of Fudan University, Shanghai, China
| | - Dahui Wang
- Department of Pediatric Orthopedics, Children's Hospital of Fudan University, Shanghai, China
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Barrera-Ochoa S, Martin-Dominguez LA, Campillo-Recio D, Alabau-Rodriguez S, Mir-Bullo X, Soldado F. Are Vascularized Periosteal Flaps Useful for the Treatment of Difficult Scaphoid Nonunion in Adults? A Prospective Cohort Study of 32 Patients. J Hand Surg Am 2020; 45:924-936. [PMID: 32773167 DOI: 10.1016/j.jhsa.2020.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 03/18/2020] [Accepted: 06/23/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate clinical and radiological outcomes after surgical treatment of difficult scaphoid nonunion in adults with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF). MATERIALS AND METHODS Thirty-two patients at least 18 years old, with scaphoid nonunion and characteristics associated with a poor prognosis, who underwent a VTMPF procedure, were included in this retrospective cohort study with a mean follow-up of 17 months. Factors associated with a poor prognosis were a delay in presentation of over 5 years, the presence of avascular necrosis, and previous nonunion surgery. All patients had at least 1 poor prognostic factor and 25% had 2 or more. RESULTS In 30 men and 2 women, the mean age was 36 years (range, 19-56 years). There were 11 type D3 nonunions (Herbert classification) and 15 type D4. Five patients had delayed presentation of over 5 years. Fourteen patients had previously undergone an unsuccessful surgical attempt to treat their nonunion. The patients experienced no postoperative complications. Overall union rate was 97% (31 of 32 patients), with 72% cross-sectional trabecular percentage bridging at 12 weeks. Pain subsided after surgery and patients experienced improvements in both their Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Modified Mayo Wrist Score (MMWS). Overall 41% and 42% gains in strength and wrist motion, relative to the contralateral normal side, were observed. At final follow-up, there were no differences between the treated and the untreated (healthy) hands, in terms of wrist range of motion, grip, or pinch strength. CONCLUSIONS In this study, the use of VTMPF for difficult scaphoid nonunion in adults was associated with good general outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Sergi Barrera-Ochoa
- ICATMA Hand and Microsurgery Unit, ICATME, Hospital Universitari Quiron-Dexeus, Barcelona, Spain.
| | | | - David Campillo-Recio
- ICATMA Hand and Microsurgery Unit, ICATME, Hospital Universitari Quiron-Dexeus, Barcelona, Spain
| | - Sergi Alabau-Rodriguez
- ICATMA Hand and Microsurgery Unit, ICATME, Hospital Universitari Quiron-Dexeus, Barcelona, Spain
| | - Xavier Mir-Bullo
- ICATMA Hand and Microsurgery Unit, ICATME, Hospital Universitari Quiron-Dexeus, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Francisco Soldado
- Barcelona University Childrens Hospital HM Nens, Barcelona, Spain; Hospital Vithas San José, Vitoria-Gasteiz, Spain
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Current controversies in management of fracture neck femur in children: A review. J Clin Orthop Trauma 2020; 11:S799-S806. [PMID: 32999559 PMCID: PMC7503071 DOI: 10.1016/j.jcot.2020.05.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/24/2020] [Accepted: 05/25/2020] [Indexed: 11/21/2022] Open
Abstract
Paediatric femur neck fracture is an uncommon injury and is known for high rate of complications. This in turn, can have significant impact on development of hip and overall function of the child. Controversy prevails in many areas of management and it still remains a difficult injury to manage. Through this paper, an attempt has been made to summarize the current concepts in management and suggest current recommendations regarding the controversies so that these injuries can be managed judiciously. A systematic review was done as per PRISMA guidelines using pre-defined inclusion and exclusion criteria. 18 studies with better scientific evidence after quality assessment were included in the systematic review. Current trends and Controversial issues in management were then identified and discussed. It was observed that existing literature is inconclusive regarding several aspects of management of this injury with no clear guideline available. However, certain recommendations useful for decision making could be made. These injuries should be managed aggressively with operative fixation at the earliest and one should not hesitate to open reduce if acceptable alignment is not obtained after one or two gentle closed manipulations. Choice of implant and their configuration in neck can vary depending on age and weight of patient, type of injury and surgeon's preference. Initial fracture displacement could be considered to be most predictive for development of osteonecrosis of the femoral head, whereas, role of surgical decompression, type of fixation and timing of surgery is still debatable. Functional outcome is primarily affected by osteonecrosis of the femoral head, nonunion and severe coxa vara, whereas mild coxa vara, shortening, and premature closure of physis when considered alone, don't have significant influence on functional outcome in short term. Treatment of fracture neck femur in children is still controversial in many aspects and needs further research. It should be understood that complications can occur regardless of the method of treatment and might reveal their full impact many years after injury. Hence, a guarded prognosis should be explained to the parents and care-givers at the time of injury.
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Abstract
BACKGROUND Femoral neck fractures in children are rare injuries, occurring due to high-energy trauma. Due to the unique anatomy and blood supply of the proximal femur in growing children, these fractures are notorious for high rates of complications despite appropriate management. Classification of these fractures is according to the Delbet system, which not only guides management but also gives prognostic clues. Multiple fixation methods have been described and there is no consensus on what constitutes the best treatment. Osteonecrosis, non-union, coxa vara and premature physeal arrest are the most frequent complications. PURPOSE To review the current knowledge, discuss controversial aspects, and provide suggestions for future research. METHODS We have reviewed the literature on paediatric proximal femur fractures and have provided an evidence-based guide to the diagnosis and management of these injuries. Common complications have been elaborated and options for their prevention and/or management discussed. CONCLUSION There is universal agreement that anatomic reduction and stable internal fixation, supplemented by spica immobilization in younger children, are essential to obtain good outcomes. The role of capsular decompression, choice and configuration of implant, and appropriate timing of surgery are aspects that continue to be debated. Multicenter prospective studies are necessary to standardize treatment of these challenging injuries.
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Abstract
Femoral neck fractures in children are rare injuries resulting from high-energy trauma. Different methods of treatment, lack of standard management protocols, and the high risk of complications make this injury one of the biggest challenges that an orthopaedic surgeon can face. This review focuses on the general aspects of the pediatric femoral neck fracture management as well as its complications and possible solutions.
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Barrera-Ochoa S, Mendez-Sanchez G, Mir-Bullo X, Knörr J, Bertelli JA, Soldado F. Vascularized Thumb Metacarpal Periosteal Flap for Scaphoid Nonunion in Adolescents: A Prospective Cohort Study of 12 Patients. J Hand Surg Am 2019; 44:521.e1-521.e11. [PMID: 30344021 DOI: 10.1016/j.jhsa.2018.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 07/15/2018] [Accepted: 08/29/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate clinical and radiological outcomes after surgical treatment of scaphoid nonunion in adolescents with a vascularized thumb metacarpal periosteal pedicled flap (VTMPF). METHODS Twelve patients younger than 18 years with scaphoid nonunion, who underwent a VTMPF procedure without bone grafting, were included for this prospective cohort study, at a mean follow-up of 10.2 months. Patients were operated on by 3 different hand surgeons at 3 hand surgery institutions. All patients received a VTMPF, but with different scaphoid internal fixation modalities, in 10 cases using 1 or 2 retrograde 2-mm headless compression screws and in 2 cases without internal fixation. RESULTS In 11 boys and 1 girl, the mean age was 15.6 years. There were 1 type D1 nonunions (Herbert classification), 6 type D2, 2 type D3, and 2 type D4. Six patients had previously undergone an unsuccessful surgical attempt to treat their nonunion. The mean anterior bone defect was 3.5 mm in length. The patients experienced no postoperative complications. Successful consolidation was achieved in all cases, with 79% cross-sectional trabecular bridging at 12 weeks. Pain subsided after surgery and patients experienced improvements in both their Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Modified Mayo Wrist Score (MMWS) results. Overall, 34% and 40% gains in strength and wrist motion, relative to the contralateral normal side, were observed. CONCLUSIONS In this study, the use of VTMPF for scaphoid nonunion in children and adolescents is associated with generally good outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Sergi Barrera-Ochoa
- Pediatric Hand Surgery and Microsurgery Unit, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain; Hand and Microsurgery Unit, ICATME, Hospital Universitari Quiron-Dexeus, Barcelona, Spain.
| | - Gerardo Mendez-Sanchez
- Hand and Microsurgery Unit, ICATME, Hospital Universitari Quiron-Dexeus, Barcelona, Spain; Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Mir-Bullo
- Hand and Microsurgery Unit, ICATME, Hospital Universitari Quiron-Dexeus, Barcelona, Spain
| | - Jorge Knörr
- Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jayme Augusto Bertelli
- Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianoópolis, Santa Catarina, Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão, Brazil
| | - Francisco Soldado
- Pediatric Hand Surgery and Microsurgery Unit, Hospital Sant Joan de Deu, Universitat de Barcelona, Barcelona, Spain
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Vascularized Periosteal Flaps Accelerate Osteointegration and Revascularization of Allografts in Rats. Clin Orthop Relat Res 2019; 477:741-755. [PMID: 30810538 PMCID: PMC6437352 DOI: 10.1097/corr.0000000000000400] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Surgical reconstruction of large bone defects with structural bone allografts can restore bone stock but is associated with complications such as nonunion, fracture, and infection. Vascularized reconstructive techniques may provide an alternative in the repair of critical bone defects; however, no studies specifically addressing the role of vascularized periosteal flaps in stimulating bone allograft revascularization and osseointegration have been reported. QUESTIONS/PURPOSES (1) Does a vascularized periosteal flap increase the likelihood of union at the allograft-host junction in a critical-size defect femoral model in rats? (2) Does a vascularized periosteal flap promote revascularization of a critical-size defect structural bone allograft in a rat model? (3) What type of ossification occurs in connection with a vascularized periosteal flap? METHODS Sixty-four rats were assigned to two equal groups. In both the control and experimental groups, a 5-cm critical size femoral defect was created in the left femur and then reconstructed with a cryopreserved structural bone allograft and intramedullary nail. In the experimental group, a vascularized periosteal flap from the medial femoral condyle, with a pedicle based on the descending genicular vessels, was associated with the allograft. The 32 rats of each group were divided into subgroups of 4-week (eight rats), 6-week (eight rats), and 10-week (16 rats) followup. At the end of their assigned followup periods, the animals were euthanized and their femurs were harvested for semiquantitative and quantitative analysis using micro-CT (all followup groups), quantitative biomechanical evaluation (eight rats from each 10-week followup group), qualitative confocal microscopic, backscattered electron microscopic, and histology analysis (4-week and 6-week groups and eight rats from each 10-week followup group). When making their analyses, all the examiners were blinded to the treatment groups from which the samples came. RESULTS There was an improvement in allograft-host bone union in the 10-week experimental group (odds ratio [OR], 19.29 [3.63-184.50], p < 0.05). In contrast to control specimens, greater bone neoformation in the allograft segment was observed in the experimental group (OR [4-week] 63.3 [39.6-87.0], p < 0.05; OR [6-week] 43.4 [20.5-66.3], p < 0.05; OR [10-week] 62.9 [40.1-85.7], p < 0.05). In our biomechanical testing, control samples were not evaluable as a result of premature breakage during the embedding and assembly processes. Therefore, experimental samples were compared with untreated contralateral femurs. No difference in torsion resistance pattern was observed between both groups. Both backscattered electron microscopy and histology showed newly formed bone tissue and osteoclast lacunae, indicating a regulated process of bone regeneration of the initial allograft in evaluated samples from the experimental group. They also showed intramembranous ossification produced by the vascularized periosteal flap in evaluated samples from the experimental group, whereas samples from the control group showed an attempted endochondral ossification in the allograft-host bone junctions. CONCLUSIONS A vascularized periosteal flap promotes and accelerates allograft-host bone union and revascularization of cryopreserved structural bone allografts through intramembranous ossification in a preclinical rat model. CLINICAL RELEVANCE If large-animal models substantiate the findings made here, this approach might be used in allograft reconstructions for critical defects using fibular or tibial periosteal flaps as previously described.
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Papalia R, Torre G, Maffulli N, Denaro V. Hip fractures in children and adolescents. Br Med Bull 2019; 129:117-128. [PMID: 30753305 DOI: 10.1093/bmb/ldz004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/03/2019] [Accepted: 01/11/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Femoral neck fractures account for <1% of the fractures in children, and are produced by high energy trauma. The most commonly accepted treatment for such fractures is gentle manual anatomical reduction and internal fixation, yielding a healing rate between 80% and 90%. SOURCES OF DATA Electronic search through major web databases (Medline, Cochrane and Google Scholar). All types of article were eligible for inclusion, except for reviews, systematic reviews, meta-analyses and case reports. The methodological quality of the studies was assessed using the Methodological Index for NOn-Randomized Studies (MINORS). AREAS OF AGREEMENT Both open reduction and internal fixation (ORIF) and closed reduction and internal fixation (CRIF) can be used to manage hip fractures in paediatric patients. ORIF is more accurate in reducing and fixing the fracture, with better clinical and functional outcomes, and lower complication rate. Delayed fixation decreases the rate of acceptable outcome and increases the rate of complications. AREAS OF CONTROVERSY The methodological quality of the included studies is average-low, and the published evidence is not of sufficient quality to allow to draw final conclusion on the topic. GROWING POINTS Good results were reported for both ORIF and CRIF techniques, but are not supported by scientific evidence of adequate quality. More and better studies, including randomized trials, should be carried out to provide more scientifically evidence based conclusions.
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Affiliation(s)
- Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Guglielmo Torre
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
| | - Nicola Maffulli
- Faculty of Medicine, Surgery and Dentistry, Department of Musculoskeletal Disorders, University of Salerno, Baronissi, Salerno, Italy.,Queen Mary University of London, Barts and The London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, England.,Institute of Science and Technology in Medicine, Department of Orthopaedics, Keele University School of Medicine, Stoke on Trent, England
| | - Vincenzo Denaro
- Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico University of Rome, Rome, Italy
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Barrera-Ochoa S, Mendez-Sanchez G, Rodriguez-Baeza A, Knörr J, Bertelli JA, Soldado F. Vascularized thumb metacarpal periosteal pedicled flap for scaphoid nonunion: An anatomical study and pediatric case report. Microsurgery 2017; 39:62-69. [DOI: 10.1002/micr.30233] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/02/2017] [Accepted: 08/25/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Sergi Barrera-Ochoa
- Pediatric Hand Surgery and Microsurgery Unit; Hospital Sant Joan de Deu, Universitat de Barcelona; Barcelona Spain
- Hand and Microsurgery Unit; Hospital Universitari Quiron-Dexeus, ICATME; Barcelona Spain
| | - Gerardo Mendez-Sanchez
- Hand and Microsurgery Unit; Hospital Universitari Quiron-Dexeus, ICATME; Barcelona Spain
| | - Alfonso Rodriguez-Baeza
- Human Anatomy and Embryology Department; Faculty of Medicine, Universitat Autònoma de Barcelona; Barcelona Spain
| | - Jorge Knörr
- Pediatric Hand Surgery and Microsurgery Unit; Hospital Sant Joan de Deu, Universitat de Barcelona; Barcelona Spain
| | - Jayme Augusto Bertelli
- Department of Orthopedic Surgery; Governador Celso Ramos Hospital, Florianoópolis, Santa Catarina; Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul); Tubarão Brazil
| | - Francisco Soldado
- Pediatric Hand Surgery and Microsurgery Unit; Hospital Sant Joan de Deu, Universitat de Barcelona; Barcelona Spain
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Barrera-Ochoa S, Velez R, Rodriguez-Baeza A, De Bergua-Domingo JM, Knörr J, Soldado F. Vascularized ulnar periosteal pedicled flap for forearm reconstruction: Anatomical study and a case report. Microsurgery 2017; 38:530-535. [DOI: 10.1002/micr.30208] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 06/15/2017] [Accepted: 07/12/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Sergi Barrera-Ochoa
- Orthopedic Surgery Department, Pediatric Upper Extremity Surgery and Microsurgery; Hospital Sant Joan de Deu. Passeig Sant Joan de Deu, 2; Esplugues de Llobregat 08950 Spain
- Hand and Microsurgery Unit; Hospital Universitari Quiron-Dexeus; ICATME. Carrer Sabino de Arana, 5-19, Barcelona 08028 Spain
| | - Roberto Velez
- Orthopedic Surgery Department; Hand Surgery Unit; Hospital Universitari Vall d'Hebron; Passeig Vall d'Hebron 119-129, Barcelona 08035 Spain
| | - Alfonso Rodriguez-Baeza
- Human Anatomy and Embryology Department, Faculty of Medicine; Universitat Autònoma de Barcelona; Barcelona Spain
| | - Josep Maria De Bergua-Domingo
- Orthopedic Surgery Department, Pediatric Upper Extremity Surgery and Microsurgery; Hospital Sant Joan de Deu. Passeig Sant Joan de Deu, 2; Esplugues de Llobregat 08950 Spain
| | - Jorge Knörr
- Orthopedic Surgery Department, Pediatric Upper Extremity Surgery and Microsurgery; Hospital Sant Joan de Deu. Passeig Sant Joan de Deu, 2; Esplugues de Llobregat 08950 Spain
| | - Francisco Soldado
- Orthopedic Surgery Department, Pediatric Upper Extremity Surgery and Microsurgery; Hospital Sant Joan de Deu. Passeig Sant Joan de Deu, 2; Esplugues de Llobregat 08950 Spain
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Soldado F, Knörr J, Haddad S, Corona PS, Barrera‐Ochoa S, Collado D, Mascarenhas VV, Gauzy JS. Vascularized tibial periosteal graft in complex cases of bone nonunion in children. Microsurgery 2014; 35:239-43. [DOI: 10.1002/micr.22342] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/28/2014] [Accepted: 10/03/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Francisco Soldado
- Department of Pediatric Upper Extremity Surgery and Microsurgery, Hospital Sant Joan de DeuUniversitat de Barcelona Spain
| | - Jorge Knörr
- Pediatric Orthopedic Surgery DepartmentHôpital des Enfants, CHU Toulouse France
| | - Sleiman Haddad
- Orthopaedic Surgery DepartmentHospital Universitari Vall d'HebronBarcelona Spain
| | - Pablo S. Corona
- Orthopaedic Surgery DepartmentHospital Universitari Vall d'HebronBarcelona Spain
| | - Sergi Barrera‐Ochoa
- Orthopaedic Surgery DepartmentHospital Universitari Vall d'HebronBarcelona Spain
| | - Diego Collado
- Orthopaedic Surgery DepartmentHospital Universitari Vall d'HebronBarcelona Spain
| | | | - Jerome Sales Gauzy
- Pediatric Orthopedic Surgery DepartmentHôpital des Enfants, CHU Toulouse France
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Yeranosian M, Horneff JG, Baldwin K, Hosalkar HS. Factors affecting the outcome of fractures of the femoral neck in children and adolescents: a systematic review. Bone Joint J 2013; 95-B:135-42. [PMID: 23307688 DOI: 10.1302/0301-620x.95b1.30161] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Fractures of the femoral neck in children are rare, high-energy injuries with high complication rates. Their treatment has become more interventional but evidence of the efficacy of such measures is limited. We performed a systematic review of studies examining different types of treatment and their outcomes, including avascular necrosis (AVN), nonunion, coxa vara, premature physeal closure (PPC), and Ratliff's clinical criteria. A total of 30 studies were included, comprising 935 patients. Operative treatment and open reduction were associated with higher rates of AVN. Delbet types I and II fractures were most likely to undergo open reduction and internal fixation. Coxa vara was reduced in the operative group, whereas nonunion and PPC were not related to surgical intervention. Nonunion and coxa vara were unaffected by the method of reduction. Capsular decompression had no effect on AVN. Although surgery allows a more anatomical union, it is uncertain whether operative treatment or the type of reduction affects the rate of AVN, nonunion or PPC, because more severe fractures were operated upon more frequently. A delay in treatment beyond 24 hours was associated with a higher incidence of AVN.
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Affiliation(s)
- M Yeranosian
- University of California San Diego, 9500 Gilman Drive, La Jolla, California 92093, USA
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Soldado F, Barrera-Ochoa S, Fontecha CG, Haddad S, Barastegui D, Barber I, Rego P. Vascularized periosteal graft from the first metatarsal bone: A new technique to prevent collapse of osteonecrosis of the talus in children. A case report. Microsurgery 2012; 33:56-9. [DOI: 10.1002/micr.22045] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 07/21/2012] [Accepted: 08/07/2012] [Indexed: 11/09/2022]
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Abstract
BACKGROUND The periosteum in children has strong osteogenic power and is quite thick, facilitating procurement. However, it has been rarely used as a vascularized flap to enhance bone union in this age range. The purpose of this study is to assess the effectiveness of a new vascularized periosteal flap harvested from the fibula for the enhancement of bone union in the pediatric age. METHODS Thirteen vascularized fibular periosteal grafts were used in 12 children, mean age 12.6 years. Indications included the prevention of bone allograft-host junction nonunion and treatment of recalcitrant bone nonunion. In 9 instances, the periosteal flap was harvested as a free flap and in 4 as a pedicled flap. Serial radiographs and computed tomography scans were used to evaluate the progression of callus formation and bone healing. RESULTS All flaps were successful in promoting bone healing and achieving bone union in a mean time of 2.8 months for metaphyseal junctions and 7.1 months for diaphyseal ones, except for 1 case, which initially failed due to a pedicle torsion. It was then resolved with a second vascularized fibular periosteal grafts, with complete union after 5 months. CONCLUSIONS Transfer of a vascularized fibular periosteal flap, either pedicled or as a free flap, is an effective treatment to enhance bone union in children in biologically unfavorable scenarios. The properties of periosteal tissue in the pediatric age are unique and its use in bone union enhancement permits new reconstructive strategies in children different from those described in adults. LEVEL OF EVIDENCE IV.
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