Does Surgeon Subspecialty Training Affect Outcomes in the Treatment of Displaced Supracondylar Humerus Fractures in Children?

Pediatric Supracondylar Humerus Fractures: Treatment by a Pediatric Orthopedic Surgeon Versus a Non-pediatric Orthopedic Surgeon

INTRODUCTION

Supracondylar humerus fractures are the most common surgically treated fracture in children. National trends have demonstrated an increase in transfers of supracondylar fractures to pediatric hospitals due to the perception that supracondylar fractures need to be treated by pediatric specialists. The objectives of the study are to compare the outcomes of surgically treated pediatric supracondylar humerus fractures (PSCHF) between a pediatric orthopedic surgeon and a non-pediatric orthopedic surgeon at a single academic medical center; to assess radiographic reduction, the number of pins used, surgical time, Flynn criteria outcomes, and complications associated with PSCHF treatment by both types of surgeons; to determine if there is a significant difference in outcomes between pediatric and non-pediatric orthopedic surgeons in the treatment of PSCHF.

METHODS

Forty-seven consecutive pediatric patients, with an average age of 5.5 years old, who had undergone surgical correction for supracondylar humerus fractures during 2019 were included in this study. The intervention performed was closed reduction and percutaneous pinning. The main outcome measured: radiographic reduction on the AP and lateral X-ray view, number of K wires used, use of a medial K wire, time of surgery, the Flynn criteria, and complications. The Human Research Protection Program (HRPP) at Penn State approval was obtained.

RESULTS

Radiographic reductions as measured by Bauman's angle and the position of the anterior humeral line were excellent and similar between surgeons. The pediatric orthopedic surgeon used more medial K wires (p=0.0007), fewer K wires (p=0.0065), and the length of surgery was shorter (p=0.019). The Flynn criteria were similar with equal excellent and good results. For both surgeons, no complications such as loss of reduction, infection, iatrogenic nerve injury, compartment syndrome, or cubitus varus occurred.

CONCLUSIONS

Outcomes of treatment of displaced PSCHF by the pediatric and non-pediatric orthopedic surgeons were equal. The results of this study reaffirm the assertion that both pediatric and non-pediatric orthopedic surgeons have sufficient training and skill to treat these common fractures, thereby contributing to a more informed decision-making process in clinical practice.

Impact of fellowship training for specialists on thyroidectomy outcomes of patients with thyroid cancer

We aimed to evaluate the impact of fellowship training (FT) for thyroid specialists on the outcomes of patients with thyroid cancer. We reviewed surgeries performed for thyroid cancer before (non-FT group) and after (FT group) fellowship training and compared several variables, including length of stay of patients, tumor diameter, surgical method, lymph node dissection, parathyroid implantation, surgical duration, intraoperative blood loss, and postoperative complications. Compared with the non-FT group, the FT group had a shorter hospital stay, more adequate fine needle aspiration biopsy of the thyroid, less intraoperative blood loss, higher rate of parathyroid implantation, higher lymph node dissection rate, and lower nerve injury and hypoparathyroidism rates. When the surgical duration was < 200 min and/or only central lymph node dissection was performed, the FT group had a lower incidence of postoperative complications than the non-FT group. When, the incidence of postoperative complications, including postoperative nerve injury and hypoparathyroidism. In conclusion, FT for thyroid specialists is beneficial for patients with thyroid cancer and may allow a shorter hospital stay and reduced incidence of postoperative complication. Accordingly, FT may facilitate a more appropriate surgical approach with a preoperative pathological diagnosis.

Value-Driven Pediatric Supracondylar Humerus Fracture Care: Implementing Evidence-Based Practices

Supracondylar humerus fractures are high-volume injuries in children; therefore, value-driven treatment has far-reaching implications for patients and families as well as healthcare systems. Children younger than 5 years can remodel posterior angulation. Most Type IIa fractures will maintain alignment after closed reduction. Many patients with surgical fractures can safely wait for nonemergent fixation. Outpatient surgery is associated with shorter surgical time, lower costs, and fewer return visits to the emergency department with no increase in adverse events. Type III fractures treated the following day do not have higher rates of open reduction, and patients with associated nerve injuries have no difference in recovery time compared with those treated more urgently. Pediatric-trained surgeons generally provide more efficient care (shorter surgical time and less after-hours surgery); however, their outcomes are equivalent to non-pediatric orthopaedic surgeons. Community hospitals have lower costs compared with teaching hospitals; therefore, transferring patients should be avoided when feasible. Postoperative care can be streamlined in uncomplicated cases to minimize radiographs, therapy referrals, and multiple visits. Splinting offers safer, lower cost immobilization over casting. With staffing shortages and an increasingly burdened healthcare system, it is imperative to maximize nonsurgical care, use outpatient facilities, and minimize postoperative requirements without negatively affecting patient outcomes.

Time of surgery and surgeon level in supracondylar humerus fractures in pediatric patients: A retrospective study

BACKGROUND

Supracondylar humerus fractures account for more than 60% of all elbow fractures and about 1/5 of all pediatric fractures. Unfortunately, these fractures can be associated with risk of complications including neurovascular injuries, malunions and limb deformities. Controversy exists regarding the effect of time of surgical intervention and/or level of surgeon performing the surgery on outcome of these fractures.

AIM

To determine whether time of surgical intervention and/or surgeon level influence the outcomes of surgically managed pediatric supracondylar humerus fractures.

METHODS

We retrospectively studied 155 pediatric patients presenting with a supracondylar humerus fracture in a level 1 trauma center from January 2006 to December 2019. The data extracted included demographic data, fracture characteristics, surgical data, and follow-up outcomes. The collected data was analyzed and P values of < 0.05 were considered statistically significant.

RESULTS

Of the cohort, 11% of patients had documented post-operative complications, of which the majority occurred in surgeries performed after day time working hours and in fractures requiring open reduction. While the lowest complication rate was found in surgeries performed by pediatric orthopaedic surgeons, this did not reach statistical significance.

CONCLUSION

In pediatric patients undergoing surgery for supracondylar fractures, we found a higher complication rate when surgeries were not performed during working hours. Surgeon level and training had no significant effect on the risk of post-operative complications.

Impact of Pediatric Orthopaedic Fellowship Training on Pediatric Supracondylar Humerus Fracture Treatment and Outcomes: A Meta-analysis

BACKGROUND

Supracondylar humerus (SCH) fractures are common pediatric injuries, typically requiring closed reduction and percutaneous pinning or open reduction. These injuries are managed frequently by both pediatric-trained (PTOS) and nonpediatric-trained (NTOS) orthopaedic surgeons. However, some literature suggests that complications for pediatric injuries are lower when managed by PTOS. Therefore, this meta-analysis sought to compile existing literature comparing patients treated by PTOS and NTOS to better understand differences in management and clinical outcomes.

METHODS

Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology, a systematic review was conducted for all articles comparing SCH fractures managed by PTOS and NTOS in 4 online databases (PubMed, Embase, CINAHL, Cochrane). Study quality was assessed through the use of the Newcastle-Ottawa Scale. Meta-analyses were then performed for postoperative outcomes using pooled data from the included studies. Statistics were reported as odds ratios and 95% CI.

RESULTS

This search strategy yielded 242 unique titles, of which 12 underwent full-text review and 7 met final inclusion. All studies were retrospective and evaluated patients treated in the United States. There were a total of 692 and 769 patients treated by PTOS and NTOS, respectively. PTOS had shorter operative times [mean difference, 13.6 min (CI, -23.9 to -3.4), P=0.01] and less frequently utilized a medial-entry pin [odds ratios, 0.36 (CI, 0.2 to 0.9), P=0.03]. There were no differences in time to treatment, the necessity of open reduction, postoperative Baumann angle, or complications including surgical site infection or iatrogenic nerve injury.

CONCLUSIONS

Despite shorter operative times and lower frequency of cross-pinning when treated by PTOS, pediatric SCH fracture outcomes are similar when treated by PTOS and NTOS. These findings demonstrate that these fractures may possibly be treated safely by both PTOS and experienced fellowship-trained academic NTOS who are comfortable managing these injuries in pediatric patients.

LEVEL OF EVIDENCE

Level III; Meta-analysis.