Letters to the Editor 489
Letters to the Editor Journal of Pediatric Orthopaedics B 2014, 23:489–491
Are they overtreated? Yueju Liua,b and Yingze Zhanga,b, aDepartment of Orthopedic Center, Third Hospital of Hebei Medical University and bKey Orthopaedic Biomechanics Laboratory of Hebei Province, Shijiazhuang, People’s Republic of China Correspondence to Yingze Zhang, MD, Department of Orthopedic Center, Third Hospital of Hebei Medical University, No. 139 Zi Qiang Road, Shijiazhuang, Hebei 050051, People’s Republic of China Tel: + 86 0311 8860 3682; fax: + 86 0311 8702 3626; e-mail: [email protected]
Karaman et al. [1] carried out a mid-term prospective study on 102 pediatric patients with long bone (the humerus, forearm, tibia, and femur) shaft fractures operated by elastic intramedullary nailing, and found that elastic intramedullary nailing is the best choice for diaphyseal fractures in children with skeletal immaturity compared with other surgical choices. However, we found that the patients are overtreated in this study, especially for forearm fractures. The author even performed an operation on a 5-year-old child with forearm shaft fractures, which is unheard of on the basis of our experience of nearly 200 pediatric shaft fractures and also rare in the English literature. Jones [2] pointed that ‘closed reduction still remains the gold standard for closed isolated pediatric forearm fractures’. Operative treatment of radial and ulnar shaft fractures is usually reserved for open fractures, those associated with compartment syndrome, floating elbow injuries, and fractures that develop unacceptable displacement during nonoperative management, and residual angulation after closed treatment is much better tolerated by younger children than older adolescents and adults because of the increased remodeling potential in the younger age group [3]. Bellemans [4] considered displaced oblique or comminuted midshaft forearm fractures in children older than 7 years of age to be an indication for elastic intramedullary nailing, which was accepted by most orthopedic doctors. In our clinical practice, we found that even significantly displaced forearm shaft fractures are usually manipulated in the emergency department using a conscious sedation protocol. Moreover, provided the child has at least 2 years of growth remaining, ∼ 20° of angulation in distal-third shaft fractures of the radius and ulna, 15° at the midshaft level, and 10° in the proximal third are accepted by most orthopedic doctors [5]. Thus, the indications for surgery in this study were severely magnified and X-ray exposure place children of only 5 years old in danger certainly, with long-term results we do not know. In addition, we, as doctors, should help parents 1060-152X © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
make the best decisions for their children, and we should not only accept their decision concerning surgery, in which they want the operation and we perform the operation
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
2 3 4
5
Karaman I, Halici M, Kafadar IH, Guney A, Oner M, Gurbuz K, Karaman ZF. Mid-term results of the elastic intramedullary nailing in paediatric long bone shaft fractures: a prospective study of 102 cases. J Pediatr Orthop B 2014; 23:212–220. Jones K, Weiner DS. The management of forearm fractures in children: a plea for conservatism. J Pediatr Orthop 1999; 19:811–815. Kay S, Smith C, Oppenheim WL. Both-bone midshaft forearm fractures in children. J Pediatr Orthop 1986; 6:306–310. Bellemans M, Lamoureux J. Indications for immediate percutaneous intramedullary nailing of complete diaphyseal forearm shaft fractures in children. Acta Orthop Belg 1995; 61 (Suppl 1):169–172. Younger AS, Tredwell SJ, Mackenzie WG, Orr JD, King PM, Tennant W. Accurate prediction of outcome after pediatric forearm fracture. J Pediatr Orthop 1994; 14:200–206.
Response to ‘Are they overtreated’ Ibrahim Karamana, Mehmet Halicia, Ibrahim H. Kafadara, Ahmet Guneya, Mithat Onera and Zehra F. Karamanb, aDepartment of Orthopaedics and Traumatology, Erciyes University Medical Faculty and bDepartment of Radiology, Training and Research Hospital, Kayseri, Turkey Correspondence to Ibrahim Karaman, MD, Orthopaedics and Traumatology Department, Gevher Nesibe Hospital, Erciyes University, Sok.Vakıf-Kınaş Apt. No. 4/18, Melikgazi 38039, Kayseri, Turkey Tel: + 90 352 2076666; fax: + 90 352 4377686; e-mail: [email protected]
Our results are in agreement with the literature as the author stated his concerns about the age limit for the indication of surgery in pediatric patients. We apply closed reduction and casting for patients younger than 10 years old [1]. Loss of reduction at follow-up or nonachievement of the required reduction is necessary for a surgical indication. The average age of the children in our study was older than 7 years and this is in agreement with the literature [1] and so we do not extend the indication of the surgery. When we reviewed the data of the patient that the author mentioned in particular, it was found that the patient had presented a day after the fracture had occurred; because of significant swelling at that time, closed reduction and casting could not be performed and so intramedullary nailing and splinting was performed. However, one limitation of our study was that we did not report detailed clinical information of this patient. Furthermore, we found that elastic intramedullary nails DOI: 10.1097/BPB.0000000000000080
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
490
Journal of Pediatric Orthopaedics B 2014, Vol 23 No 5
can be used in patients younger than 5 years old according to the literature [2]. Again, according to the literature, on comparing plating with elastic intramedullary nailing, complications occurred more often in patients with plating than patients subjected to elastic intramedullary nailing after removal of implants [3]. Thus, intramedullary nailing is the optimal choice for such patients as we reported in our study. Again, according to the literature, it was found that the longterm results of elastic intramedullary nailing are quite good [4,5]. Therefore, we believe that we did not perform unnecessary surgeries on our patients as the author stated and our patient selection is in agreement with the literature.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 Karaman I, Halici M, Kafadar IH, Guney A, Oner M, Gurbuz K, Karaman ZF. Mid-term results of the elastic intramedullary nailing in paediatric long bone shaft fractures: a prospective study of 102 cases. J Pediatr Orthop B 2014; 23:212–220. 2 Simanovskya N, Porata S, Simanovskyb N, Eylon S. Close reduction and intramedullary flexible titanium nails fixation of femoral shaft fractures in children under 5 years of age. J Pediatr Orthop B 2006; 15:293–297. 3 Makki D, Kheiran A, Gadiyar R, Ricketts D. Refractures following removal of plates and elastic nails from paediatric forearms. J Pediatr Orthop B 2014; 23:221–226. 4 Sénès FM, Catena N. Intramedullary osteosynthesis for metaphyseal and diaphyseal humeral fractures in developmental age. J Pediatr Orthop B 2012; 21:300–304. 5 Till H, Hüttl B, Knorr P, Dietz HG. Elastic stable intramedullary nailing (ESIN) provides good long-term results in pediatric long-bone fractures. Eur J Pediatr Surg 2000; 10:319–322.
Comment on the article ‘Flexibility of idiopathic congenital clubfeet treated by posteromedial release without talocalcaneal joint release’ by Machida et al. Uday Guled, Vijay G. Goni, Nirmalraj Gopinathan and Pebam Sudesh, PGIMER, Chandigarh, India Correspondence to Uday Guled, MS, #319, P Block, New Doctors Hostel, PGIMER, Chandigarh, India 160012. Tel: +91 84 37 338920; fax: +91 88 72 016237; e-mail: [email protected]
(1) The author has described the method of soft tissue release without opening the talocalcaneal joint. In one of his descriptions, the author reports that the calcaneofibular ligament is released. We believe that it is impossible to release a calcaneofibular ligament without opening the subtalar joint through a medial incision, which the author uses in his surgical method and is shown in the figures. Turco [2], in his article, used a similar incision, but released the calcaneofibular ligament through the subtalar joint. (2) In the clubfoot, the posterior end of calcaneus is displaced upwards and laterally because of a tight posterior talocalcaneal joint capsule, calcaneofibular ligament, and heel cord; the anterior end is displaced medially and downwards because of a tight deltoid ligament, spring ligament, posterior tibial tendon and interosseous talocalcaneal ligament [3]. We believe that it is necessary to release the subtalar joint to correct this deformity. (3) The author has not explained the rationale behind leaving the flexor hallusis and flexor digitorum longus tendon unsutured. (4) The author measures the forefoot range of motion by measuring the tibio-first metatarsal angle, which we believe is inappropriate as it includes both forefoot and hindfoot mobility. (5) The author has compared the results of his surgical methods with the conservative management group. We believe that it would be more useful to compare the results with the other methods of posteromedial soft tissue release in which the subtalar joint is released, although we agree that it is very difficult to avoid confounding factors. (6) In one of his statements, the author has described that pretreatment severity was assessed using the Dimeglio score. However, Dimeglio’s article [4] on the classification of the severity of clubfoot was published in 1995, and the study population in the present article was treated between 1991 and 1995 as quoted by the author; we would like to hear an explanation for this.
Acknowledgements Conflicts of interest
There are no conflicts of interest. This letter is in reference to the study of idiopathic congenital clubfeet treated omedial release without talocalcaneal joint Machida et al. [1] published in the Journal Orthopaedics B.
‘Flexibility by posterrelease’ by of Pediatric
We read the article carefully with great interest. On the basis of our reasonable experience in the management of clubfoot (100–150 cases per year), we wish to highlight a few of the shortcomings in the article.
References 1
2
3 4
Machida J, Kameshita K, Okuzumi S, Nakamura N. Flexibility of idiopathic congenital clubfeet treated by posteromedial release without talocalcaneal joint release. J Pediatr Orthop B 2014; 23:254–259. Turco VJ. Surgical correction of the resistant club foot. One-stage posteromedial release with internal fixation: a preliminary report. J Bone Joint Surg Am 1971; 53:477–497. Carroll NC, McMurtry R, Leete SF. The pathoanatomy of congenital clubfoot. Orthop Clin North Am 1978; 9:225–232. Dimeglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. J Pediatr Orthop B 1995; 4:129–136.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Letters to the Editor Journal of Pediatric Orthopaedics B 2014, 23:489–491
Are they overtreated? Yueju Liua,b and Yingze Zhanga,b, aDepartment of Orthopedic Center, Third Hospital of Hebei Medical University and bKey Orthopaedic Biomechanics Laboratory of Hebei Province, Shijiazhuang, People’s Republic of China Correspondence to Yingze Zhang, MD, Department of Orthopedic Center, Third Hospital of Hebei Medical University, No. 139 Zi Qiang Road, Shijiazhuang, Hebei 050051, People’s Republic of China Tel: + 86 0311 8860 3682; fax: + 86 0311 8702 3626; e-mail: [email protected]
Karaman et al. [1] carried out a mid-term prospective study on 102 pediatric patients with long bone (the humerus, forearm, tibia, and femur) shaft fractures operated by elastic intramedullary nailing, and found that elastic intramedullary nailing is the best choice for diaphyseal fractures in children with skeletal immaturity compared with other surgical choices. However, we found that the patients are overtreated in this study, especially for forearm fractures. The author even performed an operation on a 5-year-old child with forearm shaft fractures, which is unheard of on the basis of our experience of nearly 200 pediatric shaft fractures and also rare in the English literature. Jones [2] pointed that ‘closed reduction still remains the gold standard for closed isolated pediatric forearm fractures’. Operative treatment of radial and ulnar shaft fractures is usually reserved for open fractures, those associated with compartment syndrome, floating elbow injuries, and fractures that develop unacceptable displacement during nonoperative management, and residual angulation after closed treatment is much better tolerated by younger children than older adolescents and adults because of the increased remodeling potential in the younger age group [3]. Bellemans [4] considered displaced oblique or comminuted midshaft forearm fractures in children older than 7 years of age to be an indication for elastic intramedullary nailing, which was accepted by most orthopedic doctors. In our clinical practice, we found that even significantly displaced forearm shaft fractures are usually manipulated in the emergency department using a conscious sedation protocol. Moreover, provided the child has at least 2 years of growth remaining, ∼ 20° of angulation in distal-third shaft fractures of the radius and ulna, 15° at the midshaft level, and 10° in the proximal third are accepted by most orthopedic doctors [5]. Thus, the indications for surgery in this study were severely magnified and X-ray exposure place children of only 5 years old in danger certainly, with long-term results we do not know. In addition, we, as doctors, should help parents 1060-152X © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
make the best decisions for their children, and we should not only accept their decision concerning surgery, in which they want the operation and we perform the operation
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
2 3 4
5
Karaman I, Halici M, Kafadar IH, Guney A, Oner M, Gurbuz K, Karaman ZF. Mid-term results of the elastic intramedullary nailing in paediatric long bone shaft fractures: a prospective study of 102 cases. J Pediatr Orthop B 2014; 23:212–220. Jones K, Weiner DS. The management of forearm fractures in children: a plea for conservatism. J Pediatr Orthop 1999; 19:811–815. Kay S, Smith C, Oppenheim WL. Both-bone midshaft forearm fractures in children. J Pediatr Orthop 1986; 6:306–310. Bellemans M, Lamoureux J. Indications for immediate percutaneous intramedullary nailing of complete diaphyseal forearm shaft fractures in children. Acta Orthop Belg 1995; 61 (Suppl 1):169–172. Younger AS, Tredwell SJ, Mackenzie WG, Orr JD, King PM, Tennant W. Accurate prediction of outcome after pediatric forearm fracture. J Pediatr Orthop 1994; 14:200–206.
Response to ‘Are they overtreated’ Ibrahim Karamana, Mehmet Halicia, Ibrahim H. Kafadara, Ahmet Guneya, Mithat Onera and Zehra F. Karamanb, aDepartment of Orthopaedics and Traumatology, Erciyes University Medical Faculty and bDepartment of Radiology, Training and Research Hospital, Kayseri, Turkey Correspondence to Ibrahim Karaman, MD, Orthopaedics and Traumatology Department, Gevher Nesibe Hospital, Erciyes University, Sok.Vakıf-Kınaş Apt. No. 4/18, Melikgazi 38039, Kayseri, Turkey Tel: + 90 352 2076666; fax: + 90 352 4377686; e-mail: [email protected]
Our results are in agreement with the literature as the author stated his concerns about the age limit for the indication of surgery in pediatric patients. We apply closed reduction and casting for patients younger than 10 years old [1]. Loss of reduction at follow-up or nonachievement of the required reduction is necessary for a surgical indication. The average age of the children in our study was older than 7 years and this is in agreement with the literature [1] and so we do not extend the indication of the surgery. When we reviewed the data of the patient that the author mentioned in particular, it was found that the patient had presented a day after the fracture had occurred; because of significant swelling at that time, closed reduction and casting could not be performed and so intramedullary nailing and splinting was performed. However, one limitation of our study was that we did not report detailed clinical information of this patient. Furthermore, we found that elastic intramedullary nails DOI: 10.1097/BPB.0000000000000080
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
490
Journal of Pediatric Orthopaedics B 2014, Vol 23 No 5
can be used in patients younger than 5 years old according to the literature [2]. Again, according to the literature, on comparing plating with elastic intramedullary nailing, complications occurred more often in patients with plating than patients subjected to elastic intramedullary nailing after removal of implants [3]. Thus, intramedullary nailing is the optimal choice for such patients as we reported in our study. Again, according to the literature, it was found that the longterm results of elastic intramedullary nailing are quite good [4,5]. Therefore, we believe that we did not perform unnecessary surgeries on our patients as the author stated and our patient selection is in agreement with the literature.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1 Karaman I, Halici M, Kafadar IH, Guney A, Oner M, Gurbuz K, Karaman ZF. Mid-term results of the elastic intramedullary nailing in paediatric long bone shaft fractures: a prospective study of 102 cases. J Pediatr Orthop B 2014; 23:212–220. 2 Simanovskya N, Porata S, Simanovskyb N, Eylon S. Close reduction and intramedullary flexible titanium nails fixation of femoral shaft fractures in children under 5 years of age. J Pediatr Orthop B 2006; 15:293–297. 3 Makki D, Kheiran A, Gadiyar R, Ricketts D. Refractures following removal of plates and elastic nails from paediatric forearms. J Pediatr Orthop B 2014; 23:221–226. 4 Sénès FM, Catena N. Intramedullary osteosynthesis for metaphyseal and diaphyseal humeral fractures in developmental age. J Pediatr Orthop B 2012; 21:300–304. 5 Till H, Hüttl B, Knorr P, Dietz HG. Elastic stable intramedullary nailing (ESIN) provides good long-term results in pediatric long-bone fractures. Eur J Pediatr Surg 2000; 10:319–322.
Comment on the article ‘Flexibility of idiopathic congenital clubfeet treated by posteromedial release without talocalcaneal joint release’ by Machida et al. Uday Guled, Vijay G. Goni, Nirmalraj Gopinathan and Pebam Sudesh, PGIMER, Chandigarh, India Correspondence to Uday Guled, MS, #319, P Block, New Doctors Hostel, PGIMER, Chandigarh, India 160012. Tel: +91 84 37 338920; fax: +91 88 72 016237; e-mail: [email protected]
(1) The author has described the method of soft tissue release without opening the talocalcaneal joint. In one of his descriptions, the author reports that the calcaneofibular ligament is released. We believe that it is impossible to release a calcaneofibular ligament without opening the subtalar joint through a medial incision, which the author uses in his surgical method and is shown in the figures. Turco [2], in his article, used a similar incision, but released the calcaneofibular ligament through the subtalar joint. (2) In the clubfoot, the posterior end of calcaneus is displaced upwards and laterally because of a tight posterior talocalcaneal joint capsule, calcaneofibular ligament, and heel cord; the anterior end is displaced medially and downwards because of a tight deltoid ligament, spring ligament, posterior tibial tendon and interosseous talocalcaneal ligament [3]. We believe that it is necessary to release the subtalar joint to correct this deformity. (3) The author has not explained the rationale behind leaving the flexor hallusis and flexor digitorum longus tendon unsutured. (4) The author measures the forefoot range of motion by measuring the tibio-first metatarsal angle, which we believe is inappropriate as it includes both forefoot and hindfoot mobility. (5) The author has compared the results of his surgical methods with the conservative management group. We believe that it would be more useful to compare the results with the other methods of posteromedial soft tissue release in which the subtalar joint is released, although we agree that it is very difficult to avoid confounding factors. (6) In one of his statements, the author has described that pretreatment severity was assessed using the Dimeglio score. However, Dimeglio’s article [4] on the classification of the severity of clubfoot was published in 1995, and the study population in the present article was treated between 1991 and 1995 as quoted by the author; we would like to hear an explanation for this.
Acknowledgements Conflicts of interest
There are no conflicts of interest. This letter is in reference to the study of idiopathic congenital clubfeet treated omedial release without talocalcaneal joint Machida et al. [1] published in the Journal Orthopaedics B.
‘Flexibility by posterrelease’ by of Pediatric
We read the article carefully with great interest. On the basis of our reasonable experience in the management of clubfoot (100–150 cases per year), we wish to highlight a few of the shortcomings in the article.
References 1
2
3 4
Machida J, Kameshita K, Okuzumi S, Nakamura N. Flexibility of idiopathic congenital clubfeet treated by posteromedial release without talocalcaneal joint release. J Pediatr Orthop B 2014; 23:254–259. Turco VJ. Surgical correction of the resistant club foot. One-stage posteromedial release with internal fixation: a preliminary report. J Bone Joint Surg Am 1971; 53:477–497. Carroll NC, McMurtry R, Leete SF. The pathoanatomy of congenital clubfoot. Orthop Clin North Am 1978; 9:225–232. Dimeglio A, Bensahel H, Souchet P, Mazeau P, Bonnet F. Classification of clubfoot. J Pediatr Orthop B 1995; 4:129–136.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
