Abstract
Some concerns on “Efficacy and complications after delayed fixation of femoral neck fractures in children.” J Orthop Surg (Hong Kong), 2020, 28(1) by Wu C et al.
DOI: 2309499019889682
I have read with great interest the article in your journal by Wu C et al. titled “Efficacy and complications after delayed fixation of femoral neck fractures in children.”
1
There is an ongoing debate in the literature on the effect of various factors on outcome of pediatric femoral neck fractures with no consensus in near future.
2
The authors have done a wonderful study correlating avascular necrosis (AVN) rates with method of reduction, age, displacement and type of fracture. However, there are some points which need clarification from the authors for a better understanding of this article. All the patients in this series were treated by surgery either closed (n = 9) or open (n = 8) reduction. In the methodology section, the authors have included conservative management in their used treatment modalities; also at the end of introduction section, authors have written that after surgery patients underwent conservative management in spica which is confusing. It should be clear whether conservative management was used as a separate treatment method: What were the criteria and duration for spica cast application after surgery and in how many patients was hip spica cast used? Older patients (>10 years) with cannulated screws have stable configuration and seldom need postoperative casts unless fracture comminution and unstable fixation. Garden’s classification is used for classifying acute femoral neck fractures in adult patients and not the type of AVN in pediatric femoral heads. The authors have used it for classifying AVN in follow-up radiographs which is misguided. For classifying the type of AVN in the femoral head, Ratliff’s classification is used (which the authors have not used): and for the final outcome, Ratliff’s criteria are used.
3
Also “Table 2” is wrongly cited there and captioned which needs correction. (It is only a radiographic assessment, not a clinical one). There is no mention of the type of internal fixation used: How many patients were treated by pins, screws, or sliding hip screws? Some complications are more with certain types of implants such as physis fusion with screws: coxa vara, malunion, and implant migration with pins.
4
The Garden’s classification is used in adults with acute femoral neck fractures and is based on the fracture displacement and arrangement of the trabeculae of the proximal femur (low interobserver agreement even in adults).
5
What are the principles for using this classification in children: Which could have been simply classified as displaced or undisplaced? Complications are more and outcomes are inferior in displaced fractures. There were three patients with short femoral neck in this series, two also had associated AVN of femoral head. We would like to know the amount of shortening compared to the contralateral normal side, the effect on overall limb length and any abductor insufficiency or limp arising from the deranged hip biomechanics in these patients. In author’s opinion, what were the reasons behind no cases of coxa vara, physeal fusion, or nonunion in your series. Also what was the clinicoradiological and functional status of children with AVN at the last follow-up till this study was completed. Did they need additional surgeries for this complication?
