Pediatric supracondylar humerus fractures: is surgeon experience a surrogate for the need of open reduction?

Abstract

Although there are many factors that are likely to influence the need for open reduction and percutaneous pinning (ORPF) in the treatment of pediatric supracondylar humerus fractures (SCHFs), the role of surgeon's experience (as represented by the total number of surgically treated SCHFs) on the need for ORPF has seldom been investigated. We reviewed the data on all completely displaced, pediatric SCHFs that were treated surgically by a single, fellowship-trained, pediatric orthopedic surgeon over the first 10 years of the surgeon's clinical practice. The incidence of ORPF was calculated as the percentage of open reductions among surgically treated, completely displaced, consecutive SCHFs at any given time during the 10-year period. From September 2005 to August 2015, a total of 212 completely displaced SCHFs were treated surgically at our institution by a single surgeon. When analyzing the incidence of ORPFs among surgically treated, completely displaced SCHFs at any given time, a bimodal curve was found: there was an increasing slope over the first 30 surgically treated SCHFs, with a progressive decreasing slope afterward. The incidence of ORPF within the first 10, 20, and 30 surgically treated, completely displaced SCHFs was 10.0, 30.0, and 26.7%, respectively, decreasing to 16.0, 9.0, 6.7, and 5.0% within the first 50, 100, 150, and 200 surgeries, respectively. The incidence of ORPF was almost 17-fold higher within the first 30 surgically treated, completely displaced SCHFs (17%), when compared with the following 182 (1.1%) cases (P<0.00001). Although it is likely that many factors influence the need for ORPF in the treatment of completely displaced SCHFs, surgeon's experience appears to play a significant role. Strategies aimed to accelerate the learning curve in the treatment of pediatric SCHFs should be undertaken.

Pediatric Hip Dysplasia Surgery Outcomes by Pediatric Versus Nonpediatric Orthopedists

“…Even in adult studies, the effects of surgeon type and training on surgical outcomes remain unclear [ 18 ]. A study by Silva et al, however, demonstrated how the increased pediatric surgical experience was found to significantly reduce the need for open reduction and percutaneous pinning in the treatment of supracondylar humerus fractures, but they note that multiple factors likely influence this assertion [ 19 ].…”

Increasing Value in Subspecialty Training: A Comparison of Variation in Surgical Complications for Pediatric Versus Other Fellowship-trained American Board of Orthopaedic Surgery Candidates in the Treatment of Supracondylar Fractures

“…There are few other studies analyzing surgical complication rates for SCHF and its correlation with fellowship training. 10 , 11 , 13 , 14 Dodds et al 10 found that SCHF had a lower rate of inadequate fracture fixation when treated by a pediatric fellowship-trained surgeons (14.7%) compared with other orthopaedic surgeons (43.5%), for children aged younger than 10 years. Ralles et al, 14 compared open reduction and internal fixation and closed reduction and percutaneous pinning, found that pediatric specialists had the fewest complications, although their analysis did not include a regression analysis or consideration of the potential effect of case volumes.…”

“…10 Previous studies have attempted to examine the difference in complications among types of orthopaedic fellowship-trained surgeons, and experience in the treatment of SCHFs has mixed results. 6,8,[10][11][12][13] Dodds et al showed in a 90-patient cohort treated by pediatric (57) or nonpediatric orthopaedic surgeons (33) that despite differences in intermediate complications (eg, lower rate of open reduction and inadequate fracture fixation), there were no differences in clinical complications (eg, iatrogenic nerve injury, infection, and compartment syndrome), malreductions, or postoperative loss of reduction between providers. 10 Silva et al 13 subsequently demonstrated that surgeon experience may play a role in reducing the need for open reduction and percutaneous pinning.…”

“… 6 , 8 , 10 11 12 13 Dodds et al showed in a 90-patient cohort treated by pediatric (57) or nonpediatric orthopaedic surgeons (33) that despite differences in intermediate complications (eg, lower rate of open reduction and inadequate fracture fixation), there were no differences in clinical complications (eg, iatrogenic nerve injury, infection, and compartment syndrome), malreductions, or postoperative loss of reduction between providers. 10 Silva et al 13 subsequently demonstrated that surgeon experience may play a role in reducing the need for open reduction and percutaneous pinning. Recently, Ralles et al 14 examined the American Board of Orthopaedic Surgery (ABOS) data set and also found evidence for value of fellowship training, but the analysis was limited to gross complication rates and lacked logistical regressions thus narrowing conclusions.…”

Effect of fracture location on rate of conversion to open reduction and clinical outcomes in pediatric gartland type 3 supracondylar humerus fractures

“…Closed reductions provide accelerated fracture healing, faster superficial tissue healing, and better clinical outcomes. [3,4] Various studies have suggested associations between conversion to open reduction and factors such as time to operation, patient weight, surgeon experience, and excessive edema around the fracture; [5] however, no consensus has been reached regarding which patients are more likely to require conversion to open reduction. [6][7][8][9][10][11] Gartland type III fractures occur in the distal humerus and may be located above the isthmus (high level) (Fig.…”