Truong Walter H, Novotny Susan A, Novacheck Tom F, Shin Eyun-Jung, Howard Andrew, Narayanan Unni G
Gillette Children's Specialty Healthcare, Department of Orthopaedic Surgery, University of Minnesota, Saint Paul.
Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN.
J Pediatr Orthop. 2019 Sep;39(8):e629-e635. doi: 10.1097/BPO.0000000000001082.
Implants are commonly used to stabilize proximal femoral osteotomies in children with cerebral palsy (CP). Removal of implants is common practice and believed to avoid infection, fracture, or pain that might be associated with retained hardware. There is little evidence to support a prophylactic strategy over a reactive approach based on symptoms. The aim of this study was to compare the outcomes of prophylactic and reactive approaches to removal of proximal femoral implants in children with CP.
An intention-to-treat model was used to compare 2 institutions that followed a prophylactic (within ∼1 y) and reactive (following complication/symptoms) approach to hardware removal, respectively. Patients with CP who had femoral implants placed at or before age 16, and had ≥2-year postsurgical follow-up were included. Demographics, surgical details, reasons for removal, and complications were recorded. χ and t tests were used.
Six hundred twenty-one patients (prophylactic=302, reactive=319) were followed for an average of 6 years (range, 2 to 17 y). Two hundred eighty-seven (95%) implants were removed in the prophylactic group at 1.2 years. In the reactive group, 64 (20%) implants were removed at an average of 4.2 years. Reasons for removal included pain; infection; fracture; or for repeat reconstruction. The rate of unplanned removals due to fracture or infection was higher in the reactive group (4.7% vs. 0.7%, P=0.002), but there was no difference in the rate of complications during/after removal between the 2 groups (1.7% vs. 3.1%; P=0.616). No specific risk factor associated with unplanned removal could be identified; but children under 8 years old seemed more likely to undergo later removal (odds ratio 1.98; 95% confidence interval, 0.99-3.99).
Eighty percent of patients in the reactive removal strategy avoided surgery. This group did have a 4% higher rate of fracture or infection necessitating unplanned removal but these were successfully treated at time of removal with no difference in complication rates associated with removal between both groups. One would need to remove implants from 25 patients to avoid 1 additional complication, providing some support for a reactive approach to removal of proximal femoral implants in this population.
Level III-therapeutic.
植入物常用于稳定脑瘫（CP）患儿的股骨近端截骨术。取出植入物是常见的做法，人们认为这样可以避免与留存内固定器械相关的感染、骨折或疼痛。几乎没有证据支持预防性策略优于基于症状的应对性方法。本研究的目的是比较预防性和应对性方法取出CP患儿股骨近端植入物的效果。
采用意向性分析模型比较分别遵循预防性（约1年内）和应对性（出现并发症/症状后）取出内固定器械方法的两家机构。纳入16岁及以下置入股骨植入物且术后随访≥2年的CP患儿。记录人口统计学资料、手术细节、取出原因及并发症情况。采用χ检验和t检验。
621例患者（预防性组=302例，应对性组=319例）平均随访6年（范围2至17年）。预防性组287枚（95%）植入物在1.2年时取出。应对性组64枚（20%）植入物平均在4.2年时取出。取出原因包括疼痛、感染、骨折或用于再次重建。应对性组因骨折或感染导致的意外取出率更高（4.7%对0.7%，P=0.002），但两组取出期间/取出后的并发症发生率无差异（1.7%对3.1%；P=0.616）。未发现与意外取出相关的特定危险因素；但8岁以下儿童似乎更有可能接受后期取出（比值比1.98；95%置信区间，0.99 - 3.99）。
采用应对性取出策略的患者中有80%避免了手术。该组因骨折或感染导致需要意外取出的发生率确实高出4%，但这些在取出时均得到成功治疗，两组取出相关的并发症发生率无差异。需要从25例患者中取出植入物才能避免1例额外并发症，这为该人群股骨近端植入物取出采用应对性方法提供了一定支持。
治疗性III级。
