Rees Andrew B, Schultz Jacob D, Wollenman Lucas C, Moore-Lotridge Stephanie N, Martus Jeffrey E, Mencio Gregory A, Schoenecker Jonathan G
School of Medicine, Vanderbilt University, Nashville, Tennessee.
Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee.
JB JS Open Access. 2021 Jul 28;6(3). doi: 10.2106/JBJS.OA.21.00014. eCollection 2021 Jul-Sep.
Stabilization of the medial column is vital in preventing the loss of fixation and malunion in displaced pediatric supracondylar humeral fractures (SCHFs). The preferred percutaneous pin configuration for medial column fixation remains controversial between medial pinning (cross-pinning) and additional lateral-based pinning. The intraoperative internal rotation stress test (IRST) has been proposed to reliably determine the optimal fixation strategy for each unique fracture. This study evaluated the impact of implementing the IRST on both the choice of pin configuration and institution-wide complications in pediatric patients treated operatively for SCHFs.
Pediatric patients undergoing percutaneous pinning for SCHFs between 2007 and 2017 at a single center were retrospectively reviewed. The IRST was made a universal institutional practice in 2013. Patients were divided into 2 groups for analysis: (1) patients who underwent treatment before the IRST was implemented in 2013 (the pre-IRST group), and (2) patients who were treated after the IRST was implemented in 2013 (the IRST group). Subgroup analysis was completed for patients in the IRST group who were treated with cross-pinning or 3 lateral-based pins.
In this study, 820 patients in the pre-IRST group and 636 patients in the IRST group were included. After the IRST implementation, the rate of loss of fixation fell from 1.2% to 0% (p = 0.003), and the reoperation rate fell from 3.3% to 0.2% (p < 0.001). No cases resulted in a loss of fixation after the adoption of the IRST. The number of patients treated with cross-pinning decreased significantly from 53.2% to 31.6% (p < 0.001) after the IRST implementation, yet cross-pinning continued to be used for more severe fractures. Complication rates within the IRST group were not significantly different (p > 0.05) between cross-pinning and 3 lateral-based pins.
In the largest cohort reported on to date, to our knowledge, institutional implementation of the IRST resulted in a significant reduction in the use of cross-pinning. Although the usage of cross-pinning decreased, cross-pinning was still used frequently in the most severe fractures. The IRST use also resulted in significantly fewer complications such as loss of fixation after institution-wide implementation of the IRST for treating pediatric SCHFs.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
在防止小儿移位性肱骨髁上骨折（SCHF）的固定失败和畸形愈合方面，内侧柱的稳定至关重要。内侧柱固定的首选经皮穿针构型在内侧穿针（交叉穿针）和额外的外侧穿针之间仍存在争议。术中内旋应力试验（IRST）已被提出用于可靠地确定每例独特骨折的最佳固定策略。本研究评估了实施IRST对接受手术治疗的小儿SCHF患者穿针构型选择和全院并发症的影响。
回顾性分析2007年至2017年在单一中心接受经皮穿针治疗SCHF的小儿患者。2013年，IRST成为全院通用的操作。患者分为两组进行分析：（1）2013年实施IRST之前接受治疗的患者（IRST前组），以及（2）2013年实施IRST之后接受治疗的患者（IRST组）。对IRST组中接受交叉穿针或3根外侧穿针治疗的患者进行亚组分析。
本研究纳入了820例IRST前组患者和636例IRST组患者。实施IRST后，固定失败率从1.2%降至0%（p = 0.003），再次手术率从3.3%降至0.2%（p < 0.001）。采用IRST后无固定失败病例。实施IRST后，接受交叉穿针治疗的患者数量从53.2%显著降至31.6%（p < 0.001），但交叉穿针仍用于更严重的骨折。IRST组中交叉穿针和3根外侧穿针的并发症发生率无显著差异（p > 0.05）。
据我们所知，在迄今为止报道的最大队列中，全院实施IRST导致交叉穿针的使用显著减少。尽管交叉穿针的使用减少，但在最严重的骨折中仍频繁使用。在全院实施IRST治疗小儿SCHF后，使用IRST还导致诸如固定失败等并发症显著减少。
治疗性III级。有关证据水平的完整描述，请参阅作者指南。
