成骨不全症患者医源性术中骨折。

Department of Orthopaedic Surgery, Gillette Children's Hospital, St. Paul.

Department of Orthopaedic Surgery, University of Minnesota, Minneapolis.

J Pediatr Orthop. 2024;44(10):e945-e950. doi: 10.1097/BPO.0000000000002778. Epub 2024 Aug 5.

BACKGROUND

Osteogenesis imperfecta (OI) is a genetic defect in collagen type I, phenotypically characterized by bony fragility and a propensity to high rates of childhood fracture. Fragility fractures in patients with OI have been reported with routine hospital care. In addition, there is a nonzero rate of iatrogenic fracture during orthopaedic surgery directly related to the technical steps of the procedure itself. The rate of this latter has never been explicitly investigated.

METHODS

A review of all patients at a single OI referral center was conducted, including all patients with a diagnosis of OI seen between 2013 and 2023, inclusive. All patients who underwent orthopaedic surgery of any kind were reviewed, and clinical and radiographic details of all procedures were extracted. Among the details examined were the OI subtype, surgery details, any implants used, intraoperative and hospital stay complications, modified Clavien-Dindo classification of complications, and ultimate outcome.

RESULTS

Eleven of 60 patients experienced an unplanned, iatrogenic intraoperative fracture during orthopaedic surgery (11/60 = 18.3%). This comprised 15 fractures among 356 total orthopaedic surgical episodes (15/356 = 4.2%). All but one fracture occurred on the operative long bone segment, all were a direct result of surgical steps, and 11 of 15 fractures occurred in the femur. Most fractures were secondary to the removal, insertion, or exchange of intramedullary implants in the lower extremity (11 of 15 fractures), most often the femur. Thirteen of 15 injuries were classified as modified Clavien-Dindo II or III, requiring modification of postop rehabilitation, additional treatments, or surgical intervention (87%). Overall, iatrogenic fracture was the most common intraoperative complication experienced in the cohort.

CONCLUSIONS

Iatrogenic fracture during orthopaedic surgery for patients with OI is not uncommon. A sizeable minority of patients with OI undergoing orthopaedic surgery will experience unplanned fractures, most commonly in the femur, and care is altered in most instances. The risk of intraoperative fracture can be discussed with families of children with OI as part of informed consent and shared decision-making.

LEVEL OF EVIDENCE

Level IV-retrospective cohort series.

背景

成骨不全症（OI）是一种Ⅰ型胶原的遗传缺陷，表型特征为骨骼脆弱，儿童骨折发生率高。在常规医院护理中已报告 OI 患者发生脆性骨折。此外，在与手术本身的技术步骤直接相关的骨科手术中，还存在非零的医源性骨折发生率。后者的发生率从未被明确调查过。

方法

对单一 OI 转诊中心的所有患者进行了回顾性研究，包括 2013 年至 2023 年期间所有确诊为 OI 的患者。对所有接受过任何类型骨科手术的患者进行了回顾，并提取了所有手术的临床和影像学细节。检查的细节包括 OI 亚型、手术细节、使用的任何植入物、术中及住院期间并发症、改良 Clavien-Dindo 并发症分级和最终结果。

结果

在骨科手术中，11 例（11/60=18.3%）患者发生了计划外的医源性术中骨折。这包括 356 次骨科手术中发生的 15 次骨折（15/356=4.2%）。除 1 例外，所有骨折均发生在手术长骨段，均直接由手术步骤引起，15 例骨折中有 11 例发生在股骨。大多数骨折是下肢髓内植入物的取出、插入或更换的结果（15 例骨折中的 11 例），最常见于股骨。15 例损伤中的 13 例被归类为改良 Clavien-Dindo II 级或 III 级，需要修改术后康复、额外治疗或手术干预（87%）。总的来说，医源性骨折是该队列中最常见的术中并发症。