Nonoperative Versus Operative Treatment of Type IIA Supracondylar Humerus Fractures: A Prospective Evaluation of 99 Patients.

BACKGROUND: Although current clinical practice guidelines from the American Academy of Orthopaedic Surgeons suggest that Type II and III supracondylar humerus (SCH) fractures be treated by closed reduction and pin fixation, controversy remains as to whether type IIa fractures with no rotation or angular deformity require surgery. The purpose of our study was to prospectively compare radiographic and functional outcomes of type IIa SCH fractures treated with or without surgery. METHODS: Between 2017 and 2019, 105 patients between 2 and 12 years of age presenting with type IIa SCH fractures and without prior elbow trauma, neuromuscular or metabolic conditions, were prospectively enrolled. Ten orthopaedic surgeons managed the patients with 5 preferring surgical treatment and 5 preferring an initial attempt at nonoperative treatment. Patients in the nonoperative cohort were managed with a long-arm cast and close radiographic follow-up. Patients underwent a standardized protocol, including 3 to 4 weeks of casting, bilateral radiographic follow-up 6 months postinjury, and telephone follow-up at 6, 12, and 24 months. RESULTS: Ninety-nine patients met the inclusion criteria (45 nonoperative and 54 operatives). Of the nonoperative patients, 4 (9%) were converted to surgery up to their first clinical follow-up. No differences were identified between the cohorts with respect to demographic data, but patients undergoing surgery had on average 6 degrees more posterior angulation at the fracture site preoperatively (P<0.05). At the final clinical follow-up (mean=6 mo), the nonoperative group had more radiographic extension (176.9 vs 174.4 degrees, P=0.04) as measured by the hourglass angle, but no other clinical or radiographic differences were appreciated. Complications were similar between the nonoperative and operative groups: refracture (4.4 vs 5.6%), avascular necrosis (2.2 vs 1.9%) and infection (0 vs 1.9%) (P>0.05). Patient-reported outcomes at a mean of 24 months showed no differences between groups. CONCLUSION: Contrary to American Academy of Orthopaedic Surgeons guidelines, about 90% of patients with type IIa supracondylar fractures can be treated nonoperatively and will achieve good radiographic and functional outcomes with mild residual deformity improving over time. Patients treated nonoperatively must be monitored closely to assess for early loss of reduction and the need for surgical intervention.

Comparison of Surgical Outcomes Between a Triplane Proximal Femoral Osteotomy and the Modified Dunn Procedure for Stable, Moderate to Severe Slipped Capital Femoral Epiphysis.

BACKGROUND: Recent studies have demonstrated the intra-articular cartilage and labral damage that can occur from the proximal femoral cam-like deformity of a moderate to severe slipped capital femoral epiphysis (SCFE). The approach to treating this deformity in a symptomatic Loder stable hip is controversial. The purpose of this study was to compare radiographic outcomes, complication rates, and revision rates between Imhauser type triplane proximal femoral osteotomy (TPFO) and the modified Dunn procedure (MDP). METHODS: Twenty-six subjects with minimum 1-year follow-up were included (12 treated with a TPFO, and 14 treated with the MDP). A chart review was performed to capture data related to complications, revision procedures, surgical time, and body mass index. Radiographs were measured preoperatively and at final follow-up to evaluate epiphyseal-slip angle, neck-shaft angle, articular surface to trochanter distance, and medial proximal femoral angle. RESULTS: Surgical time was shorter for the TPFO group (150.0±57.4 min) compared with the MDP group (203.8±30 min) (P=0.005). All preoperative and postoperative radiographic measures were similar between the 2 groups except postoperative neck-shaft angle, which was significantly less in the TPFO group (129.7±8.6 vs. 140.9±9.4 degrees) (P=0.005). There were no cases of femoral head avascular necrosis (AVN) in the TPFO group. The modified Dunn group had a 29% AVN rate (P=0.1). The overall complication rate was similar between the TPFO (33%) and modified Dunn (36%) groups (P=1.0) and the reoperation rate was slightly greater in the TPFO group (33%) as compared with the modified Dunn group (21%) (P=0.67). CONCLUSIONS: The complex 3-dimensional proximal femoral deformity of a moderate to severe SCFE can be difficult to treat with relatively high complication/reoperation rates observed in both TPFO and MDP groups. All 4 instances of AVN in this study of stable slips, however, were in the MDP group. As this can be a devastating complication leading to early total hip arthroplasty, we advise against the MDP in stable SCFE patients. LEVEL OF EVIDENCE: Level III-retrospective comparative study.