Commentary & Perspective

Commentary & Perspective on
"Surgical Treatment of Femoral Fractures in Obese Children: Does Excessive Body Weight Increase the Rate of Complications?"
by Arabella I. Leet, MD, et al.

Commentary & Perspective by
John M. Flynn, MD*,
Children’s Hospital Philadelphia, Philadelphia, Pennsylvania

"Surgical Treatment of Femoral Fractures in Obese Children: Does Excessive Body Weight Increase the Rate of Complications?" is a timely article in light of the trend toward increasing obesity in American children and an increasing trend toward operative management of pediatric femoral fractures. The authors studied 103 children who had been treated with operative management of a femoral fracture at their institution during the seven years prior to the study. External fixation was used to manage fifty-nine fractures, and intramedullary fixation was performed in forty-five. Although the authors do not specifically state the type of intramedullary fixation used, presumably flexible nailing rather than rigid nailing would have been used in this population. Of the 103 children, the authors specifically studied six who were obese. Three of the six children had postoperative complications that included one refracture and two wound problems. Thus, three of six (50%) of the obese children had complications as opposed to eleven of ninety-three (12%) of the non-obese children. This difference was significant (p = 0.004).

This is an important article for surgeons and the families that they treat. During the informed consent process, families can be alerted that heavier children are more likely to have postoperative complications. The data from this study will improve the informed consent process for these families. As the authors point out that obese children have a similar increased rate of postoperative wound infection as do obese adults, surgeons who perform operative fixation of femoral fractures in obese children should be scrupulous in their attention to avoiding soft-tissue trauma and be more vigilant in the postoperative period for wound dehiscence or signs of infection.

There are several important limitations of this study. First and foremost, the group of obese children in this study is very small. In essence, this study really focuses on only six children, half of whom had a postoperative complication. If only one or two of these children had not had a wound infection, the difference from the overall group would have been difficult to detect and might not have reached significance. Second, this study was performed in an era in which external fixation was used more commonly for pediatric femoral fractures. With the more recent emphasis on methods such as flexible nailing, submuscular plating, and trochanteric intramedullary fixation¹, many of the complications (refracture and serious pin-track infection) that are associated with external fixation would be unusual now. Third, the authors define complication as “an adverse event that was important enough to have required hospital admission.” Such a definition of complication is valid; however, one must consider differences in individual surgeon practice. This definition of complication takes into account the judgment of an individual treating surgeon, which is a very subjective measure.

Interestingly, the authors did not highlight any situations in which the treatment device failed. Recent analysis of titanium elastic nailing in pediatric femoral fractures shows that the prevalence of complications rises in children who are older than twelve years and heavier than approximately 50 kg. In this group of complications, failure of fixation and malunion figure prominently^2,3. If the number of obese patients had been much larger, there would have been some instances of device failure. Therefore, the current debate about optimal management of femoral fractures in obese, skeletally immature children is not meaningfully addressed in this particular manuscript.

To summarize, the authors provide some novel information about the increased rate of complications in a small group of obese children who sustained femoral fractures that were treated over the last seven years. At the risk of sounding repetitive, what is really needed is a prospective multicenter study that focuses on the outcomes of a large number of obese children after femoral fracture management. With a large enough group of patients and with the use of more modern fixation methods, the current debate about optimal management would be advanced.

*The author did not receive grants or outside funding in support of his research for or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Flynn JM, Schwend RM. Management of pediatric femoral shaft fractures. J Am Acad Orthop Surg. 2004;12:347-59.
2. Luhmann SJ, Schootman M, Schoenecker PL, Dobbs MB, Gordon JE. Complications of titanium elastic nails for pediatric femoral shaft fractures. J Pediatr Orthop. 2003;23:443-7.
3. Flynn J, Launay F, Moroz L, Kocher M, Newton P, Frick S, Sponseller P. Titanium elastic nailing of pediatric femur fractures: predictors of complications and poor outcomes. Paper read at the Annual Meeting of the American Academy of Orthopaedic Surgeons; 2005 Feb 23; Washington, DC.

Copyright © 2005 by the The Journal of Bone and Joint Surgery, Inc.