In response to the recent letter by Kakar, et al, voicing concerns about our recent article "OPERATIVE TREATMENT OF TIBIAL FRACTURES IN CHILDREN: ARE ELASTIC STABLE INTRAMEDULLARY NAILS AN IMPROVEMENT OVER EXTERNAL FIXATION?", we would direct them to the table published as an electronic appendix (supplementary material) to the article on jbjs.org. This table lays rest to the concerns of Karkar, et al.

In response to their first point, only patients with at least 24 months follow-up were included in our study. Patients with less than 24 months follow-up were not included in the study. In fact, as stated in the body of the published text, the patients with external fixation had longer follow-up at the time of their functional assessment and would likely have improved function and yet these patients, quite to the contrary, had worse functional outcomes.

As to their point two, "these fractures were not graded according to Gustilo and Anderson", please once again refer to the table in the electronic appendix. Here, one will see that all open fractures were graded according to the systems of Gustilo and Andersen. Additionally, as we stated in the Discussion, the difference in the number of open fractures between the external fixation group and the flexible nail group, though not significant, may partly explain some of the large differences in healing rates and functional outcomes between the two patient groups.

We still maintain that flexible nails are a viable means of stabilizing open pediatric tibia fractures without segmental bone loss or with limited comminution. As demonstrated by the satisfactory results in those patients with open fractures who were treated with flexible nails.

To The Editor:

We read with interest the article by Kubiak, et al, (1). The authors should be applauded for their study design. However, we would like to draw attention to some facts which require further elaboration.

Firstly, the data collection period of this study ranged from April 1997 to June 2004. At the same time, it was mentioned in the materials and methods section that the minimum follow-up period was 2 years. We believe that there will be some patients who could not fully comply with this inclusion criterion and may subsequently influence the final results.

Secondly, the authors described that the complication rate in the form of mal-union, non-union or delayed union was high in the group with open fractures, especially the external fixator group, where 4 of 6 patients had healing problems. However, these fractures were not graded according to Gustilo and Anderson classification.(2) The evidence suggests that open fractures are associated with a higher complication rate. Gustilo and Anderson (2) reported a 27% non-union rate requiring bone grafting in 197 open long bone fractures. Similarly, in a retrospective review of 104 open tibial fractures, Rosenthal, et al, (3) reported a 27% non-union rate, with about a third of these being infected. The non-union rate was found to be higher with increasing Gustilo grades of the open fractures. (4)

Finally, the authors advocated the use of intramedullary nailing for open fractures without segmental bone loss and with limited comminution. We believe that this conclusion was not justified by their data. We do agree with the authors that a larger prospective study will be required to confirm these findings.

References:

1. Kubiak EN, Egol KA, Scher D, Wasserman B, Feldman D, Koval KJ. Operative treatment of tibial fractures in children: are elastic stable intramedullary nails an improvement over external fixation? J Bone Joint Surg Am. 2005 Aug;87(8):1761-8.

2. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976 Jun;58(4):453-8.

3. Rosenthal RE, MacPhail JA, Oritz JE. Non-union in open tibial fractures. J Bone Joint Surg Am. 1977 Mar;59(2):244-8.

4. Charalambous CP, Siddique I, Zenios M, Roberts S, Samarji R, Paul A, Hirst P. Early versus delayed surgical treatment of open tibial fractures: effect on the rates of infection and need of secondary surgical procedures to promote bone union. Injury. 2005 May;36(5):656-61.