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Objective:To explore the necessity of perioperative radiography by analyzing the risk factors for internal fixation loosening after closed reduction and internal fixation with Kirschner wire for supra-condylar fracture of the humerus in children.Methods:Retrospectively analyzed were the 502 patients with supracondylar fracture of the humerus who had been treated at Department of Orthopedics, Children's Hospital of Fudan University by closed reduction and internal fixation with Kirschner wire from January 1, 2019 to December 31, 2021. There were 307 boys and 195 girls, with an age of (60.0±27.2) months. There were 224 Gartland type Ⅱ supracondylar fractures and 278 Gartland type Ⅲ supracondylar fractures. Follow-ups revealed internal fixation loosening in 52 cases (set as a loosening group) and no internal fixation loosening in the other 460 cases (set as a non-loosening group). The angles between Kirschner wires (angle 1 and angle 2), the effective fixation ratios of the Kirschner wire (ratio 1, ratio 2, and ratio 3), the metaphyseal shaft angle α, and the distal anteversion angle of the humerus β were measured on the perioperative and postoperative elbow X-ray films and compared. Other data affecting the internal fixation loosening were collected. Multiple logistic regression was used to analyze the risk factors for internal fixation loosening after closed reduction and internal fixation of supracondylar fracture of the humerus. Results:There were no significant differences between the intraoperative and postoperative data in the angle 1 or angle 2 between Kirschner wires (26.58°±14.22° versus 26.75°±10.70°; 41.85°±8.67° versus 41.31°±7.79°), the effective fixation ratio 1, 2 or 3 of Kirschner wire (0.904±0.182 versus 0.887±0.206; 0.897±0.119 versus 0.895±0.142; 0.890±0.035 versus 0.889±0.076), the metaphyseal shaft angle α (86.25°±2.74° versus 85.52°±1.86°), or the distal anteversion angle of the humerus β (31.04°±0.97° versus 29.54°±0.45°) (all P>0.05). Multiple logistic regression analysis showed that fracture site ( P=0.032), fracture classification ( P=0.041) and postoperative infection ( P=0.004) were the risk factors for internal fixation loosening. Conclusions:As supracondylar fractures of the humerus remain stable in the perioperative period with little risk of fracture displacement or internal fixation loosening after closed reduction and internal fixation with Kirschner wire, postoperative radiography is not necessary. The risks for internal fixation loosening are positively correlated with fracture site, fracture type and postoperative infection.
RESUMO
Objective To evaluate the effectiveness of urgent surgical correction for infra-cardiac total anomalous pulmonary venous drainage (TAPVD) in infants and children. Methods From July 2000 to April 2009, seventeen patients with infra-cardiac type of total anomalous pulmonary venous connection received surgical correction in our department. The age of patients ranged from 15 days to 3.7 months at admission, 9 patients ( 52.9 % ) were younger than 1 month of age. The mean body weight was (4.10 ±0.95) kg and was less than 5 kg in 15 patients (88.2%). Deep hypothermic circulatory arrest (DHCA) without cerebral perfusion was used in 13 patients (76%), and continuous hypothermic low-flow perfusion was used in4 (24%). Incisions on the left atrium and pulmonary veins were sutured without tension, and the width of the anastomosis was 2.5 to 4.0 cm. Results Urgent operations were performed in all patients and no early death occurred during surgery.Mean bypass time was 121.9 minutes ( ranging from 70 to 277 minutes) and mean aortic cross-clamp time was 44 minutes ( ranging from 30 to 74 minutes). 6 neonates had delayed wound closure after surgery and 4 had obvious pulmonary edema. Inhalation of nitric oxide was given to 5 cases for the management of significant postoperative pulmonary hypertension, while peritoneal dialysis was performed in 2 cases with temporary renal failure. Transient atrioventricular block of grade 3 occurred in 2patients and acute renal failure occurred in 2 cases. All patients were uneventfully discharged. The mean ventilation time was 45 h (ranging from 12 to 430 h). Mean duration in ICUs and hospitals were 15 days ( ranging from 4 to 40 days) and 22. 5days ( ranging from 10 to 42 days), respectively. During the period of follow up, one patient presented with pulmonary venous obstruction and recurrent pulmonary infection with increased flow speed at the site of anastomosis, pulmonary hypertension and tricuspid regurgitation on echocardiogram. No improvement was observed in the patient spite of medical treatment and he was lost during follow up one year after operation. 16 patients received postoperative follow up for 1 month to 9 years, mean (51.8 ± 35.0) months. Echocardiography, chest radiography, and ECG were performed during this period. As a result, most children had good cardiac function, with sinus rhythm on ECG and apparently reduced pulmonary congestion on radiography.No obstructive pulmonary venous return was observed on echocardiography. Most patients had good cardiac functions. Conclusion Corrective operation for infra-cardiac TAPVC on urgent basis may provide favorite outcomes. The prognosis is associated with the size of anastomosis between the pulmonary vein and left atrium, as large anastomosis may prevent the obstruction of pulmonary venous retum.