Implant-related fractures in children: A 15-year review

Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD 21224-2780, USA.
Journal of pediatric orthopedics (Impact Factor: 1.47). 07/2012; 32(5):547-52. DOI: 10.1097/BPO.0b013e318259fe75
Source: PubMed


To our knowledge, there are no comprehensive clinical studies of implant-related fractures in children. Our goal was to identify the incidence, skeletal location, and associated diagnoses of implant-related fractures.
We reviewed our institutional database to identify cases of implant insertion (7584 cases) in patients less than 18 years old from January 1, 1995 through December 31, 2009. We calculated the overall incidence of these fractures and stratified the incidence by skeletal location and preoperative diagnoses. Fisher exact test was used to ascertain differences in fracture incidence. Risk ratios were calculated when appropriate. Significance was set at P<0.05.
There were 25 cases of implant-related fractures: 22 in the femur, 2 in the tibia, and 1 in the radius. The overall incidence of implant-related fracture was 0.33%; the incidence by skeletal location was: femur, 0.89%; tibia, 0.1%; and radius, 0.14%. Associated diagnoses were cerebral palsy (9 cases), hip dysplasia (3 cases), spina bifida (2 cases), and avascular necrosis (1 case); 10 cases were associated with "other diagnoses," which included various skeletal syndromes (5 cases) and traumatic fractures (5 cases). The incidences of implant-related fractures by diagnoses were: cerebral palsy, 1.1%; hip dysplasia, 1.1%; spina bifida, 1.3%; and avascular necrosis, 0.35%. The incidence of implant-related fracture in the "other diagnoses" group was 0.16%, and the incidence of fracture in otherwise healthy patients was 0.084%. The femur was 15.2 times more likely to fracture than other bones (P<0.001). Diagnoses of cerebral palsy, hip dysplasia, spina bifida, and avascular necrosis were 6.1 times more likely to be associated with implant-related fractures than the "other diagnoses" (P<0.001). The mean time to fracture in the study was 2.8 years. The overall implant removal rate at our institution was 24.3%, and it varied significantly by patient diagnosis (P<0.01).
Skeletal location and preoperative diagnosis should be factors of consideration in a surgeon's decision about removing implants to prevent implant-related fractures.
Prognostic Level III.

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    ABSTRACT: Purpose Implant removal in children is still a standard procedure. Implants may disturb function, and some theoretical long-term risks like growth disturbance, foreign body reaction, chronic infection and corrosion are used as arguments for removal. Implant migration or interference with any other orthopaedic treatment over the later course of life is also a matter of debate. On the other hand, the difficulty in removing single implants as well as possible perioperative complications has induced discussion about the retention of implants in childhood. Methods The current procedures are exposed and the available literature on implant removal in children reviewed. Results Actually, a clear recommendation does not exist. The current line of action still includes routine removal, as it is preferred by some authors, whereas others argue for a selective procedure. K-wires as well as intramedullary nails are usually removed because the ends may interfere with the surrounding tissue. Screws and plates can be retained if there are no local problems. The removal of external fixators is non-controversial. Conclusions Benefits have to outweigh the risks and complications in the individual case and the procedure should not require a more extensive procedure than insertion. It has to be an individual decision in view of the lack of evidence to support routine removal as well as to refute it.
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