Displaced humeral lateral condyle fractures in children:  should we bury the pins?
BACKGROUND
The purpose of this investigation was to determine if leaving Kirschner wires exposed is more cost-effective than burying them subcutaneously after open reduction and internal fixation (ORIF) of humeral lateral condyle fractures.


METHODS
A retrospective cohort study of all lateral condyle fractures treated over a 10-year period at a single institution was performed. Data on surgical technique, fracture healing, and complications were analyzed, as well as treatment costs. A decision analysis model was then constructed to compare the strategies of leaving the pins exposed versus buried. Finally, sensitivity analyses were performed, assessing cost-effectiveness when infection rates and costs of treating deep infections were varied.


RESULTS
A total of 235 children with displaced fractures were treated with ORIF using Kirschner wires. Pins were left exposed in 41 cases (17.4%) and buried in 194 cases (82.6%); the age, sex, injury mechanisms, and fracture patterns were similar in both the groups. The median time to removal of implants was shorter with exposed versus buried pins (4 vs. 6 wk, P<0.001), although there was no difference in fracture union or loss of reduction rates. The rate of superficial infection was higher with exposed pins (9.8% vs. 3.1%), but this was not statistically significant (P=0.076). There were no deep infections with exposed pins, whereas the rate of deep infection was 0.5% with buried pins (P=1.00). Buried pins were associated with additional complications, including symptomatic implants (7.2%); pins protruding through the skin (16%); internal pin migration necessitating additional surgery (1%); and skin necrosis (1%). The decision analysis revealed that leaving pins exposed resulted in an average cost savings of $3442 per patient. This strategy remained cost-effective even when infection rates with exposed pins approached 40%.


CONCLUSIONS
Leaving the pins exposed after ORIF of lateral condyle fractures is safe and more cost-effective than burying the pins subcutaneously.


METHODS
Retrospective cohort study (level III).
Department of Orthopaedic Surgery, Children's Hospital Boston, Boston, MA 02115, USA.
Soumen
S
Das De
Donald S
DS
Bae
Peter M
PM
Waters
D001858:Bone Nails; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D005260:Female; D005593:Fracture Fixation, Internal / Q000191:economics / Q000295:instrumentation / Q000379:methods*; D017102:Fracture Healing; D006801:Humans; D006810:Humeral Fractures / Q000601:surgery*; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D013530:Surgical Wound Infection; D013997:Time Factors