LAUSR

At the outset, I would like to congratulate the authors of the article published in your journal in the current issue entitled “Efficacy and complications after delayed fixation of femoral neck fractures in children.” However, certain concerns are required to be addressed for the benefit of the readers of this article. Once the internal fixation is undertaken and if fixation is rigid and stable then there is seldom any need for hip spica immobilization and confining patient to bed after surgery. Recommendations are bedside exercises like quadriceps drill and range-of-motion exercises and initiating nonweight-bearing crutch walking soon after surgery and starting gradual weight-bearing as the union starts and progresses. Follow-up radiographs are important to determine union (evidenced by bridging trabeculae across the fracture site), osteonecrosis, and angular deformity (coxa vara and valga as neck shaft angles of 130 and 150 , respectively). Author has not taken into account the various other complications apart from avascular necrosis (AVN) in his study. In fact, coxa vara is the most common complication found in such cases. Other complications found to occur commonly include nonunion, premature closure of epiphysis, chondrolysis, and limb length discrepancy, to name a few. Issues pertaining to the development of avascular necrosis of femoral head needs to be elaborated further. Literature mentions that although the time from injury to fracture reduction has been postulated to be a vital factor in determining whether a pediatric patient will develop AVN, no prospective studies are available in the English language literature which has evaluated the impact of reduction and timing on the development of AVN. Shrader et al. in their retrospective study found that the risk of AVN increases with increased time to reduction. Also, important to highlight a confirmed key issue for controlling the incidence of AVN is the aim of achieving “anatomical reduction and not the acceptable reduction.” Author resorted to closed reduction and internal fixation in majority of his patients, however consensus is on open reduction and internal fixation (ORIF). But there is decreased incidence of AVN in patients treated by ORIF. Literature also confirms the role of early decompression of the joint capsule to reduce chances for the development of osteonecrosis and is adequate with open reduction in such cases and also addressing the paramount issue of achieving anatomical reduction under direct vision. Author did not highlight on the approaches chosen in different categories of fractures based on Delbet classification, which is very important to confirm anatomical reduction under direct vision. Proximal fractures (Delbet IA and II) typically require a direct anterior approach, whereas the basicervical and intertrochanteric (Delbet III and IV) can be easily visualized via an anterolateral approach. Patients with a Delbet IB fracture may require a posterior approach to reduce the femoral head. Implants which can be used for osteosynthesis largely depend on the operating surgeon’s preference and the age of the child. These include either 6.5-mm partially threaded cancellous screws (PTCS), 4.5-mm PTCS, or the pediatric dynamic hip screw. However, author even chose K-wires for fixation which is not the recommended good implant for fixing such fractures, where shearing forces, anatomical reduction, and rigidity of fixation are the key concerns. Thanking you with a request to consider the above details to be furnished for proper and essentially relevant knowledge dissemination to the readers of this journal in relation to the topic of “Pediatric femoral neck fractures,” especially when it has bearing on the treatment outcomes.