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Background: Controversy exists regarding the treatment of length unstable pediatric femoral shaft fractures. The purpose of this study was to investigate the outcomes of skeletally immature children with length unstable femur fractures treated with titanium elastic nails (TENs). Methods: A retrospective review was conducted on all patients with femoral shaft fractures at a tertiary care pediatric hospital from April 2006 to January 2018. Patients with femoral shaft fractures treated with TEN and minimum 6 months follow-up were included. Exclusion criteria were age 11 years or above, weight >50 kg, pathologic fracture, and neuromuscular disorders. Femur fractures were categorized into 2 groups: length unstable (spiral, comminuted, or long oblique fractures) versus length stable (transverse and short oblique). Complications and reoperations were compared between the groups. Results: A total of 57 patients with 58 femoral shaft fractures were included. The mean age was 5±2 (1 to 11) years and mean follow-up was 20.4±18.1 (6.0 to 81.2) months. The mean weight was 22.9±7.7 (11.0 to 40.5) kg. There was no difference in age (P=0.32), weight (P=0.28) or follow-up length (P=0.57) between patients with length unstable fractures and those with length stable fractures. A total of 32/58 (55%) fractures were length unstable and 26/58 (45%) were length stable. Mean time to union was 4.6 months, and there was no significant difference in mean time to union between the 2 groups (P=0.71). Thirty-one complications occurred in 27 patients. There was no difference between groups in the incidence of major complications requiring revision surgery (P=0.68) and minor complications that did not require revision surgery (P>0.99). Conclusions: In children with femoral shaft fractures treated with TEN, there was no difference in the incidence of complications or reoperations between those with length unstable fractures and those with length stable fractures. TEN are a safe and effective choice for operative fixation of length unstable femoral shaft fractures in children. Level of Evidence: Level III—retrospective comparative study.

Level III-retrospective comparative study.

Background: Retrograde percutaneous pinning often involves intra-articular pin placement. Classic teaching has cautioned about the risk of septic arthritis with intra-articular pins, although an incidence has not been reported for this complication. The purpose of this study was to determine the incidence of pin tract infections and septic arthritis following retrograde percutaneous pinning of the distal femur. Methods: A retrospective review identified patients who underwent retrograde percutaneous pinning of the distal femur for osteotomy or physeal fracture fixation at a tertiary pediatric hospital from 2006 to 2017 and had at least 3 months follow-up. The incidence of pin site infections and septic arthritis was determined. Results: In total, 163 patients met criteria, 142 patients with osteotomies and 21 with physeal fractures. The mean pin duration was 33.2±9.0 days (range: 18 to 68 d). Pin duration of ≥30 days was associated with an increased rate of pin tract infections (11.2% vs. 1.4%, P=0.01). The incidence of pin tract infections was 6.7% (11/163), including 9.5% (2/21) in those with fractures and 6.3% (9/142) following osteotomy (P=0.64). There were no cases of septic arthritis. Of the 11 patients with pin tract infections, 9 were treated successfully with oral antibiotics and 2 patients (1.2%) underwent surgical intervention for infection. Treatment of pin infections with oral antibiotics alone was successful in all 7 patients whose pins were removed within 35 days of surgery, but in only 2 of 4 whose pins were removed later (P=0.11). Of the 2 patients who required irrigation and debridement, one had a superficial pin site infection and retained subcutaneous pin and the other had a pin tract abscess and osteomyelitis at the osteotomy site. Conclusions: Of 163 patients who underwent retrograde percutaneous pinning of the distal femur, no patient developed septic arthritis and the incidence of pin site infections was 6.7% (11/163). Intra-articular retrograde percutaneous pinning of the distal femur is a safe technique with a low risk of septic arthritis. Level of Evidence: Level III—case-control study.

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Previous studies demonstrated the safety of tranexamic acid (TXA) use in cerebral palsy (CP) patients undergoing proximal femoral varus derotational osteotomy (VDRO), but were underpowered to determine if TXA alters transfusion rates or estimated blood loss (EBL). The purpose of this study was to investigate if intraoperative TXA administration alters transfusion rates or EBL in patients with CP undergoing VDRO surgery. We conducted a retrospective review of 390 patients with CP who underwent VDRO surgery between January 2004 and August 2019 at a single institution. Patients without sufficient clinical data and patients with preexisting bleeding or coagulation disorders were excluded. Patients were divided into 2 groups: those who received intraoperative TXA and those who did not. Out of 390 patients (mean age 9.4 ± 3.8 years), 80 received intravenous TXA (TXA group) and 310 did not (No-TXA group). There was no difference in mean weight at surgery ( P = .25), Gross Motor Function Classification System level ( P = .99), American Society of Anesthesiologist classification ( P = .50), preoperative feeding status ( P = .16), operative time ( P = .91), or number of procedures performed ( P = .12) between the groups. The overall transfusion rate was lower in the TXA group (13.8%; 11/80) than the No-TXA group (25.2%; 78/310) ( P = .04), as was the postoperative transfusion rate (7.5%; 6/80 in the TXA group vs 18.4%; 57/310 in the No-TXA group) ( P = .02). The intraoperative transfusion rate was similar for the 2 groups (TXA: 7.5%; 6/80 vs No-TXA: 10.3%; 32/310; P = .53). The EBL was slightly lower in the TXA group, although this was not significant (TXA: 142.9 ± 113.1 mL vs No-TXA: 177.4 ± 169.1 mL; P = .09). The standard deviation for EBL was greater in the No-TXA group due to more high EBL outliers. The percentage of blood loss based on weight was similar between the groups (TXA: 9.2% vs No-TXA: 10.1%; P = .40). The number needed to treat (NNT) with TXA to avoid one peri-operative blood transfusion in this series was 9. The use of intraoperative TXA in patients with CP undergoing VDRO surgery lowers overall and postoperative transfusion rates. Level of evidence: III, Retrospective Comparative Study.

BRITISH MEDICAL JOURNAL VOLUME 285 2 OCTOBER 1982 937 patient took periodically. The presentation and clinical aspect in the form of an acute intravascular haemolytic episode, the small doses of drug sufficient to cause the attacks, the brief time lapse between administration and onset of symptoms, and the positive result of direct Coombs test, with notable components on the erythrocyte surface at the time of the attacks, all indicate that the mechanism responsible is of stibophen or "innocent bystander" type.2-5 Nalidixic acid should therefore be added to the list of drugs responsible for immune haemolytic anaemia.Mandal BK, Stevenson J. Haemolytic crisis produced by nalidixic acid.Lancet 1970;i:614.

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