Response to Letter to the Editor—Plate fixation versus flexible intramedullary nails for management of closed femoral shaft fractures in the paediatric population: A systematic review and meta-analysis of the adverse outcomes ( J Child Orthop 2023,17(5),442–452)

We thank the authors for their interest in this subject and detailed critique of our article. Their observations highlight the difficulty with systematic reviews where the included studies rarely include strict definitions of terms such as leg length difference, indications for subsequent surgery, or even infection.

In the absence of these definitions, we identified adverse outcomes through their explicit mention in the included studies. We did not assume an outcome unless expressly stated, ¹ did not double-count adverse events, ² and concentrated on outcomes of the primary rather than subsequent surgeries. ³ The guidelines for undertaking a robust systematic review were followed. All data extraction was performed by two of our authors, according to our prospectively registered protocol.

There is always scope for different interpretations of the data presented. We agree with some of the comments the authors make around differing definitions of malunion however, these are points of discussion rather than data points. It is outside the scope of this systematic review to comment on surgical techniques as illustrated in radiographs in any given paper. We disagree with our colleague’s assertion that our data support the use of flexible nails. We highlight that their pooled analysis of major complications does not account for the effect of sample size as seen in our meta-analysis.

We have outlined the paucity of literature, limitations of our work, and clearly stated that it is not possible to make robust treatment recommendations. We hope the authors of the letter agree with our conclusion that our paper advocates for prospective trials using COS (core outcome sets) with defined terminology.