Response to letter: Assessment of postoperative range of motion in pediatric patients undergoing surgical reduction and fixation of lateral condyle fractures

Range of motion assessment

We acknowledge that elbow ROM was not measured using standardized goniometry because our retrospective study relied on clinical documentation. As stated in our discussion, this is an important limitation. However, these assessments were consistently performed by fellowship-trained pediatric orthopedic surgeons during routine clinical examinations.

While we agree that subtle deficits may persist beyond early follow-up as described by Bernthal et al., ¹ our primary objective was comparative. We evaluated the relative time to functional recovery between fixation methods rather than absolute biomechanical normalization. Any imprecision in ROM documentation would be expected to affect all groups, thereby preserving the internal validity of group comparisons. Furthermore, our definition of full ROM, recorded within 0°–5° of extension and 130°–140° of flexion, represents functional restoration sufficient for discharge from routine orthopedic follow-up. ²

Anesthetic exposure and implant removal

The authors raise a valid concern regarding the 5.2% incidence of severe critical events reported in the APRICOT study. ³ However, that study reflects a broad spectrum of anesthetic procedures, including high-risk and emergent cases. The risk associated specifically with brief, outpatient hardware removal for pediatric fractures is likely substantially lower.

At our institution, the decision to use buried implants or screws is influenced by fracture pattern, stability, and the goal of preventing pin-site complications. Often, planned implant removal is combined with manipulation under anesthesia when postoperative stiffness is anticipated, serving a therapeutic purpose rather than representing a purely elective exposure.

Surgical volume and complication rates

Regarding the comparison with the cohort from Bridges et al., ⁴ we urge caution in interpretation. Our study specifically examined 62 cases of open reduction internal fixation, whereas Bridges et al. reported on 863 fractures, including closed reductions.^1,4 In small cohorts, single events can disproportionately inflate percentage-based rates.

In our series, the 3.2% (2/62) infection rate reflects one superficial pin-site infection and one case of prophylactic antibiotic administration for pin infiltration. When interpreted in absolute terms, the difference between the 1.4% (12/863) reported by Bridges et al. and our 3.2% represents a difference of only one additional minor event.^1,4 Given our smaller cohort size (n = 62), a single event disproportionately affects the percentage but does not necessarily reflect a true difference in clinical safety or treatment quality.

Similar conclusions can be drawn from the non-union rates. In absolute terms, the difference between the 1.2% reported by Bridges et al. and our 1.6% is statistically negligible.^1,4 Furthermore, the single nonunion in our cohort occurred in the screw group, which consisted of older patients and more complex fracture patterns—factors already established in literature as independent risks for delayed healing. ¹

Antibiotic prophylaxis

To clarify the authors’ inquiry regarding perioperative care, patients in our study routinely received Cefazolin as prophylaxis, although this was not recorded as a primary study variable.

Conclusion

The aim of this study was to evaluate the pros and cons of various ways to treat lateral condyle fractures, not to advocate for one method over the other. We agree that prospective, multicenter studies incorporating standardized goniometry and validated functional outcome measures are the necessary next steps to further guide fixation strategies in pediatric lateral condyle fractures.

Thank you again for the opportunity to address concerns with our study.

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