Surgical timing is one of the recently discussed topics in the treatment of pediatric SHFs. While some authors suggest operating the SHFs as soon as possible, some authors recommend operating these fractures within working hours after providing favorable conditions for both surgeon and non-surgeon factors (6, 11). In the current study, the optimal surgical timing of Gartland type 3 pediatric SHFs was investigated with early (< 12 hours) or late (> 12 hours), in daytime or nighttime and on working or non-working hours. None of these timing options were found to create a difference in terms of reduction quality, operative duration, and open reduction rate.
In the literature, there are some studies investigating the optimal surgical timing in other trauma fields besides SHFs and they reported higher complication rates during cases performed at night (12–14). However, we have reported similar operative parameters on pediatric SHFs operated in daytime or nighttime.
Controversy exists in the previous literature about the effect of surgical timing of pediatric SHFs on reduction quality. Aydoğmuş et al. showed that patients with SHFs who underwent surgery in non-working hours had poor reduction quality (15). Paci et al. investigated the results of SHFs operated during working or non-working hours. They reported no difference in terms of operative duration and outcomes, however mal-union rate was higher in patients operated at night in non-working hours (7). Yıldırım et al. reported similar reduction quality in pediatric SHFs who were operated in the same or next day of their admission. However, they showed that the likelihood of open reduction increases after 15 hours (16). We have found no effect of surgical timing on reduction quality.
Delayed surgeries may lead to higher open reduction rates during surgical treatment of pediatric SHFs. In a systematic review, Loizaou et al. showed that patients had higher open reduction rates who were not operated within the first 12 hours (17). Walmsley et al. reported higher open reduction rates in Gartland type 3 SHFs operated later than 8 hours (33.3% vs11.2%) (18). Sibinski et al. showed no difference between patients who underwent surgery within first 12 hours and after 12 hours in terms of open reduction rate, operative duration, hospital stay and outcomes (19). According to the results of the current study, surgical timing was found not affecting the open reduction rates. The controversy regarding the surgical parameters may be due to varying experience level of operating room staff on orthopedics.
The cut-off point for optimal time passed until surgery has not been clearly defined in the literature. Wenling-Keim et al. reported that the time passed until surgery was not affecting complication rates, but paresthesia was observed more frequently in cases operated between 10 am and 2 pm (20). In contrast, Abbot et al. demonstrated that the time until surgery does not affect complication rates, operative duration and open reduction rate of pediatric SHFs(11). Munaghan et al. reported that there was no difference between operating the pediatric SHFs within first 8 hours or not in terms of operative duration and reduction quality (21). Prabhakar and Ho showed that there was no difference between the operative duration and fluoroscopy time for those who were operated within first 15 hours (22). Kwatkioska et al. reported that there was no clinical and radiological difference between the patients operated within the first 6 hours and those operated after 12 hours (23). According to the results of the current study, we did not observe any difference in reduction quality, open reduction rate or operative duration in patients who were operated in first 12 hours or after 12 hours. All the patients were operated within the first 24 hours and this may be the reason for the similar outcomes at different time intervals.
One of the limitations of the current study is its retrospective design, thus randomization of the patients into time intervals was absent. Secondly, all surgical procedures were not performed by the same surgeon. Surgical exposures and pin configurations during fixation were not taken into consideration in the study which may have had an impact on the results. Further controlled studies evaluating the short- and long-term outcomes are needed to define the optimal timing of pediatric SHFs.