Challenges created by obesity during fracture care are well documented in the adult orthopaedic literature. In children, obesity also presents an additional hurdle to fracture care, in a setting where many fractures can traditionally be treated with cast immobilization. Successful cast treatment is dependent on a cast's ability to control the injured bone. As a patient's soft-tissue envelope increases, the distance from the cast to the bone increases, making it harder to adequately maintain fracture reduction. Because of this effect, several studies have evaluated the effect of obesity on cast treatment of various fractures. Okoraofor et al26 evaluated 129 children, 42% of whom were obese, with both bone forearm fractures and found that obese or overweight children were more likely to fail nonsurgical treatment than normal-weight children (34% versus 18%, respectively). They calculated an odds ratio of 3.3 for failure of nonsurgical management in obese patients. DeFrancesco et al27 found obese children were 6 times more likely than nonoverweight patients to lose reduction of complete both bone diaphyseal fractures. Likewise, Auer et al28 showed that obese children had an increased risk of displacement requiring repeat reduction of distal radius fractures. With the findings of these studies, it is recommended that obese patients with fractures treated conservatively be followed up closely to assure maintenance of fracture alignment along with family counseling on the risk of reduction loss and need for possible surgical fixation.
Overweight children are thought to be at higher risk of nonorthopaedic complications during generalized trauma care and may have a higher cost burden than nonobese patients, although there is some disagreement in the literature regarding the effect of obesity on hospitalized patients. Fleming-Dutra et al1 did not find a notable difference in the cost of acute care for overweight children compared with normal-weight children. However, they did find that patients hospitalized with fractures or dislocations had higher hospital costs in overweight children compared with those with normal weight. Rana et al5 did not reveal a notable difference in length of stay, ICU days, ventilator days, or mortality between obese and nonobese patients. In contrast, Brown et al29 showed longer ICU and hospital stays in obese patients; but similar to Rana et al,5 did not show a difference in mortality rates. Both studies demonstrated increased complications in obese patients, including deep vein thrombosis (DVTs), decubitus ulcers, post-op fistulas, wound infections, and sepsis.29 Backstrom et al30 found that obese patients were more likely to be admitted in the ICU and die in the hospital, but these differences were insignificant when adjusted for injury severity score. A recent systematic review,2 which included the abovementioned studies, concluded that obese trauma pediatric patients have a higher mortality rate than nonobese patients. However, only one of the included studies came to a similar conclusion and the review methods did not control for injury severity, which eliminated significance in the only report that demonstrated a higher mortality rate.30 This conclusion should therefore be taken with caution.
Obesity has been posited to delay the diagnosis or alter the natural history of various common pediatric orthopaedic conditions. Neal et al31 investigated the effects of obesity as related to Legg-Calvé-Perthes disease (LCPD). In this single site investigation, the odds of undergoing a containment procedure was 2.4 times less for obese patients and 2.8 times less for bony procedures. They found a notable correlation between increasing BMI and later Waldenstrom stage at initial presentation. With 28% of their patients being obese and 16% overweight, the authors postulated that traditional Perthes demographics are changing, creating a scenario for delayed diagnosis, which may ultimately produce worsened hip deformity that can trigger aberrant hip forces leading to poor long-term outcomes. In a separate region of the United States, Kessler and Cannamela32 assessed the demographics of LCPD and also found a high association between obesity and LCPD; 30.9% of their overall cohort was obese and 45.2% was overweight or obese, similar to Neal et al.31 The overall odds ratio of LCPD was 3.4 in obese patients compared with normal-weight patients.32 Given the changes in demographics in a condition routinely managed by pediatric orthopaedic surgeons, researchers should use results such as this in fine-tuning specific studies on the effects obesity has on other musculoskeletal conditions.
In obese patients, routine sedation and anesthesia contains a higher risk level for obese pediatric patients because drug volumes of distribution of anesthesia drugs, most notably inhaled anesthetics, are altered. For many commonly used sedation drugs, the metabolism of these drugs is unpredictable due to increased adiposity because they are lipid soluble.36 In the study by Hirsch et al,37 patients who required sedation for long bone fracture reduction were assessed. Obese patients experienced twice the oxygen desaturation rates of all patients studied, especially when propofol was used in older patients (12 to 17 years of age). Dosing of anesthetic agents is usually based on lean or ideal body weight rather than total body weight, and there are charts available outlining the optimal specific body weight for these drugs.36
Morbid obesity is associated with a decrease in all respiratory functions, as well as increased risk for asthma and sleep apnea.14 Sleep apnea has been found in 2% of children and is associated with increasingly difficult intubation and acute respiratory failure requiring prolonged ventilation. In their study, Nafiu et al38 found obese patients had increased American Society of Anesthesiologists (ASA) scores because of increased medical comorbidities such as hypertension, type II diabetes, and bronchial asthma. Surgeons should be aware of these risks before performing any elective procedure in obese children and should consider preoperative anesthesia and pulmonary consults to optimize pulmonary health.
Multiple studies have assessed perioperative complications related to obese pediatric patients. In assessing short-term complications associated with pediatric orthopaedic procedures, Basques et al39 found the most common complication risk was a return to the operating room, with the factors related to any complication risk being obesity (odds ratio of 2.3), American Society of Anesthesiologists score ≥ 3, and impaired cognitive status. In the single-center National Surgical Quality Improvement Program study by Blackwood et al,40 underweight, overweight, and obese patients had greater surgical site infection risk than normal-weight patients. Patients with an increased number of cardiac risk factors (found in obese patients) were also at greater risk for surgical site infection.
Implant failure is a known complication risk when treating obese patients with guided growth techniques. Burghardt et al50 performed a Pediatric Orthopaedic Society of North America member survey and found that 15% of members reported mechanical failures of guided growth implant. Failures were related to the cannulated nature of the screws and occurred at the region of the screw shank at the metaphyseal bone-plate junction. Ninety-three percent of patients with broken implants were overweight or obese. This has led surgeons who treat angular deformities to use solid screws more often along with plates that have options for multiple screws on either side of the physis.
Patient visit times in current medical practice place a notable strain on all physicians to provide a comprehensive preventive health review, and orthopaedic surgeons are no exception. Although orthopaedic surgeons are not primary care physicians, they can and should be advocates for the general health of their patients. Orthopaedic surgeons can best focus on those areas that directly relate to musculoskeletal health and do not to be laborious in scope. For obese pediatric patients, the following points can be discussed or performed efficiently and do not necessitate in-depth discussion or work-up to provide sufficient information. Emphasis should be placed on a diet rich in nutritious foods (i.e., fruits and vegetables, whole grains) and low in junk food and sugar-laden drinks such as soda and juice.51 All children should be encouraged to be as active as possible, with preschool aged children being active throughout the day in a variety of activities. Children aged 6 to 17 years should have 60 minutes or more of moderate to vigorous physical activity every day emphasizing aerobic, muscle-strengthening, and bone-strengthening activities.52 A referral to a local healthy weight or obesity center can be made to assist patients in receiving the information and follow-up necessary to help attain a future healthy weight. Vitamin D screening is recommended in obese patients especially before major elective procedures, such as posterior spinal fusion or osteotomies,53 and should be considered for obese patients posttrauma to improve future bone health. Fractures treated conservatively should be followed up closely in obese pediatric patients, and if loss of reduction occurs, surgical fixation should be strongly considered. Caution should be high when performing fracture reductions on obese children with appropriate resuscitation equipment readily available in case of oxygen desaturation. Preoperative cleansing baths and prophylactic antibiotic dosing/re-dosing should be strictly observed to deter postoperative infection risk. Finally, as discussed previously, intraoperative mechanical DVT/PE prophylaxis should be performed in all patients older than 12 years with a procedure expected to last more than 1 hour.
Obesity markedly alters the physiologic and mechanical forces in pediatric patients. This is a modifiable factor that can be positively altered, leading to decreased postoperative complication risk and improved patient health and safety. Orthopaedic surgeons who take care of children should be aware of the effects of obesity on the growing skeleton in an effort to improve care in the long run, encouraging patients and families to be proactive in helping themselves achieve lifelong orthopaedic health. Orthopaedic surgeons should also work closely with primary care providers with screening of the secondary physiologic effects related to obesity to improve long-term patient health.
Levels of evidence are described in the table of contents. In this article, reference 6 is a level 1 studies. References 2, 4, 5, 12, 17, 19-21, 25, 26, 29, 30, 37, 38, 40, 41, 44, and 47 are level 2 studies. References 1, 10, 15, 18, 22, 23, 27, 28, 31, 33-35, 39, 42, 43, 45, and 49 are level 3 studies. References 24, 32, 48, and 50 are level 4 studies. References 3, 7-9, 11, 13, 14, 16, 36, 46, 51-54 are level 5 studies.
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