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Orthopaedic Journal of Sports Medicine Sep 2023There is no consensus regarding the management of posterior cruciate ligament (PCL) avulsion fractures and the expected outcomes after treatment. (Review)
Review
BACKGROUND
There is no consensus regarding the management of posterior cruciate ligament (PCL) avulsion fractures and the expected outcomes after treatment.
PURPOSE
To systematically review clinical outcomes and complications after management of tibial-sided avulsion fractures of the PCL.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
A literature search of Scopus, PubMed, Medline, and the Cochrane Central Register for Controlled Trials was performed in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included were studies with evidence levels 1 to 4 that reported clinical outcomes after treatment of PCL tibial-sided avulsion fractures in humans. The quality of the included studies was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. A meta-analysis was performed for patient-reported outcome measures using random-effects modeling with 95% CIs.
RESULTS
A total of 58 studies published between 1999 and 2022 were identified. The mean MINORS score was 9.90 ± 4.12, indicating overall low-quality evidence with high risk of bias. The studies comprised 1440 patients (mean age, 32.59 ± 5.69 years; 75.2% males) with a mean follow-up of 26.9 ± 19.6 months (range, 5.3-126 months). Most patients were treated with open surgery (63.6%), followed by arthroscopic surgery (29.7%) and nonoperative treatment (6.7%). All patients reported significant posttreatment improvement in both subjective and objective outcomes ( < .05 for all). Arthroscopic surgery was associated with lower postoperative posterior tibial translation compared with open surgery (range, 0.6-3.2 vs 1.7-3.1 mm), greater preoperative to postoperative improvement in Lysholm score (54.6 vs 48.8; < .0001), higher postoperative Tegner score (6.64 ± 1.03 vs 6.14 ± 2.29; = .0448), and a higher rate of return to sport (100% vs 89.5%; = .009). Nonoperative management was associated with a significantly lower fracture union rate (87% vs 99.1%; < .0001) and greater postoperative side-to-side posterior translation (4.9 ± 4.3 mm) when compared with operative management.
CONCLUSION
Although nonoperative and surgical management of PCL tibial avulsion fractures resulted in high rates of fracture union and improvement in functional outcome scores and a low incidence of complications, nonoperative treatment yielded a high side-to-side posterior displacement (>4 mm) with a lower rate of fracture union compared to surgical treatment.
PubMed: 37724253
DOI: 10.1177/23259671231188383 -
JSES Reviews, Reports, and Techniques Aug 2021Although fracture of the coracoid process (CF) used to be considered rare, it is now more commonly encountered due to increased awareness and advances in imaging... (Review)
Review
BACKGROUND
Although fracture of the coracoid process (CF) used to be considered rare, it is now more commonly encountered due to increased awareness and advances in imaging methods. This review aimed to analyze reported cases of CF to determine its mechanism and appropriate treatment.
METHODS
PubMed and Scopus were searched using the terms "scapula fracture" and "coracoid fracture." The inclusion criteria were English full-text articles concerning CF that described patient characteristics with appropriate images. The exclusion criteria included cases without appropriate images and those with physeal injury or nonunion. Citation tracking was conducted to find additional articles and notable full-text articles in other languages. Fractures were mainly classified using Ogawa's classification.
RESULTS
Ninety-seven studies were identified, including 197 patients (131 men, 33 women; average age 37.0±16.9 years). CF was classified as type I in 77%, type II in 19%, and avulsion fracture at the angle in 5%. Concurrent shoulder girdle injuries included acromioclavicular injury in 33%, clavicular fracture in 17%, acromion or lateral scapular spine fracture in 15%, and anterior shoulder instability in 11%. Among patients with type I CF, 69% had multiple disruptions of the superior shoulder suspensory complex. Conservative treatment was applied in 71% of isolated type I CF, while surgical treatment was applied in 76% of type I CF with multiple disruptions. Although the evaluation methods varied, 60% of patients were followed up for more than 6 months, and the outcomes were generally satisfactory for both conservative and surgical treatments.
CONCLUSION
CF occurred commonly in the age group with higher social activity. The most common fracture type was type I. The possible mechanism of CF is violent traction of the attached muscles, except for avulsion fracture at the angle. Type I CF with multiple disruptions of the superior shoulder suspensory complex requires surgical treatment, whereas conservative care is recommended for isolated type I and type II CFs.
PubMed: 37588963
DOI: 10.1016/j.xrrt.2021.04.008 -
Injury Aug 2017Neglected tibial eminence avulsion fractures of the anterior cruciate ligament (ACL) are uncommonly seen in modern times, but are fairly common due to a missed... (Review)
Review
INTRODUCTION
Neglected tibial eminence avulsion fractures of the anterior cruciate ligament (ACL) are uncommonly seen in modern times, but are fairly common due to a missed diagnosis/mismanagement in developing countries.
OBJECTIVES
To determine the outcomes after open reduction and internal fixation of late presenting ACL avulsion fractures, and to review the literature for similar cases, in an attempt to evaluate the ideal surgical management in this unique scenario.
STUDY DESIGN
Retrospective observational study and systematic review MATERIALS: The study included 10 male and 2 female cases (mean age 29.9 years). Patients were assessed for the pre-operative knee range-of-motion (ROM), flexion deformity and stability; functional assessment was conducted using the Lysholm scale, both pre and post-operatively. Open reduction and internal fixation with two partially threaded screws (via a mini anterior approach) was performed in all 12 cases. All patients were clinically followed up for a minimum duration of 12 months. We searched PubMed, Embase and Cochrane databases from the period of inception to January 15, 2017 for similar case series/reports involving management of chronic/neglected ACL avulsion fractures and systematically reviewed these studies following standard PRISMA guidelines.
RESULTS
The median duration of presentation after injury was 12 months (range 3 to 312 months; mean 45.3 months). The mean follow-up duration was 24.1 months (range 12-48 months). All patients achieved normal knee extension except one patient who had a residual 5° flexion contracture. On physical examination, Lachman and pivot-shift tests were negative in all but 1 patient. No case required ACL reconstruction, and the fractures united radiologically within 12 weeks; all patients regained former activity levels.
DISCUSSION
Eleven published studies, mainly case reports, reported on the management of chronic/neglected ACL avulsion fractures. Arthroscopic suture/wire fixation, arthroscopic debridement of avulsed fragment and open reduction, internal fixation (ORIF) with screws are the described techniques for this uncommon entity. However, anatomic reduction of ACL avulsion fractures is difficult arthroscopically as crater depth assessment and repositioning of the avulsed fragment become a problem; the avulsed fragment may also hypertrophy, and some contractures in ACL may develop. A mini-open procedure does not add to the morbidity, overcomes reduction obstacles and allows easy fixation with screws, and can be done even in centers that do not have arthroscopic experience. The key point is accurate reduction and rigid fixation, ensuring no impingement on full extension CONCLUSIONS: Mini-open fixation allows accurate, anatomic reduction and stable fixation with screws, and should be the preferred method of fixation for late presenting ACL avulsion fractures; embedding the fragment deep into the crater or size reduction are key to preventing extension deficits.
Topics: Adult; Anterior Cruciate Ligament Injuries; Arthroscopy; Female; Follow-Up Studies; Fracture Fixation, Internal; Humans; Knee Joint; Male; Observational Studies as Topic; Range of Motion, Articular; Retrospective Studies; Suture Techniques; Tibial Fractures; Treatment Outcome
PubMed: 28802422
DOI: 10.1016/S0020-1383(17)30495-3 -
Arthroscopy : the Journal of... May 2016To develop evidence-based recommendations for the diagnosis and treatment of skeletally immature patients with subscapularis and lesser tuberosity avulsion injuries. (Review)
Review
PURPOSE
To develop evidence-based recommendations for the diagnosis and treatment of skeletally immature patients with subscapularis and lesser tuberosity avulsion injuries.
METHODS
We searched the online databases PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews (CDSR) for relevant publications on subscapularis and lesser tuberosity injuries in skeletally immature patients. All publication dates and languages were included. From studies identified, data were extracted to identify patient characteristics, history and physical examination findings, time to diagnosis, results from imaging studies, and treatment outcomes. These findings were combined and descriptively analyzed.
RESULTS
We identified 32 publications on 60 patients with a mean age of 13.5 ± 1.7 years. The most common physical examination finding at the time of diagnosis was anterior shoulder pain, followed by subscapularis muscle weakness. The sensitivity of imaging was 16% for radiographs and 95% for magnetic resonance imaging. The median time to diagnosis was 2 months (interquartile range, 1 to 7 months). Of 60 patients, 10 (17%) underwent successful nonoperative treatment. Fifty patients (83%) underwent surgical repair, without differences in clinical outcomes after open versus arthroscopic repair. Five cases (8%) were identified where delayed treatment was associated with suboptimal outcomes and ongoing shoulder pain.
CONCLUSIONS
Subscapularis and lesser tuberosity avulsion injuries in skeletally immature patients are most commonly seen in male patients during early adolescence. A high index of suspicion should be maintained in patients with anterior shoulder pain and subscapularis muscle weakness, especially after a fall on an outstretched arm or an eccentric external rotation injury. Magnetic resonance imaging should be considered early, even if radiographic findings are negative. Both open and arthroscopic repairs are effective in restoring function, if fixation respects the soft bone of the lesser tuberosity.
LEVEL OF EVIDENCE
Level IV, systematic review of low-quality studies.
Topics: Adolescent; Arthroplasty; Arthroscopy; Child; Fractures, Avulsion; Humans; Humeral Fractures; Magnetic Resonance Imaging; Physical Examination; Postoperative Complications; Radiography; Rotation; Rotator Cuff Injuries; Shoulder Pain; Treatment Outcome
PubMed: 26786826
DOI: 10.1016/j.arthro.2015.10.022 -
Knee Surgery, Sports Traumatology,... Sep 2021The purpose of this study was to systematically review case reports and case series about meniscal ossicle, to summarize existing evidence. Specifically, to identify the... (Review)
Review
PURPOSE
The purpose of this study was to systematically review case reports and case series about meniscal ossicle, to summarize existing evidence. Specifically, to identify the etiology, demographic characteristics, localization, clinical features, diagnostic procedures and treatment options of this rare entity. Although, case reports/ series are of low level of evidence, a systematic review of such studies can provide and help us to gain a better understanding and awareness of meniscal ossicle.
METHODS
Two authors searched three online databases (MEDLINE, SCOPUS and GOOGLE SCHOLAR) from inception until March 2020 for the literature on meniscal ossicle. Inclusion criteria included case series, case reports and case-based reviews, available in full-text version, in English and that concern humans. Reports published in languages other than English were excluded, as well as articles with no electronic full text availability. Case reports using the term "meniscal ossicle" to describe an acute avulsion fracture of the tibial root of the meniscus, were also excluded.
RESULTS
Of 453 initial studies, 38 studies satisfied inclusion criteria. In total 169 patients were included of whom 107 (63%) were males and 62 (37%) were females. Mean age was 44 years (range 12-87). According to Magnetic resonance imaging findings, in 144 knees (86%) the ossicle was localized at the posterior root or horn of the medial meniscus. 60% of the patients had a history of trauma. The predominant symptom in 87% of patients was knee pain. In all patients was detected an intra-articular density structure in computed radiography. 76% had associated meniscal tear, 61% had intraarticular cartilage loss, 34% meniscal extrusion and 28% anterior cruciate ligament injury. Treatment modalities included conservative regimen in 40 patients, while 59 patients underwent surgical excision.
CONCLUSION
The most possible etiology of meniscal ossicle is posttraumatic heterotopic ossification and small occult bony avulsion fracture. It is commonly observed in individuals complaining about knee pain with history of antecedent trauma. The presence of a meniscal ossicle should alert the physician to the high likelihood of the patient having an associated meniscal tear, articular cartilage loss, ACL injury or meniscal extrusion. Along with the meniscal ossicle, the associated meniscal tear should be treated as well.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anterior Cruciate Ligament Injuries; Child; Female; Humans; Knee Injuries; Magnetic Resonance Imaging; Male; Menisci, Tibial; Middle Aged; Osteogenesis; Retrospective Studies; Tibial Meniscus Injuries; Young Adult
PubMed: 33128588
DOI: 10.1007/s00167-020-06338-1 -
Orthopaedic Journal of Sports Medicine May 2022Arm wrestling is a popular sport in which various injuries have occurred, even in children. (Review)
Review
BACKGROUND
Arm wrestling is a popular sport in which various injuries have occurred, even in children.
PURPOSE
To analyze reported fracture-separation of the medial humeral epicondyle (MHE) caused by arm wrestling to determine its mechanism and provide a current overview.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
The PubMed and Web of Science databases were searched using the terms "arm wrestling" and "humeral fracture" or "medial humeral epicondyle fracture"; and "sports" and "humeral fracture" or "medial humeral epicondyle fracture," following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The inclusion criteria were English full-text articles on arm wrestling-induced MHE fracture that described patient characteristics and presented appropriate images. Studies with a lack of appropriate images or detailed description of the injury situation were excluded. The patient characteristics were evaluated, and the ratios of treatment selection and outcomes were evaluated using the chi-square test.
RESULTS
Included were 27 studies with a total of 68 patients, all boys with a mean age of 14.6 ± 1.24 years (based on n = 65, with 3 patients excluded from this calculation as no definitive age was provided). Boys aged 14 to 15 years accounted for 72% (49/68) of the cases. Fracture occurred suddenly during arm wrestling in 63 boys, while the other 5 boys experienced antecedent medial elbow pain. The match status at the time of injury, provided for 46 patients, was varied. In 31 boys with known match details, injury occurred when a participant suddenly added more force to change the match status. Eight patients displayed anterior and/or proximal displacement of the MHE fragment. Treatment was nonoperative in 25 patients and operative in 38 patients (n = 63, excluding 5 unknown patients). In 35 patients followed up for ≥3 months (mean, 17.6 ± 12.3 months), outcomes were not significantly different between the operative and nonoperative groups.
CONCLUSION
MHE fracture-separation caused by arm wrestling occurred mostly in boys aged 14 to 15 years regardless of the match status. The likely direct cause is forceful traction of the attached flexor-pronator muscles. A relative mechanical imbalance during adolescence may be an underlying cause. A sudden change from concentric to eccentric contraction of the flexor-pronator muscles increases the likelihood of fracture occurrence.
PubMed: 35528993
DOI: 10.1177/23259671221087606 -
JSES Reviews, Reports, and Techniques May 2022The terrible triad of the elbow (TTE) is a complex injury consisting of simultaneous elbow dislocation or subluxation, radial head fracture, and coronoid fracture.... (Review)
Review
BACKGROUND
The terrible triad of the elbow (TTE) is a complex injury consisting of simultaneous elbow dislocation or subluxation, radial head fracture, and coronoid fracture. During the initial assessment of a TTE, the typical severity of presenting pain, swelling, and limited range of motion may limit the ability to perform a thorough physical examination and thus divert a clinician's attention away from additional injuries to the ipsilateral upper extremity. Therefore, the purpose of this study was to review the literature for reported cases of concomitant ipsilateral upper extremity injuries associated with a TTE and discuss various strategies to increase clinician awareness to avoid underdiagnosis and missed diagnoses.
METHODS
A systematic review of five databases in four languages (English, Spanish, French, and Portuguese), from inception to May 2021, was conducted. Articles describing a TTE with a concomitant osseous, chondral, ligamentous, or musculotendinous injury occurring on the ipsilateral upper extremity were included. The patients were divided into two groups, those presenting with a classic TTE and concomitant ipsilateral upper extremity injury (group 1) and those in whom a TTE variant was described (group 2). A TTE variant was defined as a combination of osseous and/or chondral injuries to the elbow other than the classic description of TTE, in which at least two of the three classical elements of a TTE (elbow dislocation, coronoid fracture, and radial head fracture) were present in addition to other unique elbow osteoarticular injury.
RESULTS
Nineteen articles met inclusion criteria and were further analyzed. A total of 27 patients were analyzed, 23 from group 1 and 4 from group 2. Overall, 33 concomitant injuries were documented in group 1, the most common being an olecranon fracture (27.3%), followed by Essex-Lopresti injury, triceps tendon avulsion, and carpal fracture-dislocation with 4 (12.1%) cases each. Group 2 had four patients, all of whom presented with a unique variant of the classically described TTE.
CONCLUSION
Despite a characteristic radiographic appearance of the classic TTE, additional injuries of the ipsilateral extremity or variants of the classic TTE may be easily missed, especially in cases resulting from high-energy mechanisms of injury. By analyzing the available data on associated injuries and variants that may occur with a TTE, we hope to increase awareness so that clinicians may recognize these less common but more complex injury patterns.
PubMed: 37587951
DOI: 10.1016/j.xrrt.2021.10.004 -
Archives of Orthopaedic and Trauma... Jun 2024The ideal surgical management for tibial eminence avulsion fractures remains controversial with varying approach, methods of fixation and post-operative regimes reported...
PURPOSE
The ideal surgical management for tibial eminence avulsion fractures remains controversial with varying approach, methods of fixation and post-operative regimes reported throughout literature. The current systematic review and meta-analysis aims to compare between the different approaches, methods of fixation and post-operative regimes for tibial eminence fractures.
METHODS
The systematic review was conducted according to PRISMA guidelines. A search was conducted using PubMed, MEDLINE and CINAHL databases. The keywords used were "anterior cruciate ligament", "tibial spine" or "tibial eminence" and "fracture" or "avulsion". All original human studies that reported the surgical outcomes of tibial eminence fractures were included. Individual patient data meta-analysis was performed.
RESULTS
48 studies with 1367 patients were included. Arthroscopic fixation resulted in significantly greater stability in terms of anterior drawer test (p = 0.018) and Lachman's test (p = 0.042), as compared to open fixation, though there was no significant difference for pivot shift test. There was no significant difference identified in functional scores and activity, including Lysholm score, IKDC subjective score, Tegner score and return to sports. Suture fixation had significantly increased stability compared to screw fixation, in terms of anterior drawer test (p = 0.001) and Lachman's test (p = 0.001), though no significant difference was identified for pivot shift test. Significantly better subjective scores and return to activity were also noted for suture fixation, in terms of Lysholm score (p = 0.008), IKDC subjective score (p = 0.001) and Tegner score (p = 0.001), though no significant difference was identified for return to sports.
CONCLUSION
Arthroscopic and suture fixation had significantly superior outcomes when compared to open and screw fixation. Arthroscopic fixation resulted in significantly improved stability of the knee as compared to open fixation, though no significant difference was identified in terms of functional knee scores and return to activity. Suture fixation resulted in significantly improved stability of the knee and functional knee screws as compared to screw fixation.
PubMed: 38896276
DOI: 10.1007/s00402-024-05318-1 -
Foot & Ankle Specialist Jun 2023The aim of this review was to determine operative indications for Lisfranc injuries. (Review)
Review
OBJECTIVE
The aim of this review was to determine operative indications for Lisfranc injuries.
METHODS
A systematic review using a MEDLINE literature search was performed using the index "Lisfranc Injury" from 1980 onward using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines where applicable. Inclusion criteria were all clinical studies reporting on the management of Lisfranc injuries obtained via the search index, including case reports, review articles, cohort studies, and randomized trials. Non-English-language articles, inaccessible articles, those not relevant to the management of Lisfranc injuries (biomechanical, cadaveric, and technique articles), and those that did not explicitly state operative indications (vague or absent indications) were excluded.
RESULTS
After identifying 737 studies, the full text of 391 studies was reviewed, and 58 reports providing explicit operative indications were included in the final analysis. Fifty-one (81.1%) studies provided diastasis cutoffs varying ≥2 mm (35/58; 60.4%), ≥ ≥3 mm (3; 5.2%); the diastasis location was most commonly unspecified (31/58; 53.5%) or varied between combinations of metatarsal, tarsal, cuboid, and cuneiform bones (20/58; 27.6%). Specific imaging criteria for surgery included an avulsion fracture or fleck sign (3/58; 5.2%), arch height loss (3/58; 5.2%), and a tear on magnetic resonance imaging (5; 8.6%). The 11 (19%) studies defining operative indications in terms of classification schemes used the Nunley and Vertullo (8/58; 13.8%), Myerson (2; 3.5%), and Buehren (1; 1.7%) systems. Twenty-one (36.2%) studies provided multiple operative indications.
CONCLUSION
The most common Lisfranc operative indications among the limited reporting studies varied from a 1- to 3-mm diastasis across several locations. It is imperative for operative indications to be reported with an increased frequency and in a homogenous fashion to guide the clinical management of these subtle injuries.
LEVELS OF EVIDENCE
Level IV; systematic Review.
PubMed: 37278226
DOI: 10.1177/19386400231175376 -
Journal of Shoulder and Elbow Surgery Mar 2024Terrible triad injury is a complex injury of the elbow, involving elbow dislocation with associated fracture of the radial head, avulsion or tear of the lateral ulnar... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Terrible triad injury is a complex injury of the elbow, involving elbow dislocation with associated fracture of the radial head, avulsion or tear of the lateral ulnar collateral ligament, and fracture of the coronoid. These injuries are commonly managed surgically with fixation or replacement of the radial head and repair of the collateral ligaments with or without fixation of the coronoid. Postoperative mobilization is a significant factor that may affect patient outcomes; however, the optimal postoperative mobilization protocol is unclear. This study aimed to systematically review the available literature regarding postoperative rehabilitation of terrible triad injuries to aid clinical decision making.
METHODS
We systematically reviewed the PubMed, Embase, Cochrane, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The inclusion criteria were studies with populations aged ≥16 years with terrible triad injury in which operative treatment was performed, a clear postoperative mobilization protocol was defined, and the Mayo Elbow Performance Score (MEPS) was reported. Secondary outcomes were pain, instability, and range of motion (ROM). Postoperative mobilization was classified as either "early," defined as active ROM commencement before or up to 14 days, or "late," defined as active ROM commencement after 14 days.
RESULTS
A total of 119 articles were identified from the initial search, of which 11 (301 patients) were included in the final review. The most common protocols (6 studies) favored early mobilization, whereas 5 studies undertook late mobilization. Meta-regression analysis including mobilization as a covariate showed an estimated mean difference in the pooled mean MEPS between early and late mobilization of 6.1 (95% confidence interval, 0.2-12) with a higher pooled mean MEPS for early mobilization (MEPS, 91.2) than for late mobilization (MEPS, 85; P = .041). Rates of instability reported ranged from 4.5% to 19% (8%-11.5% for early mobilization and 4.5%-19% for late mobilization).
CONCLUSION
Our findings suggest that early postoperative mobilization may confer a benefit in terms of functional outcomes following surgical management of terrible triad injuries without appearing to confer an increased instability risk. Further research in the form of randomized controlled trials between early and late mobilization is advised to provide a higher level of evidence.
Topics: Humans; Radius Fractures; Elbow Injuries; Treatment Outcome; Fracture Fixation, Internal; Joint Dislocations; Elbow Joint; Range of Motion, Articular; Retrospective Studies; Ulna Fractures
PubMed: 38036253
DOI: 10.1016/j.jse.2023.10.012