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Journal of Orthopaedic Surgery and... Jul 2022Intertrochanteric hip fractures are common and devastating injuries, especially for the elderly. Surgical treatment is the optimal strategy for managing... (Meta-Analysis)
Meta-Analysis
In reply to the letter to the editor regarding "Comparison of a twin interlocking derotation and compression screw cephalomedullary nail (InterTAN) with a single screw derotation cephalomedullary nail (proximal femoral nail antirotation): a systematic review and meta-analysis for intertrochanteric...
BACKGROUND
Intertrochanteric hip fractures are common and devastating injuries, especially for the elderly. Surgical treatment is the optimal strategy for managing intertrochanteric fractures as it allows early rehabilitation and functional recovery. The relative effects of internal fixation strategies for intertrochanteric fracture after operation remain limited to relatively small studies which create uncertainty in attempts to establish evidence-based best practice.
METHODS
We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) and observational studies to assess the clinical effectiveness of two commonly used intramedullary devices: a twin-screw integrated cephalomedullary nail (InterTAN) versus a single-screw cephalomedullary nail (proximal femoral nail antirotation) in patients with intertrochanteric fractures. The following outcomes were considered: revisions, implant-related failures, non-unions, pain, Harris hip score and intra-operative outcomes. Odds ratios or mean differences with 95% confidence intervals in brackets are reported.
RESULTS
Six studies met the inclusion criteria: two randomised controlled trials and four observational studies enrolling 970 patients with a mean age of 77 years and 64% of patients being female. There was a statistically significant difference (p value < 0.05) for revisions OR 0.27 (0.13-0.56), implant-related failures OR 0.16 (0.09-0.27) and proportion of patients complaining of pain OR 0.50 (0.34-0.74). There was no difference in non-unions and Harris hip score (p value > 0.05). There was a significant difference in blood loss and fluoroscopy usage in favour of PFNA, while no difference in operating times was observed between the two devices.
CONCLUSIONS
Our meta-analysis suggests that a twin-screw integrated cephalomedullary nail (InterTAN) is clinically more effective when compared to a single-screw cephalomedullary nail proximal femoral nail antirotation resulting in fewer complications, fewer revisions and fewer patients complaining of pain. No difference has been established regarding non-unions and Harris hip score. Intra-operative outcomes favour PFNA with less blood loss and fluoroscopy usage. Further studies are warranted to explore the cost-effectiveness of these and other implants in managing patients with intertrochanteric fractures.
Topics: Aged; Bone Nails; Bone Screws; Female; Fracture Fixation, Intramedullary; Hip Fractures; Humans; Male; Pain; Treatment Outcome
PubMed: 35842668
DOI: 10.1186/s13018-022-03244-9 -
Journal of Orthopaedic Science :... Jan 2016A systematic review and meta-analysis was conducted to compare the relative effectiveness of bridging external fixation and non-bridging external fixation for distal... (Comparative Study)
Comparative Study Meta-Analysis Review
OBJECTIVE
A systematic review and meta-analysis was conducted to compare the relative effectiveness of bridging external fixation and non-bridging external fixation for distal radius fractures treatment.
METHOD
Relevant literature were comprehensively searched using the PubMed, Springer Link, Karger Medical and Scientific Publishers, Chinese Biomedical Database (CBM) and Chinese National Knowledge Infrastructure (CNKI) databases without any language restrictions. STATA Version 12.0 software and Comprehensive Meta-analysis 2.0 were applied.
RESULTS
A total of 905 patients with distal radius fracture from six eligible cohort studies were selected for statistical analysis. Our meta-analysis results indicate that the non-bridging cases had a higher risk of pin track infection, rupture of the extensor pollicis longus and nerve injury than the bridging cases. Subgroup analysis stratified by country indicated non-bridging patients showed evidence of an increased risk of pin track infection and higher risk of rupture of the extensor pollicis longus compared with the patients treated with bridging external fixation in the UK population. The follow-up results showed flexion degree of patients treated with non-bridging external fixation was slightly better than that of patients treated with bridging external fixation (P < 0.05).
CONCLUSION
There is evidence in our systematic review and meta-analysis to support that bridging external fixation can reduce the incidence of pin tract infections and nerve injury compared to non-bridging external fixation, but have no significant difference in other complications and the recovery of wrist joint function. Bridging external fixation could therefore be a better choice in patients with distal radius fractures.
Topics: Fracture Fixation; Humans; Radius Fractures; Wrist Joint
PubMed: 26686771
DOI: 10.1016/j.jos.2015.10.021 -
Orthopaedics & Traumatology, Surgery &... Sep 2017Previous studies have reported conflicting findings concerning the efficacy and safety of the treatment of intertrochanteric fractures (OTA 31-A1,A2 and A3) using short... (Meta-Analysis)
Meta-Analysis Review
UNLABELLED
Previous studies have reported conflicting findings concerning the efficacy and safety of the treatment of intertrochanteric fractures (OTA 31-A1,A2 and A3) using short intramedullary nails (SIN) and long intramedullary nails (LIN). The present meta-analysis and literature review investigated the outcomes of SIN and LIN, thereby providing guidance for the treatment of intertrochanteric femur fractures. When used to treat intertrochanteric femur fractures, LIN did not decrease the secondary femoral shaft refracture or reoperation rates. Eight electronic databases were searched for studies related to the use of SIN compared to LIN in treating intertrochanteric fractures. The modified Jadad Scale and the Newcastle-Ottawa Scale (NOS) were used to assess the methodological quality and the risk of bias of these studies. The two groups were compared based on nine indicators, including the surgical times, intraoperative blood loss, transfusion, length of hospital stay, secondary femoral shaft refracture, reoperation, 1-year mortality, Harris hip scores (1 year) and complications. A total of 2431 patients were included in the analysis, with 1498 LIN cases and 940 SIN cases (bilateral nails were used in 7 cases), and the average patient age was 74.83 years. The pooled results indicated that patients in the LIN group had longer surgical times (MD [mean difference]: 12.56; 95% CI: 8.28-16.84; P<0.00001), more intraoperative blood loss (MD: 37.44; 95% CI: 8.06-66.82, P=0.01) and a higher transfusion rate (OR [odds ratio]: 1.53; 95% CI: 1.12-2.10, P=0.008) than patients in the SIN group. However, there was no significant difference in the length of hospital stay (MD: 0.24; 95% CI: -0.58-1.06, P=0.56), occurrence of secondary femoral shaft refractures (OR: 0.72; 95% CI: 0.34-1.53, P=0.39), reoperation rate (OR: 0.95; 95% CI: 0.60-1.50, P=0.82), 1-year mortality (OR: 1.1; 95% CI: 0.67-1.8, P=0.71), Harris hip score (MD: 1.87; 95% CI: -2.8-6.54, P=0.43) or complication rate (OR: 1.29; 95% CI: 0.84-1.99, P=0.25). LIN may not be a better method or provide more effective treatment for intertrochanteric femur fractures; the LIN patients demonstrated the same prognosis as the SIN patients, particularly in terms of secondary femoral shaft refracture and reoperation rate, but they experienced greater trauma. Due to the limitations of the included studies, however, more highly powered randomized controlled trials are needed to clarify the findings. Systematic review and meta-analysis.
LEVEL OF EVIDENCE
III.
Topics: Blood Loss, Surgical; Blood Transfusion; Bone Nails; Femoral Fractures; Fracture Fixation, Intramedullary; Hip Fractures; Humans; Length of Stay; Operative Time; Prognosis; Reoperation; Treatment Outcome
PubMed: 28546048
DOI: 10.1016/j.otsr.2017.04.003 -
Orthopaedics & Traumatology, Surgery &... Apr 2023Anterior femoral cortical impingement and perforation are known risks of cephalomedullary nailing. The incidence of and risk factors for these findings have not been...
BACKGROUND
Anterior femoral cortical impingement and perforation are known risks of cephalomedullary nailing. The incidence of and risk factors for these findings have not been fully established in the literature. The purpose of this review was to answer: (1) What is the incidence of anterior femoral cortical impingement and perforation associated with cephalomedullary nailing of proximal femur fractures? (2) How does incidence vary by nail radius of curvature (ROC)? (3) What populations are at increased risk of impingement and perforation? (4) What surgical techniques prevent their occurrence?
HYPOTHESIS
Our hypothesis was that impingement would be a relatively common finding following cephalomedullary nailing, and perforation would be much less frequent but still an appreciable risk. Secondarily, nails with a larger ROC would have a higher rate of impingement.
PATIENTS AND METHODS
In this systematic review, PubMed, MEDLINE, and Cochrane databases were searched for articles from 1990-2020 written in English using the terms "cephalomedullary nail" or "femoral nail" and "perforation" or "impingement", and similar words. Inclusion criteria were studies discussing the complication of anterior femoral cortical impingement or perforation associated with the use of a cephalomedullary nail. Fourteen studies met inclusion criteria. Rates of anterior femoral cortical impingement or perforation, patient demographics, nail type, and ROC were extracted. Surgical techniques to prevent perforation were qualitatively reviewed.
RESULTS
The rate of anterior cortical impingement with long cephalomedullary nails was 17.2% (192/1117 patients) and with short nails was 29.2% (176/602). The rate of anterior cortical perforation with long nails was 1.0% (11/1116) and with short nails was 0% (0/234). Long nails with ROC>150cm showed an impingement rate of 10.9% (62/567) and perforation rate of 1.1% (7/617 patients). Nails with ROC 150cm or 100cm had an impingement rate of 1.1% (1/93) and perforation rate of 0% (0/93).
DISCUSSION
Impingement and perforation of the anterior femoral cortex during cephalomedullary nailing are appreciable risks that surgeons should anticipate and avoid, especially in certain populations and with nails with larger ROC. Surgeons may consider use of long nails with ROC 150cm and below, given a nearly 10-fold lower incidence of impingement and no reported perforations.
LEVEL OF EVIDENCE
Therapeutic, level IV.
Topics: Humans; Bone Nails; Femoral Fractures; Femur; Fracture Fixation, Intramedullary; Hip Fractures; Retrospective Studies; Treatment Outcome
PubMed: 36496157
DOI: 10.1016/j.otsr.2022.103505 -
Foot and Ankle Surgery : Official... Oct 2022This study aims to provide an updated systematic review and meta-analysis of comparative studies on the outcomes and complications of locked IMNs in comparison to ORIF... (Meta-Analysis)
Meta-Analysis
Locked intramedullary nailing provides superior functional outcomes and lower complication rates than plate fixation of distal fibula fractures. A systematic review and meta-analysis of comparative studies.
PURPOSE
This study aims to provide an updated systematic review and meta-analysis of comparative studies on the outcomes and complications of locked IMNs in comparison to ORIF using plates and screws, while avoiding limitations of similar published reviews.
METHODS
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, two independent team members electronically searched MEDLINE (PubMed), EMBASE, Google Scholar, SCOPUS, and Cochrane databases throughout May 2021 using the following keywords with their synonyms: "Ankle fracture fixation" AND "Open reduction and internal fixation", "locked intramedullary nail", or "complications". The primary outcomes were (1) functional outcomes, (2) complications, and (3) reoperation, while the secondary outcomes were: (1) union rate, and (2) cost.
INCLUSION CRITERIA
comparative studies on outcomes and complications of plate open reduction and internal fixation (ORIF) vs. locked intramedullary nailing (IMN) of ankle fractures reporting at least one of the following parameters: functional outcomes, complications (infection, dehiscence, reoperation etc.), union, and cost. Studies reporting on non-locked intramedullary fibular nails were also excluded.
RESULTS
After the removal of duplicates, a total of 1461 studies were identified. After screening those records, 63 studies remained for full-text assessment. Out of those, four comparative studies with a total of 262 ankle fractures met the inclusion criteria for this meta-analysis. The mean 12 months postoperative Olerud and Molander Ankle Scores (OMAS) were reported by two studies, with a statistically significant difference in favor of IMNs (MD= 6.72, CI: 3.77-9.67, p<0.001, I= 94%). In the ORIF group, the overall complication rate was 39/134 (29.1%) vs. 10/128 (7.8%) in the IMN group, with a statistically significant difference in favor of the IMN group (RR=3.23, CI:1.71-6.11, p<0.001, I=34%). In the ORIF group, the overall infection rate was 11/134 (8.2%), while there were no infections in the IMN group, with a statistically significant difference in favor of the IMN group (RR=8.05, CI:1.51-42.82, p=0.01, I=0%). In the ORIF group, the overall reoperation rate was 10/134 (7.5%) while the overall reoperation rate was 6/128 (4.7%) in the IMN group, with no statistically significant difference between groups (RR=1.49, CI: 0.60-3.70, p = 0.39, I=0%).
CONCLUSION
Locked intramedullary nail fixation of distal fibula fractures could provide superior functional outcomes and lower complication rates in comparison to open reduction and plate fixation. Despite the high incidence of ankle fractures, the number of high-quality comparative studies remains limited in literature, especially on newer locked fibular nails, and large multicentric clinical trials are required before recommending locked IMNs as the new standard of care in distal fibula fractures.
Topics: Ankle Fractures; Bone Nails; Bone Plates; Fibula; Fracture Fixation, Intramedullary; Humans; Tibial Fractures; Treatment Outcome
PubMed: 35184992
DOI: 10.1016/j.fas.2022.02.005 -
Archives of Orthopaedic and Trauma... Jun 2021Our purpose was to perform a systematic review and meta-analysis to evaluate complication and revision rates for periprosthetic distal femur fractures (PPDFF) treated... (Meta-Analysis)
Meta-Analysis
Early complications and reoperation rates are similar amongst open reduction internal fixation, intramedullary nail, and distal femoral replacement for periprosthetic distal femur fractures: a systematic review and meta-analysis.
BACKGROUND
Our purpose was to perform a systematic review and meta-analysis to evaluate complication and revision rates for periprosthetic distal femur fractures (PPDFF) treated with: (1) ORIF using periarticular locking plates (ORIF), (2) retrograde intramedullary nail (IMN), and (3) distal femoral replacement (DFR).
METHODS
Systematic review of the literature was performed to identify eligible studies (N = 52). Identified treatment groups were: ORIF (N = 1205 cases), IMN (N = 272 cases), and DFR (N = 353 cases). Median follow-up was 30 months (range 6-96 months). Primary outcomes were: (1) major complication rates and (2) reoperation rates over the follow-up period. Secondary outcomes were incidence of deep infection, periprosthetic fracture, mortality over the follow-up period, 1-year mortality, non-union, malunion, delayed union, and hardware failure. Data for primary and secondary outcomes were pooled and unadjusted analysis was performed. Meta-analysis was performed on subset of individual studies comparing at least two of three treatment groups (N = 14 studies). Odds-ratios and their respective standard errors were determined for each treatment group combination. Maximum likelihood random effects meta-analysis was conducted for primary outcomes.
RESULTS
From the systematic review, major complication rates (p = 0.55) and reoperation rates (p = 0.20) were not significantly different between the three treatment groups. DFR group had a higher incidence of deep infection relative to IMN and ORIF groups (p = 0.03). Malunion rates were higher in IMN versus ORIF (p = 0.02). For the meta-analysis, odds of major complications were not significantly different between IMN versus DFR (OR 1.39 [0.23-8.52]), IMN versus ORIF (OR 0.86 [0.48-1.53]), or the ORIF versus DFR (OR 0.91 [0.52-1.59]). Additionally, odds of a reoperation were not significantly different between IMN versus DFR (OR 0.59 [0.08-4.11]), IMN versus ORIF (OR 1.26 [0.66-2.40]), or ORIF versus DFR (OR 0.91 [0.51-1.55]).
CONCLUSIONS
There was no difference in major complications or reoperations between the three treatment groups. Deep infection rates were higher in DFR relative to internal fixation, malunion rates were higher in IMN versus ORIF, and periprosthetic fracture rates were higher in DFR and IMN versus ORIF.
Topics: Bone Nails; Femoral Fractures; Fracture Fixation, Internal; Humans; Open Fracture Reduction; Postoperative Complications; Reoperation
PubMed: 33743062
DOI: 10.1007/s00402-021-03866-4 -
Medicine Mar 2015Multiple meta-analyses have been published to compare intramedullary nail and plate for treating humeral shaft fractures; however, results are discordant.The purposes of... (Comparative Study)
Comparative Study Meta-Analysis Review
Multiple meta-analyses have been published to compare intramedullary nail and plate for treating humeral shaft fractures; however, results are discordant.The purposes of current study were to perform a systematic review of overlapping meta-analyses comparing intramedullary nail and plate fixation for the treatment of humeral shaft fractures, to appraise the methodological quality and the quality of reporting of meta-analyses, and to propose a guide through the currently discordant available evidence.This systematic review was performed according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analysis. The literature was systematically reviewed to identify meta-analyses comparing intramedullary nail and plate fixation for the treatment of humeral shaft fractures. Only meta-analyses exclusively including randomized clinical trials (RCTs) met eligibility criteria in this systematic review. Methodological quality for each included study was assessed using the Oxford Levels of Evidence and the Assessment of Multiple Systematic Reviews Instrument. We extracted all variables from the included studies and listed the results reported by them. Heterogeneity information of each variable was extracted for the included studies. An I of <60% is accepted in this systematic review. The Jadad algorithm was then applied to determine which meta-analyses provided the best evidence.Seven studies met the inclusion criteria in this study. All studies included RCTs or quasi-RCT and were Level II of evidence. Assessment of Multiple Systematic Reviews scores varied from 6 to 10 with a median of 7.86. Heterogeneity of each outcome was acceptable in those meta-analyses pooled results. The Jadad algorithm suggested that the meta-analyses can be selected based on the search strategies and application of selection. As a result, 2 meta-analyses with more RCTs were selected in this systematic review. The best available evidence suggested that the differences between intramedullary nail and plate fixation were not significant in fracture union, radial nerve injury, and infection. But intramedullary nail significantly increased the risk of shoulder complications (shoulder impingement and restriction of shoulder movement) and reoperation.We concluded that plate fixation is superior to intramedullary nail for the treatment of humeral shaft fractures.
Topics: Algorithms; Bone Nails; Bone Plates; Fracture Fixation, Intramedullary; Humans; Humeral Fractures
PubMed: 25789949
DOI: 10.1097/MD.0000000000000599 -
Injury Apr 2018Surgical treatment of displaced midshaft clavicle fractures requires a decision between plate fixation and intramedullary (IM) fixation. Numerous studies report on the... (Comparative Study)
Comparative Study Review
PURPOSE
Surgical treatment of displaced midshaft clavicle fractures requires a decision between plate fixation and intramedullary (IM) fixation. Numerous studies report on the biomechanical properties of various repair constructs. The goal of this systematic review was to provide an overview of studies describing the biomechanical properties of the most commonly used surgical fixations of midshaft clavicle fractures. Additionally, we aimed to translate these biomechanical results into clinically relevant conclusions.
METHODS
A computer-aided search of the EMBASE and PudMed/MEDLINE databases was conducted. Studies included for review compared biomechanical properties of plate fixation with IM fixation and superiorly positioned plates with anteroinferiorly positioned plates for midshaft clavicle fractures.
RESULTS
Fifteen studies were eligible for inclusion. Plate fixation seemed to form a more robust construct than IM fixation in terms of stiffness and failure loading. The remaining clavicle was stronger after removal of the IM device than after removal of the plate. Superior plating of transverse fractures generally seemed to provide greater stiffness and strength during bending loads than anteroinferior plating did. The absence of cortical alignment in wedge and comminuted fractures directly influenced the fixation stability for both IM fixation and plate fixation, regardless of location.
CONCLUSION
Each type of fracture fixation has biomechanical advantages and disadvantages. However, exact thresholds of stiffness for inducing healing and failure strength to withstand refractures are unknown. The clinical relevance of the biomechanical studies may be arguable. Since none of the studies investigate the effect of tissue adaptation over time they should be interpreted with caution.
Topics: Biomechanical Phenomena; Bone Plates; Bone Screws; Clavicle; Fracture Fixation, Internal; Fractures, Bone; Humans; Materials Testing; Treatment Outcome
PubMed: 29523350
DOI: 10.1016/j.injury.2018.02.017 -
Injury Mar 2016Segmental tibial fractures are complex injuries associated with significant soft tissue damage that are difficult to treat. This study aimed to identify the most... (Review)
Review
INTRODUCTION
Segmental tibial fractures are complex injuries associated with significant soft tissue damage that are difficult to treat. This study aimed to identify the most effective method of treating segmental tibial fractures.
METHOD
A PRISMA compliant systematic review was conducted. Studies investigating the management of segmental tibial fractures with intramedullary nail fixation (IMN), open reduction and internal fixation (ORIF) or circular external fixation (CEF) were included for review. The primary outcome measure was time to fracture union. Secondary outcomes were complications and functional outcome. A narrative analysis was undertaken as meta-analysis was inappropriate due to heterogeneity of the data.
RESULTS
Thirteen studies were eligible and included. No randomised controlled trials were identified. Fixation with an intramedullary nail provided the fastest time to union, followed by open reduction and internal fixation and then CEF. The rate of deep infection was highest after IMN (5/162 [3%]), followed by open reduction and internal fixation (2/78 [2.5%]) and CEF (1/54 [2%]). However, some studies reported particularly high rates of infection following IMN for open segmental tibial fractures. There was limited reporting of postoperative deformities. From the studies that did include such data, there was a higher rate of deformity following ORIF (8/53 [15%]), compared to IMN (13/138 [9%]), and CEF (4/44 [9%]). Three studies, not including IMN, described patient reported outcome measures with results ranging from 'excellent' to 'fair'.
DISCUSSION
The available evidence was of poor quality, dominated by retrospective case series. This prevented statistical analysis, and precludes firm conclusions being drawn from the results available.
CONCLUSION
IMN has the fastest time to fracture union, however there are concerns regarding an increased deep infection rate in open segmental tibial fractures. In this subgroup, the data suggests CEF provides the most satisfactory results. However, the available literature does not provide sufficient detail to make this statement with certainty. We recommend a randomised controlled study to further investigate this challenging problem.
Topics: Bone Nails; Fracture Fixation, Intramedullary; Fracture Healing; Fractures, Open; Humans; Recovery of Function; Soft Tissue Injuries; Tibial Fractures; Treatment Outcome
PubMed: 26776463
DOI: 10.1016/j.injury.2015.11.022 -
The Journal of Foot and Ankle Surgery :... 2022Large osseous defects of the hindfoot and ankle pose a surgical challenge. Tibiotalocalcaneal (TTC) arthrodesis utilizing a structural allograft may be required to fill... (Meta-Analysis)
Meta-Analysis Review
Large osseous defects of the hindfoot and ankle pose a surgical challenge. Tibiotalocalcaneal (TTC) arthrodesis utilizing a structural allograft may be required to fill the osseous void, preserve limb length and achieve fusion. Several authors have reported small case series on this topic, however outcomes have varied and no systematic review of this data has been published to date. The primary aim of this study is to report rates of osseous union, limb salvage and complications in patients undergoing TTC arthrodesis with a structural allograft. A total of 11 publications were identified that met the inclusion criteria. One hundred seventy-five patients were included with a weighted mean age of 60.5 (range 50-72) years and follow-up period of 29.7 (range 3-62) months. Femoral head allograft was the most commonly utilized structural graft and a retrograde intramedullary nail was the most common fixation construct. Results demonstrated an overall union rate of 67.4%, limb salvage rate of 92.5% and complication rate of 26.6%. Allograft-related complications were rare with an allograft fracture rate of 0.1% and allograft collapse rate of 1.2%. There was no significant difference in union rate when using a retrograde intramedullary nail versus a plate construct (p = .9148). TTC arthrodesis with use of a structural allograft is a viable treatment option for limb salvage when faced with complex hindfoot and ankle pathology involving large osseous defects. Despite high rates of radiographic nonunion, this approach can provide patients with a stable and functional limb while avoiding amputation.
Topics: Allografts; Ankle; Ankle Joint; Arthrodesis; Bone Nails; Child; Child, Preschool; Femur Head; Humans; Retrospective Studies; Treatment Outcome
PubMed: 35585002
DOI: 10.1053/j.jfas.2022.01.003