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The Cochrane Database of Systematic... Sep 2014Intramedullary nails may be used for the surgical fixation of extracapsular hip fractures in adults. This is an update of a Cochrane review first published in 2005 and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Intramedullary nails may be used for the surgical fixation of extracapsular hip fractures in adults. This is an update of a Cochrane review first published in 2005 and last updated in 2008.
OBJECTIVES
To assess the effects (benefits and harms) of different designs of intramedullary nails for treating extracapsular hip fractures in adults.
SEARCH METHODS
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (6 January 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 12, 2013), MEDLINE (1966 to November Week 3, 2013), MEDLINE In-Process & Other Non-Indexed Citations (3 January 2014), EMBASE (1988 to 2014, Week 1) and the World Health Organization (WHO) International Clinical Trials Registry Platform (accessed January 2014).
SELECTION CRITERIA
All randomised or quasi-randomised trials comparing different types, or design modifications, of intramedullary nails in the treatment of extracapsular hip fractures in adults.
DATA COLLECTION AND ANALYSIS
At least two review authors independently selected studies, assessed risk of bias and extracted data. We performed limited meta-analysis using the fixed-effect model.
MAIN RESULTS
We included eight new trials, testing seven new comparisons in this update. Overall, we included 17 trials, testing 12 comparisons of different cephalocondylic nail designs. The trials involved a total of 2130 adults (predominantly female and older people) with mainly unstable trochanteric fractures.All trials were at unclear risk of bias for most domains, with the majority at high risk of detection bias for subjective outcomes. The three quasi-randomised trials were at high risk for selection bias.Four trials (910 participants) compared the proximal femoral nail (PFN) with the Gamma nail. There was no significant difference between the two implants in functional outcome (the very low quality evidence being limited to results from single trials), mortality (low quality evidence: 86/415 versus 80/415; risk ratio (RR) 1.08, 95% confidence interval (CI) 0.82 to 1.41), serious fixation complications (operative fracture of the femur, cut-out, non-union and later fracture of the femur) nor re-operations (low quality evidence: 45/455 versus 36/455; RR 1.25, 95% CI 0.83 to 1.90).Two trials (185 participants) provided very low quality evidence of a lack of clinically significant difference in outcome (functional score, mortality, fracture fixation complications and re-operation) between the ACE trochanteric nail and the Gamma nail.Two trials (200 participants) provided very low quality evidence of a lack of significant difference in outcome (mobility score, pain, fracture fixation complications or re-operations) between the proximal femoral nail antirotation (PFNA) nail and the Gamma 3 nail.Seven of the nine trials evaluating different comparisons provided very low quality evidence of a lack of significant between-group differences in all of the reported main outcomes for the following comparisons: ACE trochanteric nail versus Gamma 3 nail (112 participants); gliding nail versus Gamma nail (80 participants); Russell-Taylor Recon nail versus long Gamma nail (34 participants, all under 50 years); proximal femoral nail antirotation (PFNA) nail versus Targon PF nail (80 participants); dynamically versus statically locked intramedullary hip screw (IMHS) nail (81 participants); sliding versus non-sliding Gamma 3 nail (80 participants, all under 60 years); and long versus standard PFNA nails (40 participants with reverse oblique fractures).The other two single comparison trials also provided very low quality evidence of a lack of significant between-group differences in all of the main outcomes with single exceptions. The trial (215 participants) comparing the ENDOVIS nail versus the IMHS nail found low quality evidence of poorer mobility in the ENDOVIS nail group, where more participants in this group were bedridden after their operation (29/105 versus 18/110; RR 1.69, 95% CI 1.00 to 2.85; P = 0.05). The trial (113 participants) comparing the InterTan nail versus the PFNA II nail found very low quality evidence that more PFNA II group participants experienced thigh pain (3/47 versus 12/46; RR: 0.24, 95% CI 0.07 to 0.81).
AUTHORS' CONCLUSIONS
The limited evidence from the randomised trials undertaken to date is insufficient to determine whether there are important differences in outcome between different designs of intramedullary nails used in treating extracapsular hip fractures. Given the evidence of superiority of the sliding hip screw compared with intramedullary nails for extracapsular hip fractures, further studies comparing different designs of intramedullary nails are not a priority. Any new design should be evaluated in a randomised comparison with the sliding hip screw.
Topics: Aged; Aged, 80 and over; Bone Nails; Female; Fracture Fixation, Intramedullary; Hip Fractures; Humans; Male; Middle Aged; Outcome Assessment, Health Care; Prosthesis Design; Randomized Controlled Trials as Topic
PubMed: 25212485
DOI: 10.1002/14651858.CD004961.pub4 -
Life (Basel, Switzerland) Jul 2023Nonunion (NU) is one of the most feared complications of femoral shaft fracture treatment. Femoral shaft fracture treatment is often linked with poor bone stock and... (Review)
Review
Nonunion (NU) is one of the most feared complications of femoral shaft fracture treatment. Femoral shaft fracture treatment is often linked with poor bone stock and reduced bone metabolism. In this paper, the goal is to carefully analyze the best treatment options for patients who developed nonunion after the intramedullary nailing of a femoral shaft fracture. A systematic review of the literature available in the PubMed, EMBASE and Cochran library databases was carried out, and 16 studies were included. Exclusion criteria included case reports and case series that do not have data about clinical outcomes or functional outcomes and included fewer than 10 patients. The reviewed data provide evidence for very good results about the treatment of this pathology with exchanging intramedullary nails or the implantation of a plate and screws (general healing rate of 96.3%). Moreover, the data support the utilization of autologous bone graft in order to stimulate the healing process. In conclusion, the choice between these two types of treatment must be guided by the type of pseudarthrosis that the patient presents. Additionally, bone grafting or growth factors promote bone regenerative processes, especially in patients with oligo-atrophic pseudoarthrosis.
PubMed: 37511883
DOI: 10.3390/life13071508 -
Journal of Orthopaedic Trauma Feb 2021To evaluate the quality of research and reporting of randomized controlled trials comparing the use of reamed and unreamed intramedullary nails for tibial fractures with...
OBJECTIVES
To evaluate the quality of research and reporting of randomized controlled trials comparing the use of reamed and unreamed intramedullary nails for tibial fractures with validated scoring systems.
DATA SOURCE
PubMed using the search terms "tibia" AND "reamed OR unreamed" AND "intramedullary OR nail." Filters were applied for the years 1991-2019, full articles, human subjects, and English language.
STUDY SELECTION
Inclusion criteria were (1) prospective and randomized trials, (2) studies reported >80% follow-up, and (3) articles amenable to scoring with the chosen scoring systems. Exclusion criteria were (1) skeletally immature patients or (2) incomplete data sets.
DATA EXTRACTION
Articles were assessed with the Coleman Methodology Score, the Consolidated Standards of Reporting Trials systems, and Cowan's Categorical Rating by 2 independent observers.
DATA SYNTHESIS
Scores for individual articles were averaged for the 2 observers. The total and subcategory scores for all included articles were also averaged with SD from both observers. Categories from the 2 grading systems with deficient reporting were measured as a percentage based on grading from both observers. Data were analyzed using kappa statistic and correlation coefficient to assess agreement and reliability.
CONCLUSIONS
All included articles supported the use of reamed tibial intramedullary nails, but the overall quality of the literature fell in the middle of both the modified Coleman Score and Consolidated Standards of Reporting Trials grading scheme ranges despite being Oxford Level 1.
LEVEL OF EVIDENCE
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Topics: Bone Nails; Fracture Fixation, Intramedullary; Humans; Prospective Studies; Randomized Controlled Trials as Topic; Reproducibility of Results; Tibial Fractures
PubMed: 33079845
DOI: 10.1097/BOT.0000000000001910 -
Injury Nov 2016Supracondylar humeral fractures (SCHF) are among the most common injuries in children. The aim of this systematic review was to investigate functional and radiographic... (Comparative Study)
Comparative Study Meta-Analysis Review
PURPOSE
Supracondylar humeral fractures (SCHF) are among the most common injuries in children. The aim of this systematic review was to investigate functional and radiographic outcome after crossed and lateral K-wire fixation for displaced extension-type SCHF, and complications related to the type of K-wire construction used.
METHODS
RCTs and prospective comparative cohorts on the functional outcome and complications after fracture reduction and K-wire fixation were identified in MEDLINE, Embase, Web of Science and the Cochrane Library.
RESULTS
Thirteen studies were identified, including 1158 patients in seven RCTs and six prospective comparative cohorts. According to the Flynn criteria, there was no difference in outcome between the K-wire configurations (Relative Risk 1.07). Loss of reduction occurred in 27 (11.6%) of 232 patients treated with crossed K-wires, and in 35 (12.4%) of 282 patients treated with lateral entry K-wires. Twenty (4.1%) of 493 patients in the crossed group were diagnosed with iatrogenic ulnar nerve injury, compared with 2 (0.3%) of 666 patients in the lateral entry group. The overall incidence of persistent ulnar nerve related complaints was 3.5/1000.
CONCLUSIONS
Crossed and lateral entry pin fixation of SCHF result in similar construct stability and functional outcome. Although ulnar nerve injury was three times more likely in the crossed K-wire group, the overall incidence of this complication was very low. The available evidence does not support the use of either approach for daily practice. If the surgeon wishes to avoid all potential risk of iatrogenic ulnar nerve injury, the lateral K-wire approach is safest.
Topics: Bone Nails; Bone Wires; Child; Fracture Fixation, Internal; Humans; Humeral Fractures; Prospective Studies; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 27596688
DOI: 10.1016/j.injury.2016.08.022 -
Journal of Orthopaedics 2020Forearm fractures are common injuries among children and adolescents. Traditionally, they were managed conservatively with closed reduction and cast immobilization. The... (Review)
Review
BACKGROUND
Forearm fractures are common injuries among children and adolescents. Traditionally, they were managed conservatively with closed reduction and cast immobilization. The last decade there is an increasing trend towards operative treatment. The treatment modalities available include plate and screws, flexible intramedullary nailing and external fixation devices - rarely used nowadays. The aim of this systematic review is to investigate the indications of flexible intramedullary nailing in the childhood population, to compare its results with plating and to provide detailed information considering technical pitfalls and complications that may be encountered.
MATERIALS AND METHODS
An extensive search was performed in the electronic databases (PubMed, EMBASE) from their inception up to June 2019 in order articles relevant to this review to be retrieved. The search terms used were the following: forearm fracture, both-bone fracture, pediatric, nailing, fixation. 56 articles were considered suitable for inclusion.
RESULTS
The indications for surgery are unstable and irreducible fractures, open and fractures with neurovascular compromise. As far as the fracture site is concerned, radius and ulna shaft fractures, radial head and Monteggia fractures are suitable for nailing.Although plates and nailing have comparable clinical outcomes and complication rates, flexible intramedullary nailing has the advantage of smaller incisions, less tissue disruption, shorter operative and hospital times and an ease in hardware removal.Controversy exists over the need of single or double nailing in both-bone fractures of the forearm. In addition, there is no consensus as to which is the preferred nail diameter. Yet, all the authors agree that open reduction must be considered after certain failed closed reductions in order compartment syndrome to be avoided.Flexible intramedullary nailing is not complication-free. Skin irritation, Extensor Pollicis Longus rupture, superficial radial nerve injury, delayed union or even nonunion, malunion and refractures are some of the complications that may be encountered.
DISCUSSION
Flexible nails are excellent implants combining stability and elasticity. The procedure of passing the nails across radius and ulna is relatively simple, requiring a small learning curve. Flexible intramedullary nailing is an excellent treatment modality for the treatment of forearm fractures in children and adolescents.
PubMed: 32025135
DOI: 10.1016/j.jor.2020.01.002 -
BMC Musculoskeletal Disorders Jun 2020An alternative to the current gold standard in operative treatment of displaced midshaft clavicle fractures (DMCF) using plate osteosynthesis, is internal fixation by... (Meta-Analysis)
Meta-Analysis
BACKGROUND
An alternative to the current gold standard in operative treatment of displaced midshaft clavicle fractures (DMCF) using plate osteosynthesis, is internal fixation by means of intramedullary fixation devices. These devices differ considerably in their specifications and characteristics and an evaluation of their clinical results is warranted. The aim of this systematic review is to generate an overview of functional outcomes and complications in the management of DMCF per available intramedullary device.
METHODS
A systematic review was conducted to identify all papers reporting functional outcomes, union rates and/or complications using an intramedullary fixation device for the management of midshaft clavicle fractures. Multiple databases and trial registries were searched from inception until February 2020. Meta-analysis was conducted based on functional outcomes and type of complication per type of intramedullary fixation device. Pooled estimates of functional outcomes scores and incidence of complications were calculated using a random effects model. Risk of bias and quality was assessed using the Cochrane risk of bias and ROBINS-I tools. The confidence in estimates were rated and described according to the recommendations of the GRADE working group.
RESULTS
Sixty-seven studies were included in this systematic review. The majority of studies report on the use of Titanium Elastic Nails (TEN). At 12 months follow up the Titanium Elastic Nail and Sonoma CRx report an average Constant-Murley score of 94.4 (95%CI 93-95) and 94.0 (95%CI 92-95) respectively (GRADE High). The most common reported complications after intramedullary fixation are implant-related and implant-specific. For the TEN, hardware irritation and protrusion, telescoping or migration, with a reported pooled incidence 20% (95%CI 14-26) and 12% (95%CI 8-18), are most common (GRADE Moderate). For the Rockwood/Hagie Pin, hardware irritation is identified as the most common complication with 22% (95%CI 13-35) (GRADE Low). The most common complication for the Sonoma CRx was cosmetic dissatisfaction in 6% (95%CI 2-17) of cases (GRADE Very low).
CONCLUSION
Although most studies were of low quality, good functional results and union rates irrespective of the type of device are found. However, there are clear device-related and device-specific complications for each. The results of this systematic review and meta-analysis can help guide surgeons in choosing the appropriate operative strategy, implant and informing their patient.
LEVEL OF EVIDENCE
IV.
Topics: Bone Plates; Clavicle; Fracture Fixation, Internal; Fracture Fixation, Intramedullary; Fractures, Bone; Humans; Postoperative Complications; Randomized Controlled Trials as Topic; Recurrence; Reoperation
PubMed: 32571362
DOI: 10.1186/s12891-020-03256-8 -
Journal of Orthopaedics and... Dec 2016Both long and short cephalomedullary nails (CMN) may be used to treat trochanteric femur fractures. The objective of this paper was to compare the clinical outcomes... (Review)
Review
BACKGROUND
Both long and short cephalomedullary nails (CMN) may be used to treat trochanteric femur fractures. The objective of this paper was to compare the clinical outcomes between long and short CMN in the treatment of trochanteric hip fractures.
MATERIALS AND METHODS
A literature search was performed, identifying 135 papers; 4 of which met inclusion and exclusion criteria. Papers included were those that compared cohorts of long and short nails for stable trochanteric femur fractures of level III evidence or superior. Data was pooled and analyzed, focusing on reoperation rate, secondary femoral shaft fracture rate, estimated blood loss, transfusion rate, operative time and length of stay.
RESULTS
Included in the analysis were 1276 patients, with 438 short and 838 long CMN. The average age was 82.0 years for short CMN and 79.0 years for long CMN (P = 0.0002). The average follow up was 18 months, 46 % were male, and 71 % had an ASA (American Society of Anesthesiologists score) classification ≥3. The rate of reoperation was 5.0 % and 3.8 % for short and long CMN, respectively (P = 0.31). The rate of refracture was 1.6 % and 0.95 % for short and long CMN, respectively (P = 0.41). As compared to long nails, short nails had an average blood loss of 39 mL less (P = 0.0003), an 8.8 % decrease in transfusion rate (P = 0.07), and incurred 19 min less operative time (P < 0.0001). No significant differences between short and long nails were observed for either other complications, hardware complications, non-union, or mortality.
CONCLUSIONS
For trochanteric femur fractures, short CMN have a low reoperation rate while significantly decreasing operative time and estimated blood loss with the additional benefit of being cost effective.
LEVEL OF EVIDENCE
Level 3.
Topics: Bone Nails; Femoral Fractures; Fracture Fixation, Intramedullary; Hip Fractures; Humans
PubMed: 27093971
DOI: 10.1007/s10195-016-0405-z -
Journal of Orthopaedic Trauma Sep 2014To undertake a systematic review to determine whether there are advantages in using plate or nail fixation for distal meta-diaphyseal tibial fractures with or without... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
To undertake a systematic review to determine whether there are advantages in using plate or nail fixation for distal meta-diaphyseal tibial fractures with or without articular involvement.
DATA SOURCES
Searches using MEDLINE, EMBASE, and Cochrane library.
STUDY SELECTION
Studies of parallel group design comparing plate or nail fixation for distal tibial fractures.
DATA EXTRACTION
Information on study methods and outcomes.
DATA SYNTHESIS
We conducted random effects meta-analysis to evaluate risk of nonunion or delayed union, wound complications and superficial infection, deep infection, and fracture malalignment.
RESULTS
We found 8 studies (n = 455, 4 prospective randomized and 4 retrospective cohort) that evaluated plate compared with nail for distal tibial fractures. No significant difference was found between the use of a plate and nail regarding bone union complications [plate, 5.4%; nail, 8.3%; odds ratio (OR), 0.66; 95% confidence interval (CI), 0.28-1.54; I = 0%; P = 0.34], wound complications including superficial infection (plate, 7.9%; nail, 3.2%; OR, 1.83; 95% CI, 0.40-8.46; I = 48%; P = 0.44), and deep infection (plate, 3.5%; nail, 2.8%; OR, 1.32; 95% CI, 0.44-3.91; I = 0%; P = 0.62). We found a significantly reduced risk of fracture malalignment with the use of a plate compared with a nail (plate, 8.7%; nail, 24.9%; OR, 0.33; 95% CI, 0.17-0.64; I = 0%; P = 0.001).
CONCLUSIONS
Plate fixation compared with intramedullary nailing is associated with a reduced risk of fracture malalignment with no differences in bone union, wound complications, and superficial infection or deep infection. Current evidence might recommend plate over nail unless there are concerns with the soft tissues. Additional larger scale multicentre randomized controlled trials are required to clarify these issues.
Topics: Bone Malalignment; Bone Nails; Bone Plates; Fracture Fixation, Internal; Fracture Fixation, Intramedullary; Humans; Tibial Fractures
PubMed: 24464094
DOI: 10.1097/BOT.0000000000000068 -
International Journal of Spine Surgery Feb 2021The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to provide an easily administered patient-outcome questionnaire that was adaptable to...
BACKGROUND
The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to provide an easily administered patient-outcome questionnaire that was adaptable to a variety of medical and surgical subspecialties. Numerous authors have examined the effectiveness of PROMIS in various areas of spine surgery. Our goal was to systematically review PROMIS scores compared with legacy patient-reported outcomes measures (PROMs) in spinal surgery and spine pathology.
METHODS
A systematic search of the PubMed, EMBASE, and Cochrane databases using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines was performed, yielding 254 unique studies reporting on "PROMIS" in "spine." Each study was independently reviewed. A total of 16 studies were selected for inclusion.
RESULTS
The pooled sample size yielded a total of 4268 patients. In the cervical population, PROMIS physical function (PF; |r| = .47-.87, pain intensity (PIn; |r| = .61-.74), pain interference (PIf; |r| = .65-.88), and pain behavior (PB; |r| = .59-.74) correlated with the Neck Disability Index (NDI). PROMIS PF also strongly correlated with the modified Japanese Orthopaedic Association scale (mJOA; |r| = .61-.72). Among patients with lumbar pathology and adult spinal deformities, PROMIS PF (|r| = .53-.85), PIn (|r| = .73-.78), PIf (|r| = .59-.89), and PB (|r| = .58-.82) strongly correlated with the Oswestry Disability Index (ODI). PF (|r| = .51-.78), PIf (|r| = .60-.70), and anxiety (|r| = .73) also strongly correlated with the Scoliosis Research Society (SRS)-22 and SRS-30. When comparing measures of global health, PROMIS PF was strongly correlated with the Short Form (SF)-12 and SF-36 (|r| = .50-.85). On average, all PROMIS domains required less time to complete (49.6-56 seconds) than the ODI (176 seconds), NDI (190.3 seconds), SF-12 (214 seconds), and SF-36 physical function domains (99 seconds). The responsiveness of the PROMIS PF, PIf, and PB was comparable to that of legacy measures ODI, NDI, and SF-12.
CONCLUSIONS
The PROMIS PF, PIn, PIf, and PB demonstrated moderate to strong correlations with NDI, mJOA, ODI, SRS, and SF-12 measures in various populations of spine patients. All PROMIS domains had decreased time to completion and similar responsiveness compared with legacy measures.
LEVEL OF EVIDENCE
2.
CLINICAL RELEVANCE
These results highlight the potential of PROMIS as a valid and reliable tool to assess patient-reported outcomes in spinal surgery patients and support more widespread use of PROMIS in spine.
PubMed: 33900973
DOI: 10.14444/8024 -
Journal of Pediatric Orthopedics. Part B Sep 2015To compare the biomechanical stability of various pin configurations for pediatric supracondylar humeral fractures under varus, internal rotation, and extension... (Review)
Review
To compare the biomechanical stability of various pin configurations for pediatric supracondylar humeral fractures under varus, internal rotation, and extension conditions. After electronic retrieval, 11 biomechanical studies were included. Stiffness values of pin configurations under different loading conditions were extracted and pooled. There were no statistically significant differences between two cross pins and two divergent lateral pins on the basis of the 'Hamdi method' (P=0.249-0.737). An additional pin did not strengthen two-pin construct (P=0.124-0.367), but better stabilized fractures with medial comminution (P<0.01). Isolated lateral pins are preferable because of a better balance of a lower risk of nerve injury and comparable fixation strength. Limitations such as differences in experimental setup among recruited studies and small sample size may compromise the methodologic power of this study.
Topics: Biomechanical Phenomena; Bone Nails; Child; Fracture Fixation, Internal; Fractures, Comminuted; Humans; Humeral Fractures; Humerus
PubMed: 25932826
DOI: 10.1097/BPB.0000000000000196