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European Journal of Orthopaedic Surgery... Jan 2024A locking plate (LP) or non-locking plate (NLP) can be used for distal fibula fracture fixation. However, the advantages of LP over NLP in patients with distal fibula... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
A locking plate (LP) or non-locking plate (NLP) can be used for distal fibula fracture fixation. However, the advantages of LP over NLP in patients with distal fibula fractures are not clear. In terms of indications, the role of the two plates probably differs; however, to draw comparative conclusions, we conceptualized this systematic review and meta-analysis of studies that directly compared the two plates, wherein both groups' indications and baseline parameters were similar.
METHODS
An electronic literature search was performed using PubMed/Medline, Embase, Scopus, and Cochrane Library databases for studies comparing the LP versus NLP fixation for the lateral malleolus fracture. A total of 18 studies were included in qualitative and quantitative analysis. A subgroup analysis was performed for patients aged < 55 years and patients aged > 55 years. The statistical analysis was performed by Review Manager Software version 5.4.1.
RESULTS
A meta-analysis of 4243 fractures was performed across 18 studies. The rate of fracture union and overall complication rates did not differ between the two fixation groups with an OR of 0.71 (95% CI 0.26, 1.96, p = 0.51 and 1.11 (95% CI 0.84, 1.47, p = 0.47, respectively. There is no difference in the reoperation rate due to minor or major complications between the two groups. There was no difference in functional outcome (MD -0.85, with 95% CI -5.63, 3.93, p = 0.73), but NLP has a shorter surgical duration (MD 3.0, with 95% CI 0.26, 5.75, p = 0.03). A leave-one-out sensitivity analysis performed for overall complications affected the final outcome of the meta-analysis.
CONCLUSION
This meta-analysis demonstrates no clear benefit in selecting LP over NLP for the fixation of lateral malleolus fractures.
Topics: Humans; Ankle Fractures; Fracture Fixation, Internal; Fibula Fractures; Reoperation; Bone Plates; Fibula; Treatment Outcome
PubMed: 37656278
DOI: 10.1007/s00590-023-03694-9 -
Journal of Orthopaedic Trauma Nov 2023To determine the diagnostic accuracy of various stress tests for deltoid ligament and syndesmosis injury in patients with ankle fracture. (Meta-Analysis)
Meta-Analysis
OBJECTIVES
To determine the diagnostic accuracy of various stress tests for deltoid ligament and syndesmosis injury in patients with ankle fracture.
DATA SOURCES
A systemic literature search was conducted in the MEDLINE, Embase, and Cochrane Library databases to identify studies published from January 1990 to August 2022.
STUDY SELECTION
Studies that evaluated external rotation or gravity stress tests or hook or tap tests for the diagnosis of deltoid ligament or syndesmosis injury were included.
DATA EXTRACTION
Authors, publication years, study design, index tests, reference standards, demographic features of participants, reliability, and the numbers of true-positive, true-negative, false-positive, and false-negative subjects were extracted from 14 included studies. Article quality was assessed through the revised Quality Assessment of Diagnostic Accuracy Studies tool.
DATA SYNTHESIS
The pooled sensitivity and specificity of each index test for each structure were calculated with a random-effects model using the extracted data of true-positive, true-negative, false-positive, and false-negative outcomes in all relevant studies. The overall diagnostic performance of the different index tests for different structures was determined with the estimation of the area under the curve using the summary receiver operating characteristics curve.
CONCLUSIONS
The gravity stress test and the tap test exhibited high sensitivity and specificity in diagnosing deltoid ligament injury. The hook test has relatively high accuracy in diagnosing syndesmosis injury. Further studies with large sample sizes are warranted to confirm the results of this review.
LEVEL OF EVIDENCE
Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Topics: Humans; Ankle Fractures; Exercise Test; Reproducibility of Results; Ankle Injuries; Ligaments; Sensitivity and Specificity
PubMed: 37448133
DOI: 10.1097/BOT.0000000000002651 -
Journal of Orthopaedics Aug 2024Syndesmotic injuries are frequently stabilized using syndesmotic screws. Traditionally, these screws were routinely removed during the postoperative period, however... (Review)
Review
BACKGROUND
Syndesmotic injuries are frequently stabilized using syndesmotic screws. Traditionally, these screws were routinely removed during the postoperative period, however recent literature has brought into question the necessity of routine removal, citing no change in functional outcomes and the inherent risks of a second surgery. Our study aimed to compare outcomes of patients undergoing routine syndesmotic screw removal versus those undergoing an on-demand approach to removal.
METHODS
A systematic search of studies comparing routine syndesmotic screw removal to on-demand screw removal following an acute ankle fracture, or an isolated syndesmotic injury was conducted across seven databases. Only Prospective randomized controlled trials were eligible for inclusion. Data reported on by at least 2 studies was pooled for analysis.
RESULTS
Three studies were identified that met inclusion and exclusion criteria. No significant difference in Olerud-Molander Ankle Score (MD -2.36, 95% CI -6.50 to 1.78, p = 0.26), American Orthopedic Foot and Ankle Hindfoot Score (MD -0.45, 95% CI -1.59 to .69, p = 0.44), or dorsiflexion (MD 2.20, 95% CI -0.50 to 4.89, p = 0.11) was found between the routine removal group and on-demand removal group at 1-year postoperatively. Routine removal was associated with a significantly higher rate of complications than on-demand removal (RR 3.02, 95% CI 1.64 to 5.54, p = 0.0004). None of the included studies found significant differences in pain scores or range of motion by 1-year postoperatively.
CONCLUSION
Given the increased risk of complications with routine syndesmotic screw removal and the comparable outcomes when screws are retained, an as-needed approach to syndesmotic screw removal should be considered.
PubMed: 38567192
DOI: 10.1016/j.jor.2024.03.012 -
Archives of Orthopaedic and Trauma... Jan 2024The role of concomitant fibula fracture fixation in distal-third tibia fractures regarding alignment, union, and functional outcome is still a topic of debate. In this... (Review)
Review
OBJECTIVE
The role of concomitant fibula fracture fixation in distal-third tibia fractures regarding alignment, union, and functional outcome is still a topic of debate. In this review, we summarize the available comparative literature regarding fibula fixation in distal third lower leg fractures.
MATERIALS AND METHODS
A systematic literature review of articles published between January 2000 and January 2022 in the PubMed, Cochrane, and EMBASE databases about this topic was performed.
RESULTS
746 unique studies were identified of which four randomized-controlled trials and six retrospective studies were included. Nine studies compared alignment after tibia fixation with or without fibula fixation, six studies reported on tibial union, and three studies reported on functional outcome between groups. Pooling of data was not possible due to varying outcome measures and inclusion criteria. Fibula fixation was associated with less rotational malalignment, while there does not seem to be consensus regarding the effect on sagittal and coronal alignment. Six studies reported on the effect of fibula fixation on tibial union. None of these studies found a significant difference between treatment modalities. Furthermore, one out of three studies reporting functional outcome described a marginal beneficial functional outcome after fibula fixation. Ultimately, no differences in complication rates between treatment modalities were described.
CONCLUSION
Fixation of the fibula in distal-third lower leg fractures does not seem to have a significant effect on coronal and sagittal tibial alignment. Furthermore, fibula fixation is associated with significantly less rotational malalignment, although the clinical importance of this finding is questionable as true differences in rotational alignment between treatment modalities are small. Finally, fibula fixation does not affect union, functional outcome, or complication rate as adjuvant to tibia fixation.
LEVEL OF EVIDENCE
II.
Topics: Humans; Tibia; Fibula; Fracture Fixation, Internal; Retrospective Studies; Fibula Fractures; Tibial Fractures; Ankle Fractures; Fracture Fixation, Intramedullary; Treatment Outcome
PubMed: 37831196
DOI: 10.1007/s00402-023-05092-6 -
Foot & Ankle Specialist Jun 2024The literature largely addresses questions of diagnostic accuracy and therapeutic accuracy. However, the magnitude of the clinical impact of syndesmosis injury is...
INTRODUCTION
The literature largely addresses questions of diagnostic accuracy and therapeutic accuracy. However, the magnitude of the clinical impact of syndesmosis injury is commonly described in intuitive yet qualitative terms. This systematic review aimed to quantify the impact of syndesmosis injury.
METHODS
Published clinical outcomes data were used to compute an effect size reflecting the impact of syndesmosis injury. This was done within the clinical contexts of isolated syndesmosis injury and syndesmosis injury with concomitant ankle fracture. Clinical outcomes data included Olerud-Molander (OM) and American Orthopaedic Foot and Ankle Society (AOFAS) scores, visual analog scale for pain, and days missed from sport competition. Parametric data were compared with Student t tests. Effect size was computed using Cohen's d.
RESULTS
In ankle fracture patients, syndesmosis injury demonstrated a large effect size for OM (d = 0.96) and AOFAS (d = 0.83) scores. In athletic populations without concomitant ankle fracture, syndesmosis injury demonstrated a large effect size on days missed from competition (d = 2.32).
DISCUSSION
These findings confirm the magnitude of the negative impact of syndesmosis injury in athletic populations with isolated injury and in ankle fracture patients. In ankle fracture patients, this large negative effect remains despite surgery. Thus, syndesmosis repair may not fully mitigate the impact of the injury.
LEVELS OF EVIDENCE
Level III: Systematic review.
Topics: Female; Humans; Male; Ankle Fractures; Ankle Injuries; Athletic Injuries
PubMed: 35048741
DOI: 10.1177/19386400211067865 -
PloS One 2024Weber Type B fractures often arise from external rotation with the foot supinated or pronated. Altered tibiofibular joint kinematics in Weber B fractures are responsible...
Weber Type B fractures often arise from external rotation with the foot supinated or pronated. Altered tibiofibular joint kinematics in Weber B fractures are responsible for syndesmotic damage seen in Weber B fractures. Weber B fractures are managed using open reduction and internal fixation if displaced. The syndesmosis is injured in up to 40% of cases resulting in an unstable injury with a syndesmotic diastasis. This systematic review aimed to evaluate the current literature on syndesmotic fixation in Weber B fractures, assess the outcomes and complications of syndesmotic fixation and assess the necessity of syndesmotic fixation in Weber B fractures. A search was carried out on the EMBASE, PubMed and CINAHL databases and eight studies assessing the outcomes of syndesmotic fixations versus no syndesmotic fixation with 292 Weber B ankle fractures were included in this systematic review. Results showed significant heterogeneity so a narrative review was conducted. Results of these studies showed that functional, radiological, and quality-of-life outcomes and incidences of post-traumatic osteoarthritis in patients with syndesmotic screws were similar to those of patients not managed with syndesmotic screws. Only one favoured syndesmotic fixation in all cases of diastasis. As such, syndesmotic fixation with screws may not be necessary in the management of Weber B fractures. Screws are also associated with breakage, loosening, local irritation and infections. Suture button devices and antiglide fixation techniques appear to be valid alternatives to syndesmotic screws. It was found that there was no need for routine hardware removal unless the hardware was causing significant side effects for the patient.
Topics: Humans; Ankle Fractures; Fracture Fixation, Internal; Ankle Injuries; Ankle Joint; Bone Screws; Treatment Outcome
PubMed: 38857233
DOI: 10.1371/journal.pone.0304148 -
Foot and Ankle Surgery : Official... May 2024There are two main surgical fixation methods for the posterior malleolar fractures (PMFs), the anterior-to-posterior (AP) screws or via the posterolateral (PL) approach...
Comparison between anterior-to-posterior screw fixation versus posterolateral approach plate fixation for posterior malleous fracture: A systematic review and meta-analysis.
PURPOSE
There are two main surgical fixation methods for the posterior malleolar fractures (PMFs), the anterior-to-posterior (AP) screws or via the posterolateral (PL) approach utilizing a buttress plate. This review aims to compare the clinical outcome between the AP screw fixation and the PL plate fixation for treating PMFs.
METHODS
We searched all relevant publications about PMFs treated with AP screws or PL plates through electronic databases including the PubMed, the Cochrane Library, the Embase, the Wiley online library and the Web of Science. The meta-analysis was conducted to evaluated clinical outcomes including reduction quality, post-operative function and complications.
RESULTS
Six studies (one single randomized controlled trial and five retrospective cohort studies) were enrolled. 172 patients underwent AP screw fixation and 214 patients underwent PL plate fixation with a total of 386 patients (169 males and 217 females). The PL plating group yielded better AOFAS scores(MD = 6.97, 95 % CI=[4.68, 9.27], P<0.00001, I =0 %) and was more likely to achieve excellent anatomical reduction(OR=5.49, 95 % CI=[1.06, 28.42], P = 0.04, I =80 %). No differences were found in the bad reduction quality, incidences of complications (arthritis, neuralgia, superficial wound healing problems and implant failure), the walking VAS scores and the dorsiflexion restriction degrees.
CONCLUSION
We suggest that the PL plate fixation method has the clinical benefit of achieving anatomical reduction and better AOFAS scores over the AP screw fixation for treating PMFs. No differences were found in the incidences of complications ( arthritis, neuralgia, superficial wound healing problems and implant failure), the walking VAS scores and the dorsiflexion restriction degrees. The posterior approach and the direct reduction are recommended for the treatment of the PMFs.
LEVEL OF CONFIDENCE
Ⅱb.
PubMed: 38824055
DOI: 10.1016/j.fas.2024.05.004 -
European Journal of Orthopaedic Surgery... Feb 2024Existing research has established a correlation between post-traumatic mental health conditions, including anxiety and depression, and various aspects of recovery,... (Review)
Review
INTRODUCTION
Existing research has established a correlation between post-traumatic mental health conditions, including anxiety and depression, and various aspects of recovery, such as pain exacerbations, reduced functional recovery, and lowered patient satisfaction. However, the influence of pre-existing mental health conditions on orthopaedic trauma outcomes has not been thoroughly investigated. The objective of this study was to systematically review literature addressing the association between pre-existing mental health conditions and patient outcomes following surgical interventions for lower extremity fractures in non-geriatric populations.
METHODS
A systematic literature review was conducted using Medline, Embase, and Scopus databases following PRISMA-ScR guidelines to select studies that examined lower extremity orthopaedic trauma outcomes in relation to pre-existing mental health conditions. Studies that evaluated patients with surgically treated lower extremity fractures and a history of mental health conditions such as anxiety, depression, or mood disorders were included. Studies with a mean patient age above 65 years of age were excluded to focus on non-geriatric injury patterns.
RESULTS
The systematic review identified 12 studies investigating the relationship between surgical outcomes of orthopaedic lower extremity fractures and pre-existing mental health disorders in non-geriatric populations. Studies included patients with pelvis, femur, tibia, and ankle fractures. A majority (83%) of these studies demonstrated that patients with pre-existing mental health diagnoses had inferior functional outcomes, heightened pain levels, or an increase in postoperative complications.
DISCUSSION
The presence of pre-existing mental health conditions, particularly anxiety and depression, may predispose orthopaedic trauma patients to an elevated risk of suboptimal functional outcomes, increased pain, or complications after surgical intervention for lower extremity fractures. Future research should focus on interventions that mitigate the impact of mental health conditions on orthopaedic outcomes and patient wellness in this population.
Topics: Humans; Aged; Orthopedics; Mental Health; Leg Injuries; Ankle Fractures; Lower Extremity; Pain
PubMed: 37955721
DOI: 10.1007/s00590-023-03768-8 -
Bone & Joint Open Mar 2024Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior...
AIMS
Posterior malleolar (PM) fractures are commonly associated with ankle fractures, pilon fractures, and to a lesser extent tibial shaft fractures. The tibialis posterior (TP) tendon entrapment is a rare complication associated with PM fractures. If undiagnosed, TP entrapment is associated with complications, ranging from reduced range of ankle movement to instability and pes planus deformities, which require further surgeries including radical treatments such as arthrodesis.
METHODS
The inclusion criteria applied in PubMed, Scopus, and Medline database searches were: all adult studies published between 2012 and 2022; and studies written in English. Outcome of TP entrapment in patients with ankle injuries was assessed by two reviewers independently.
RESULTS
Four retrospective studies and eight case reports were accepted in this systematic review. Collectively there were 489 Pilon fractures, 77 of which presented with TP entrapment (15.75%). There were 28 trimalleolar fractures, 12 of which presented with TP entrapment (42.86%). All the case report studies reported inability to reduce the fractures at initial presentation. The diagnosis of TP entrapment was made in the early period in two (25%) cases, and delayed diagnosis in six (75%) cases reported. Using modified Clavien-Dindo complication classification, 60 (67%) of the injuries reported grade IIIa complications and 29 (33%) grade IIIb complications.
CONCLUSION
TP tendon was the commonest tendon injury associated with pilon fracture and, to a lesser extent, trimalleolar ankle fracture. Early identification using a clinical suspicion and CT imaging could lead to early management of TP entrapment in these injuries, which could lead to better patient outcomes and reduced morbidity.
PubMed: 38545805
DOI: 10.1302/2633-1462.53.BJO-2023-0139 -
The Journal of Foot and Ankle Surgery :... 2024Open reduction and internal fixation are the standard of care to stabilize tibial plafond fractures. However, it remains uncertain as to whether fixation of the fibula... (Meta-Analysis)
Meta-Analysis Review
Should We Fix the Fibula in Tibial Plafond Fractures? A Meta-analysis Reviewing the Evidence Base for Fibula Open Reduction and Internal Fixation in Tibial Plafond Fractures.
Open reduction and internal fixation are the standard of care to stabilize tibial plafond fractures. However, it remains uncertain as to whether fixation of the fibula affects the outcome. This study aimed to review the evidence base for comparable outcomes in tibial plafond fractures when undergoing open reduction and internal fixation of ipsilateral fibula fractures compared with open reduction and internal fixation of the tibia alone. A systematic review and meta-analysis of the literature was completed; 4 studies were included for analysis. This study demonstrated no statistically significant differences in the incidence of nonunion (p = .784) or mal-union (p = .416). There was a greater rate of removal of metalwork in the fibula operative group compared to the tibia alone group (p < .001). The current evidence demonstrates that open reduction and internal fixation of ipsilateral fibula fractures in tibial plafond fractures is not necessarily routinely indicated for all fractures.
Topics: Humans; Fracture Fixation, Internal; Fibula; Tibial Fractures; Open Fracture Reduction; Treatment Outcome
PubMed: 38151112
DOI: 10.1053/j.jfas.2023.12.007