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Annals of the Royal College of Surgeons... Dec 2023Proximal humerus fractures are common in the older population. A consensus on the optimal management of complex fractures requiring surgery has yet to be reached. A... (Review)
Review
INTRODUCTION
Proximal humerus fractures are common in the older population. A consensus on the optimal management of complex fractures requiring surgery has yet to be reached. A systematic review and meta-analysis was performed to compare clinical outcomes between reverse total shoulder arthroplasty (RTSA) and open reduction and internal fixation (ORIF).
METHODS
A systematic search of the literature was undertaken using the Medline, PubMed, Embase™ and Cochrane Central Register of Controlled Trials databases. Prospective and retrospective studies comparing clinical and patient reported results as primary outcome measures were included in this review, with secondary outcome measures including complications and revision surgery. A meta-analysis was conducted.
RESULTS
A total of 326 patients from 5 studies were eligible for inclusion in this review. Superior Constant-Murley scores (mean difference [MD]: 13.4, 95% confidence interval [CI]: 6.2-20.6; <0.001), Oxford shoulder scores (MD: 4.3, 95% CI: 1.2-7.4; =0.007), simple shoulder test scores (MD: 0.95, 95% CI: 0.01-1.89; =0.05) and DASH (Disabilities of the Arm, Shoulder and Hand) scores (MD: 5.1 [1 study], 95% CI: 2.1-8.1; =0.034) were noted in patients receiving RTSA. Range of motion and revision surgery rates were also superior in this group.
CONCLUSIONS
This study suggests that RTSA affords more favourable outcomes and lower revision rates than ORIF following proximal humerus fractures. Definitive conclusions are precluded, however, owing to small sample sizes and risk of bias in retrospective studies.
PubMed: 38038170
DOI: 10.1308/rcsann.2022.0120 -
Journal of Shoulder and Elbow Surgery Apr 2024Complex elbow dislocations in which the dorsal cortex of the ulna is fractured can be difficult to classify and therefore treat. These have variably been described as... (Review)
Review
BACKGROUND
Complex elbow dislocations in which the dorsal cortex of the ulna is fractured can be difficult to classify and therefore treat. These have variably been described as either Monteggia variant injuries or trans-olecranon fracture dislocations. Additionally, O'Driscoll et al classified coronoid fractures that exit the dorsal cortex of the ulna as "basal coronoid, subtype 2" fractures. The Mayo classification of trans-ulnar fracture dislocations categorizes these injuries in 3 types according to what the coronoid remains attached to: trans-olecranon fracture dislocations, Monteggia variant fracture dislocations, and trans-ulnar basal coronoid fracture dislocations. The purpose of this study was to evaluate the outcomes of these injury patterns as reported in the literature. Our hypothesis was that trans-ulnar basal coronoid fracture dislocations would have a worse prognosis.
MATERIALS AND METHODS
We conducted a systematic review to identify studies with trans-ulnar fracture dislocations that had documentation of associated coronoid injuries. A literature search identified 16 qualifying studies with 296 fractures. Elbows presenting with basal subtype 2 or Regan/Morrey III coronoid fractures and Jupiter IIA and IID injuries were classified as trans-ulnar basal coronoid fractures. Patients with trans-olecranon or Monteggia fractures were classified as such if the coronoid was not fractured or an associated coronoid fracture had been classified as O'Driscoll tip, anteromedial facet, basal subtype I, or Regan Morrey I/II.
RESULTS
The 296 fractures reviewed were classified as trans-olecranon in 44 elbows, Monteggia variant in 82 elbows, and trans-ulnar basal coronoid fracture dislocations in 170 elbows. Higher rates of complications and reoperations were reported for trans-ulnar basal coronoid injuries (40%, 25%) compared to trans-olecranon (11%, 18%) and Monteggia variant injuries (25%, 13%). The mean flexion-extension arc for basal coronoid fractures was 106° compared to 117° for Monteggia (P < .01) and 121° for trans-olecranon injuries (P = .02). The mean Mayo Elbow Performance Score was 84 points for trans-ulnar basal coronoid, 91 for Monteggia (P < .01), and 93 for trans-olecranon fracture dislocations (P < .05). Disabilities of the Arm, Shoulder and Hand and American Shoulder and Elbow Surgeons scores were 22 and 80 for trans-ulnar basal coronoid, respectively, compared to 23 and 89 for trans-olecranon fractures. American Shoulder and Elbow Surgeons was not available for any Monteggia injuries, but the mean Disabilities of the Arm, Shoulder and Hand was 13.
DISCUSSION
Trans-ulnar basal coronoid fracture dislocations are associated with inferior patient reported outcome measures, decreased range of motion, and increased complication rates compared to trans-olecranon or Monteggia variant fracture dislocations. Further research is needed to determine the most appropriate treatment for this difficult injury pattern.
Topics: Humans; Elbow; Olecranon Fracture; Treatment Outcome; Fracture Fixation, Internal; Ulna; Ulna Fractures; Elbow Joint; Joint Dislocations; Monteggia's Fracture; Range of Motion, Articular
PubMed: 38036255
DOI: 10.1016/j.jse.2023.10.014 -
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 -
Trauma Surgery & Acute Care Open 2023Clavicle fracture (CF) is the tenth most prevalent fracture, accounting for an annual incidence of 37/10,000. This systematic review highlights the factors contributing...
BACKGROUND
Clavicle fracture (CF) is the tenth most prevalent fracture, accounting for an annual incidence of 37/10,000. This systematic review highlights the factors contributing to the nonunion union of the clavicular fracture.
METHOD
A systematic search was conducted using three web-based databases up to August 12, 2022, for conducting qualitative analysis. Articles were screened for relevance, and only studies that met inclusion criteria based on PECOS; P (patients): participants diagnosed with clavicular fracture; E (exposure): nonunion, C (control): not applicable; O (outcomes): factors contributing to nonunion or delayed union; S (studies): trials and observational studies. The Newcastle-Ottawa Scale was used to assess the quality of the cohort studies. The Cochrane risk of bias tool was used to assess the bias in randomized control trials.
RESULTS
Ten studies were selected after the final literature search. Two thousand seven hundred and sixty-six adult participants who were radiologically and clinically diagnosed with nonunion clavicular fracture were included to pool the qualitative results. Fall was the most dominant cause of clavicular fracture, followed by road traffic collisions. Open reduction was widely used to treat nonunion correction. The qualitative results suggested a prominent correlation of nonunion with advancing age, female gender, high energy trauma, high Disabilities of the Arm, Shoulder, and Hand Score, smoking, fracture displacement, clavicular shortening, the callus on radiography, and fracture movement. The mid-shaft fracture was the most dominant type of fracture in the included studies; highly associated with nonunion in comparison to medial or lateral CF. The previous history of operation was an independent factor contributing to nonunion.
CONCLUSION
The results of this systematic review suggested the predictors contributing to nonunion in the CF. Demographic factors such as advancing age with female gender are at higher risk of developing clavicular nonunion. Smoking was the most dominantly highlighted environmental factor contributing to nonunion. Diaphyseal or midshaft fracture was the most common site for nonunion. Therefore, we suggested that patients with the predictors mentioned above require special attention to prevent nonunion of the CFs. More studies should be conducted on this subject to assess the factors that pose a risk associated with the nonunion of the bone for better clinical management and outcomes of the fracture.
PubMed: 38020862
DOI: 10.1136/tsaco-2023-001188 -
Journal of Shoulder and Elbow Surgery Mar 2024This systematic review and meta-analysis aimed to (1) estimate the prevalence of clavicular tunnel widening (TW) after coracoclavicular stabilization surgery and its... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
This systematic review and meta-analysis aimed to (1) estimate the prevalence of clavicular tunnel widening (TW) after coracoclavicular stabilization surgery and its risk factors and (2) assess whether TW is correlated with clavicle fracture or loss of reduction of the acromioclavicular joint (ACJ).
METHODS
In January 2023, 3 electronic databases were searched to collect data on postoperative clavicular TW, its prevalence, magnitude, and correlation with fracture and ACJ loss of reduction. Studies were classified according to the time of surgical intervention, and the clavicular tunnels were categorized by their anatomic location. Mean differences were calculated using a DerSimonian-Laird random-effects model, while binomial outcomes were pooled using the Freeman-Tukey double arcsine transformation. Univariate and multivariate meta-regression analyses were performed to determine the effect of several variables on the proportion of cases with TW.
RESULTS
Fifteen studies (418 shoulders) were included. At the final follow-up, evidence of clavicular TW was found in 70% (95% confidence interval [CI]: 70%-87%; I = 89%) of 221 shoulders. Surgeries in acute cases had a lower prevalence of TW (52%) compared to chronic cases (71%) (P < .001). Significant TW was found in the central tunnel (3.2 mm; 95% CI: 1.8-4.6 mm; P < .001; I = 72%) for acute injuries and in the medial (1.2 mm; 95% CI: 0.7-1.7 mm; P < .001; I = 77%) and lateral (1.5 mm; 95% CI: 0.7-2.3 mm; P < .001; I = 77%) tunnels for chronic cases. Single central-tunnel techniques were positively associated with the prevalence of TW (P = .046), while biotenodesis screw fixation was associated with a lower prevalence (P = .004) in chronic cases. Reconstruction of the ACJ ligament complex with tendon grafts or sutures was associated with a higher prevalence of TW (P < .001). Drill sizes between 2.5 and 5 mm were significantly associated with a lower prevalence of TW, regardless of injury chronicity (P = .012). No correlation was found between TW and the loss of ACJ reduction or clavicle fractures.
CONCLUSIONS
This systematic review and meta-analysis explored TW occurrence following coracoclavicular stabilization surgery. TW was observed in 70% of patients at final follow-up, with a higher prevalence in chronic than in acute cases. Modifiable surgical variables, such as single-tunnel tendon graft constructs for acute or chronic injuries and knotted graft procedures for chronic injuries, were significantly associated with TW. Furthermore, the prevalence of TW increased with concomitant surgical treatment of the ACJ ligament complex, and decreased with drill sizes between 2.5 and 5 mm, regardless of lesion chronicity. These surgical variables should be considered when establishing transosseous tunnels for coracoclavicular stabilization. Clavicle fractures and TW mechanisms require further investigation.
Topics: Humans; Clavicle; Ligaments, Articular; Shoulder; Acromioclavicular Joint; Joint Dislocations; Fractures, Bone
PubMed: 37977250
DOI: 10.1016/j.jse.2023.09.037 -
Shoulder & Elbow Nov 2023Reverse total shoulder arthroplasty (RTSA) is an increasingly popular salvage treatment option for proximal humeral fracture (PHF) sequelae. This meta-analysis aimed to...
BACKGROUND
Reverse total shoulder arthroplasty (RTSA) is an increasingly popular salvage treatment option for proximal humeral fracture (PHF) sequelae. This meta-analysis aimed to conduct a pooled analysis of functional outcomes of RTSA in PHF sequelae, with subgroup analysis comparing between intracapsular (Class 1) and extracapsular (Class 2) PHF sequelae.
METHODS
A multi-database search (PubMed, OVID, EMBASE) was performed according to PRISMA guidelines on 27th July 2020. Data from all published literature meeting inclusion criteria were extracted and analysed.
FINDINGS
Eleven studies were included, comprising 359 shoulders (167 Class 1 and 192 Class 2). The mean age was 68.2 years, and the mean time between injury and surgery was 49 months, (1-516 months). Constant score and forward flexion improved by 31.8 (95%CI: 30.5-33.1, p < 0.001) and 60o (95%CI: 58o-62o, p < 0.001) respectively between pre-operative and post-operative values for both groups. Constant scores were better in Class 1 patients (MD = 3.60, 95%CI: 1.0-6.2, p < 0.001) pre-operatively and post-operatively (MD = 7.4, 95%CI: 5.8-9.0, p < 0.001). Forward flexion was significantly better in Class 1 patients (MD = 13o, 95%CI: 7o-17o, p < 0.001) pre-operatively, but was slightly better in Class 2 patients post-operatively (MD = 7o, 95%CI: 4o-10o, p < 0.001). Overall complication rate was 16.8%.
CONCLUSION
Salvage RTSA is effective for PHF sequelae, with multiple factors contributing to the high complication rate.
PubMed: 37974647
DOI: 10.1177/17585732221088496 -
Shoulder & Elbow Nov 2023Salvage reverse shoulder arthroplasty (RSA) for failed proximal humerus fractures (PHFs) fixation and hemiarthroplasty (HA) may maximize outcomes in the absence of... (Review)
Review
BACKGROUND
Salvage reverse shoulder arthroplasty (RSA) for failed proximal humerus fractures (PHFs) fixation and hemiarthroplasty (HA) may maximize outcomes in the absence of tuberosity healing or a chronically torn rotator cuff. The purpose of this systematic review was to examine the improvement in clinical outcomes for patients after revision RSA was performed for failed PHFs fixation or HA.
METHODS
An electronic database search of SCOPUS, PubMed, Embase, MEDLINE, SPORTDiscus, CINAHL, and ClinicalTrials.gov was performed. A meta-analysis was carried out to determine weighted mean outcome differences between two primary intervention cohorts (failed fixation: open reduction and internal fixation, intramedullary nail, or K-wire vs. failed HA).
RESULTS
Fifteen studies were included (primary fixation: 208 patients; HA: 162 patients). Patients improved meaningfully in all clinical outcomes after revision surgery (constant: 18.5-48.3; abduction: 44-95; forward flexion: 47-107; external rotation: 5-10), with a 16.2% complication and 9.4% revision rate. The failed fixation group performed significantly better than the failed HA group in postoperative constant (fixation: 53.3 vs. HA: 45.1, = 0.016) and shoulder abduction (fixation: 102 vs. HA: 87, = 0.026).
CONCLUSIONS
RSA is a successful revision intervention for primary PHF operative failures with the greatest benefit for failures of primary fixation versus HA.
PubMed: 37974637
DOI: 10.1177/17585732221099200 -
JSES Reviews, Reports, and Techniques Nov 2023Currently, there is limited information on the incidence of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE) after surgical... (Review)
Review
BACKGROUND
Currently, there is limited information on the incidence of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE) after surgical treatment of proximal humerus fractures (PHFs). Therefore, the purpose of this systematic review is to evaluate the incidence of VTE, DVT, and PE following surgery for PHFs.
METHODS
A comprehensive search of several databases was performed from inception to May 27, 2022. Studies were screened and evaluated by 2 reviewers independently utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Only original, English studies that evaluated the incidences of VTE following surgical management of PHFs were included. Surgical procedures consisted of shoulder arthroplasty (SA) including both hemiarthroplasty (Hemi) and reverse shoulder arthroplasty (RSA) in addition to open reduction and internal fixation (ORIF). A pooled incidence for postoperative DVT, PE, and overall VTE was reported.
RESULTS
Twelve studies met the inclusion and exclusion criteria, encompassing a total of 18,238 patients. The overall DVT, PE, and VTE rates were 0.14%, 0.59%, and 0.7%, respectively. VTE was more frequently reported after SA than ORIF, (1.27% vs. 0.53%, respectively). Among SA patients, a higher rate of DVT was seen with RSA (1.2%) with the lowest DVT rate was observed for ORIF with 0.03%.
CONCLUSIONS
Symptomatic VTEs following surgical treatment of PHFs, are rare, yet still relevant as a worrisome postoperative complication. Among the various procedures, VTE was the most frequently reported after SA when compared to ORIF, with RSA having the highest VTE rate.
PubMed: 37928990
DOI: 10.1016/j.xrrt.2023.06.003 -
JPRAS Open Dec 2023Affecting mainly the working population, metacarpal shaft fractures account for up to 31% of hand fractures. To manage this entity, conservative management can be equal... (Review)
Review
BACKGROUND
Affecting mainly the working population, metacarpal shaft fractures account for up to 31% of hand fractures. To manage this entity, conservative management can be equal to operative management. However, surgeons tend to favor operative management in order to reduce the rate of complications, such as shortening and malunion. This meta-analysis was conducted to compare conservative to operative management of displaced metacarpal shaft fractures.
METHODS
PubMed, Cochrane, and Google Scholar (pages 1-20) were searched until August 2023. The clinical outcomes consisted of postoperative shortening, Disabilities of Arm, Shoulder, and Hand (DASH) score, and mean grip strength.
RESULTS
Only three studies were included in this meta-analysis. Operative management was shown to reduce postoperative shortening (p<0.00001). However, conservative management had a better postoperative DASH score (p=0.001).
CONCLUSION
Better DASH scores were seen in the conservative group, but there was a higher postoperative shortening. However, studies have shown that the shortening has no effect on the functional outcome. Nevertheless, more randomized controlled studies and cost-effectiveness studies are needed to confirm these findings.
PubMed: 37920285
DOI: 10.1016/j.jpra.2023.10.002 -
Medicina (Kaunas, Lithuania) Sep 2023The proximal humeral fracture (PHF) is one of the most common fractures in elderly patients. A PHF might influence the quality of life (QoL) on several different... (Review)
Review
The proximal humeral fracture (PHF) is one of the most common fractures in elderly patients. A PHF might influence the quality of life (QoL) on several different levels, especially in elderly patients, but it is unclear which treatment option results in a better QoL outcome. Therefore, we aimed to systematically review the current literature for studies that have analyzed the QoL and pain of elderly patients treated either surgically or non-operatively for PHF. A comprehensive search of the literature was performed in the PubMed database from January to April 2023. Studies describing the QoL or the level of pain of patients older than 60 years with the EuroQoL-5 Dimension (EQ-5D) score or the visual analogue scale (VAS) after the treatment of PHF, either non-operatively (non-OP), with open-reduction and internal fixation using a locking plate (LPF), or with reverse total shoulder arthroplasty (RTSA) were included. Twelve studies were analyzed descriptively and the individual risk of bias was assessed using the ROB2 and ROBINS-I tools. A total of 12 studies with 712 patients at baseline were included (78% female sex, mean age 75.2 years). The reported VAS scores at 12-month follow-up (FU) ranged from 0.7 to 2.5. The calculated overall mean VAS score across all studies showed a decreasing tendency for all treatments, with an increasing FU time up to 12 months after PHF. None of the studies reported any significant differences of the EQ-5D across the groups. The overall calculated EQ-5D indices showed an increasing trend after 6-8 weeks FU, but did not differ significantly between the three treatments. In conclusion, the current literature suggests that there are no clinically important differences between the QoL or pain in elderly patients with PHF after non-operative treatment or surgical treatment with LPF or RTSA. However, the number of studies and level of evidence is rather low and further trials are urgently needed.
Topics: Humans; Female; Aged; Male; Treatment Outcome; Quality of Life; Arthroplasty, Replacement, Shoulder; Fracture Fixation, Internal; Pain; Shoulder Fractures; Retrospective Studies
PubMed: 37893445
DOI: 10.3390/medicina59101728