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Patient Safety in Surgery Oct 2021Comminuted intra-articular tibial pilon fractures can be challenging to manage, with high revision rates and poor functional outcomes. This study reviewed [1] treatment,...
BACKGROUND
Comminuted intra-articular tibial pilon fractures can be challenging to manage, with high revision rates and poor functional outcomes. This study reviewed [1] treatment, complications, and clinical outcomes in studies of complex comminuted tibial pilon fractures (type AO43-C3); and [2] primary ankle arthrodesis as a management option for these types of complex injuries.
METHODS
A systematic literature search was performed on PubMed from 1990 to 2020 to determine complications and outcomes after staged fracture fixation and primary ankle joint arthrodesis for comminuted C3-type tibial pilon fractures. The search was conducted in compliance with the PRISMA guidelines, using the following MeSH terms: "tibial pilon"/"pilon fracture"/"plafond fracture"/"distal tibial"/"43-C3"/"ankle fracture"/"ankle fusion"/"primary ankle arthrodesis"/"pilon fracture staged"/"pilon external fixation" and "pilon open reduction internal fixation." Inclusion criteria were restricted to original articles in English language on adult patients ≥18 years of age. Eligibility criteria for retrieved publications were determined using a "PICO" approach (population, intervention/exposure, comparison, outcomes). Weighted analysis was used to compare treatment groups on time to definitive treatment, follow-up time, range of motion, fracture classification, and complications.
RESULTS
The systematic literature review using the defined MeSH terms yielded 72 original articles. Of these, 13 articles met the eligibility criteria based on the PICO statements, of which 8 publications investigated the outcomes of a staged fixation approach in 308 cumulative patients, and 5 articles focused on primary ankle arthrodesis in 69 cumulative patients. For staged treatment, the mean wound complication rate was 14.6%, and the malunion/nonunion rate was 9.9%. For primary arthrodesis, the mean wound complication rate was 2.9%, and the malunion/nonunion rate was 2.9%. After risk stratification for fracture type and severity, the small cumulative cohort of patients included in the primary arthrodesis publications did not provide sufficient power to determine a clinically relevant difference in complications and long-term patient outcomes compared to the staged surgical fixation group.
CONCLUSIONS
At present, there is insufficient evidence in the published literature to provide guidance towards consideration of ankle arthrodesis for complex comminuted C3-type tibial pilon fractures, compared to the standard treatment by staged surgical fracture fixation.
PubMed: 34663412
DOI: 10.1186/s13037-021-00298-2 -
Injury Feb 2022Supination-external rotation (SER) ankle fractures account for the majority of ankle fractures and can be divided into stable or unstable fractures, based on the state... (Meta-Analysis)
Meta-Analysis
Diagnostic tools to evaluate ankle instability caused by a deltoid ligament rupture in patients with supination-external rotation ankle fractures: A systematic review and meta-analysis.
AIM
Supination-external rotation (SER) ankle fractures account for the majority of ankle fractures and can be divided into stable or unstable fractures, based on the state of the deltoid ligament. The objective of this review was to appraise the available literature concerning diagnostic tools to evaluate deltoid ligament integrity in patients with SER-type ankle fractures.
METHODS
A comprehensive literature search of Pubmed and Embase was performed up to December 2020. The outcome measures were sensitivity, specificity and positive and negative predictive value of the diagnostic tools. A meta-analysis was performed to obtain an overview of sensitivity, specificity and area under the curve (AUC). The methodological quality of the articles was evaluated using Quality Assessment of Diagnostic Accuracy Studies.
RESULTS
A total of 12 studies investigating tools for deltoid ligament rupture in patients with SER-type ankle fractures were included. The present study found sensitivity (and specificity) ranges of 0.20-0.90 (and 0.38-0.97) for clinical features, Magnetic Resonance Imaging (MRI) 0.57-0.85 (and 0.81-1.00), ultrasonography 1.00 (and 0.89-1.00), Malleolar Medial Fleck Sign (MMFS) 0.25 (and 0.99), conventional ankle mortise radiography 0.33-0.57 (and 0.60-0.94), gravity stress radiography 0.71-1.00 (and 0.72-0.88) and manual stress ankle radiography 0.65-1.00 (and 0.00-0.77). The largest AUC was found for ultrasonography, followed by MMFS, gravity stress radiography and MRI.
CONCLUSION
Ultrasonography and gravity stress radiography seem the most accurate diagnostic tools to evaluate deltoid ligament integrity. To strengthen this conclusion, future research should use an identical reference test to ensure comparability of results. Nevertheless, present study is of high value to close the knowledge gap about which presently available diagnostic tool is to be preferred to evaluate deltoid ligament integrity in patients with SER-type ankle fractures.
Topics: Ankle; Ankle Fractures; Ankle Joint; Humans; Ligaments, Articular; Range of Motion, Articular; Supination
PubMed: 34602247
DOI: 10.1016/j.injury.2021.09.034 -
Foot & Ankle International Feb 2022The exact benefit of locking plates over nonlocking plates in patients with lateral malleolus fractures remains unclear. The primary aim of this study was to compare the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The exact benefit of locking plates over nonlocking plates in patients with lateral malleolus fractures remains unclear. The primary aim of this study was to compare the functional outcome of locking plates vs nonlocking plates in patients with a lateral malleolus fracture. The secondary aims were to compare the number of complications and hardware removals and to compare whether results differed for older patients and for patients treated with anatomical locking plates.
METHODS
The PubMed/MEDLINE, Embase, Cochrane, and CINAHL databases were searched for studies comparing locking plates with nonlocking plates in patients with fixated lateral malleolus fractures. All included studies were assessed on their methodologic quality using the MINORS. Subgroup analyses were performed on older patients and patients treated with anatomical locking plates.
RESULTS
A total of 11 studies were included. The meta-analysis showed that functional outcome did not differ between patients treated with locking plates and nonlocking plates (MD 2.38, 95% CI -2.71 to 7.46). No difference in both complication rate (OR 1.10, 95% CI 0.74-1.63) and the amount of hardware removals (OR 0.77, 95% CI 0.52-1.14) was found. Even after analyzing older patients and patients treated with anatomical locking plates, no benefit was shown.
CONCLUSION
This meta-analysis demonstrates no clear benefit in selecting locking plates over nonlocking plates in the treatment of lateral malleolus fractures.
CLINICAL RELEVANCE
Locking plates are increasingly being used in the treatment of lateral malleolus fractures. Biomechanical studies have shown an increased stability with use of locking vs nonlocking plates. This clinical review does not support a benefit of use of locking plates for these fractures.
Topics: Ankle Fractures; Bone Plates; Fibula; Fracture Fixation, Internal; Humans
PubMed: 34581226
DOI: 10.1177/10711007211040508 -
The American Journal of Sports Medicine Oct 2022It is unclear whether the results of osteochondral transplant using autografts or allografts for talar osteochondral defect are equivalent. (Meta-Analysis)
Meta-Analysis
BACKGROUND
It is unclear whether the results of osteochondral transplant using autografts or allografts for talar osteochondral defect are equivalent.
PURPOSE
A systematic review of the literature was conducted to compare allografts and autografts in terms of patient-reported outcome measures (PROMs), MRI findings, and complications.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
This study was conducted according to the PRISMA guidelines. The literature search was conducted in February 2021. All studies investigating the outcomes of allograft and/or autograft osteochondral transplant as management for osteochondral defects of the talus were accessed. The outcomes of interest were visual analog scale (VAS) score for pain, American Orthopaedic Foot and Ankle Society (AOFAS) score, and Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score. Data concerning the rates of failure and revision surgery were also collected. Continuous data were analyzed using the mean difference (MD), whereas binary data were evaluated with the odds ratio (OR) effect measure.
RESULTS
Data from 40 studies (1174 procedures) with a mean follow-up of 46.5 ± 25 months were retrieved. There was comparability concerning the length of follow-up, male to female ratio, mean age, body mass index, defect size, VAS score, and AOFAS score ( > .1) between the groups at baseline. At the last follow-up, the MOCART (MD, 10.5; = .04) and AOFAS (MD, 4.8; = .04) scores were better in the autograft group. The VAS score was similar between the 2 groups ( = .4). At the last follow-up, autografts demonstrated lower rate of revision surgery (OR, 7.2; < .0001) and failure (OR, 5.1; < .0001).
CONCLUSION
Based on the main findings of the present systematic review, talar osteochondral transplant using allografts was associated with higher rates of failure and revision compared with autografts at midterm follow-up.
Topics: Allografts; Autografts; Cartilage; Cartilage Diseases; Cartilage, Articular; Female; Humans; Intra-Articular Fractures; Magnetic Resonance Imaging; Male; Retrospective Studies; Talus; Transplantation, Autologous; Treatment Outcome
PubMed: 34554880
DOI: 10.1177/03635465211037349 -
Archives of Orthopaedic and Trauma... Nov 2022This article is a systematic review of the literature on elderly aged 80 and over with an ankle fracture. Low energy trauma fractures are a major public health burden in... (Review)
Review
INTRODUCTION
This article is a systematic review of the literature on elderly aged 80 and over with an ankle fracture. Low energy trauma fractures are a major public health burden in developed countries that have aged populations. Ankle fractures are the third most common fractures after hip and wrist fractures. The purpose of this review is to provide an overview of the treatments and the used outcome factors.
METHODS
PubMed, Embase, Cochrane Library, and CINAHL were searched to retrieve relevant studies. Studies published in English or Dutch concerning the treatment of ankle fractures in patients aged 80 and over were included.
RESULTS
Initially 2054 studies were found in the databases. After removing duplicate entries, 1182 remained. Finally, after screening six studies were included, of which three cohorts studies and three case series. Six different treatments were identified and described; ORIF, transarticular Steinmann pin, plaster cast with or without weight-bearing, Gallagher nail and the TCC nail. Furthermore, 32 outcome factors were identified.
DISCUSSION
The various studies show that practitioners are careful with early weight-bearing. However, if we look closely to the results and other literature, this seems not necessary and it could potentially be of great value to implement early weight-bearing in the treatment. Furthermore, quality of life seems underreported in this research field.
CONCLUSIONS
ORIF with plaster cast and permissive weight-bearing should be considered for this population since it seems to be a safe possibility for a majority of the relatively healthy patients aged 80 and over. In cases where surgery is contra-indicated and a plaster cast is the choice of treatment, early weight-bearing seems to have a positive influence on the outcome in the very old patient.
Topics: Aged; Aged, 80 and over; Ankle Fractures; Ankle Joint; Casts, Surgical; Female; Humans; Male; Quality of Life; Treatment Outcome
PubMed: 34546421
DOI: 10.1007/s00402-021-04161-y -
Annals of Palliative Medicine Aug 2021This study aimed to apply meta-analysis to study the efficacy of surgical repair treatment on ankle fractures. (Meta-Analysis)
Meta-Analysis
BACKGROUND
This study aimed to apply meta-analysis to study the efficacy of surgical repair treatment on ankle fractures.
METHODS
The Boolean logic search method was adopted to retrieve relevant randomized control trials (RCTs), with "Fracture", "Ankles", "Fractured Foot", "Fractures Merge", and "Surgical Treatment" as search terms. The databases PubMed, Medline, HowNet, and others were searched from the time of their establishment. The software Review Manager (Rev Man 5.3) was used for meta-analysis.
RESULTS
A total of 10 references were included in the study, and most of them had low-risk bias (medium-high quality). The results of meta-analysis showed that after surgical repair treatment, gait was good, while the gait score of the non-surgical group was poor. The result was Chi2 (Chi-squared Test) =57.91, df (degree of freedom) =5, I2=91%, P<0.1, mean difference (MD) =-9.21, 95% CI: -10.25 to -8.17, Z=17.36, P<0.05. The non-surgical group showed a higher degree of pain and poorer ankle and hindfoot functions vs. the surgical group. Also, the pain degree of the non-surgical repair combined with surrounding tissue group was higher, and the ankle and hindfoot functions were poorer vs. the surgical repair treatment group. The Pain intensity results of the surgical and non-surgical groups were Chi2 =12.89, df =2, I2=84%, P<0.1, MD =-9.51, 95% CI: -10.47 to -8.55, Z=19.39, P<0.05; the AOFAS scores of surgical repair treatment and non-surgical repair treatment were Chi2 =27.07, df =6, I2=78%, P<0.1, MD =8.89, 95% CI: 8.26 to 9.71, Z=24.30, P<0.05. It was revealed that surgical repair treatment can significantly reduce the postoperative pain of patients with ankle joint fractures, while the non-surgical repair treatment group had a higher degree of postoperative pain. The result was (MD =2.32, 95% CI: 2.16 to 2.48, I2=100%, Z=28.33, P<0.05).
DISCUSSION
Surgical repair treatment of ankle fracture demonstrated significant curative effects, with fewer adverse reactions, and the stability of the ankle joint was well restored.
Topics: Ankle Fractures; Ankle Joint; Humans
PubMed: 34488374
DOI: 10.21037/apm-21-1618 -
International Journal of Environmental... Aug 2021The integrity of the talus is crucial for the physiologic function of the feet. The present study sought to summarize the available evidence on clinical outcomes and... (Meta-Analysis)
Meta-Analysis Review
The integrity of the talus is crucial for the physiologic function of the feet. The present study sought to summarize the available evidence on clinical outcomes and complications following conservative and surgical treatment of talar fractures. We systematically searched Medline via OVID to find relevant studies with a follow-up of at least six months. Hereafter, the success and complication rates were extracted and analyzed in a random effects proportion meta-analysis. Complications were defined as avascular bone necrosis (AVN) and posttraumatic osteoarthritis (OA). Additionally, a subgroup analysis was performed for fracture localization (talar neck fractures (TN) and combined talar body/neck fractures (TN/TB)) and severity of the fracture. The quality of the included studies was assessed utilizing the Coleman Methodology Score (CMS). A total of 29 retrospective studies, including 987 fractures with a mean follow-up of 49.9 months, were examined. Success rates were 62%, 60%, and 50% for pooled fractures, TN, and TN/TB, respectively. The overall complication rate for AVN was 25%. The rate was higher for TN (43%) than TN/TB (25%). Talar fractures revealed a 43% posttraumatic osteoarthritis (OA) rate in our meta-analysis. Success rates showed an association with fracture severity, and were generally low in complex multi-fragmentary fractures. The mean CMS was 34.3 (range: 19-47), indicating a moderate methodological quality of the studies. The present systematic review on clinical outcomes of patients undergoing conservative or surgical treatment for talar fractures reveals a lack of reliable prospective evidence. Talar fractures are associated with relatively poor postoperative outcomes, high rates of AVN, and posttraumatic osteoarthritis. Poor outcomes revealed a positive association with fracture severity. Prospective studies investigating predictors for treatment success and/or failure are urgently needed to improve the overall quality of life and function of patients undergoing surgical treatment due to talar fractures.
Topics: Fracture Fixation, Internal; Fractures, Bone; Humans; Prospective Studies; Quality of Life; Retrospective Studies
PubMed: 34444022
DOI: 10.3390/ijerph18168274 -
International Orthopaedics Oct 2021This meta-analysis aims to provide updated evidence on the success rate, return to play (RTP) rate, time to RTP, and complications of operatively and conservatively... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
This meta-analysis aims to provide updated evidence on the success rate, return to play (RTP) rate, time to RTP, and complications of operatively and conservatively managed navicular stress fractures (NSFs) as well as delays in diagnosis while avoiding limitations of previous similar studies.
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 February 2021 using the following keywords with their synonyms: "Navicular stress fracture," "return to play," and "athletes." The primary outcomes were (1) management success rate, (2) RTP rate, and (3) time to RTP. The secondary outcomes were (1) non-union, (2) time to diagnosis, (3) refracture, and (4) other complications. Inclusion criteria were clinical studies on NSFs reporting at least one of the desirable outcomes. Studies not reporting any of the outcomes of interest or the full text was not available in English, German, French, or Arabic were excluded. Case reports, case series with less than ten cases, and studies reporting exclusively on navicular non-union management were also excluded. The Newcastle-Ottawa scale was used for quality assessment while Review Manager (RevMan) Version 5.4 was used for the risk of bias assessment. Data were presented by type of treatment (surgical or conservative). If enough studies were present that were clinically and statistically homogeneous and data on them adequately reported, a meta-analysis was performed using a fixed-effects model. In case of statistical heterogeneity, a random-effects model was used. If meta-analysis was not possible, results were reported in a descriptive fashion. The need to explore for statistical heterogeneity was determined by an I greater than 40%.
RESULTS
Eleven studies met the inclusion criteria with a total of 315 NSF. Out of those, 307 (97.46%) NSFs were in athletes. One hundred eight (34.29%) NSFs were managed operatively, while 207 (65.71%) NSFs were managed conservatively. Successful outcomes were reported in 104/108 (96.30%) NSF treated operatively with a mean success rate of 97.9% (CI: 95.4-100%, I = 0%). Successful outcomes were reported in 149/207 (71.98%) NSF treated conservatively, with a mean success rate of 78.1% (CI: 66.6-89.6%, I = 84.93%). Successful outcome differences were found to be significant in favor of operative management (OR = 5.52, CI: 1.74-17.48, p = 0.004, I = 4.6%). RTP was noted in 97/98 (98.98%) NSF treated operatively and in 152/207 (73.43%) NSF treated conservatively, with no significant difference between operative and conservative management (OR = 2.789, CI: 0.80-9.67, p = 0.142, I = 0%). The pooled mean time to RTP in NSF treated operatively was 4.17 months (CI: 3.06-5.28, I = 92.88%), while NSF treated conservatively returned to play at 4.67 months (CI: 0.97-8.37, I = 99.46%) postoperatively, with no significant difference between operative and conservative management (SMD = - 0.397, CI: - 1.869-1.075, p = 0.60, I = 92.24). The pooled mean duration of symptoms before diagnosis was 9.862 (3.3-123.6) months (CI: 6.45-13.28, I = 94.92%), reported in ten studies. Twenty (23.53%) refractures were reported after conservative management of 85 NSFs, while one (1.28%) refracture was reported after operative management of 78 NSFs, with a significant difference in favor of operative management (OR = 0.083, CI: 0.007-0.973, p = 0.047, I = 38.78%).
CONCLUSION
Operative management of NSF provides a higher success rate, a lower refracture rate, and a lower non-union rate as compared to other non-operative management options. While not significant, there is a notable trend towards superior RTP rates and time to RTP following operative management. Therefore, we recommend operative fixation for all NSFs type I through III in athletes. Athletes continue to exhibit an alarmingly long duration of symptoms before diagnosis is made; a high index of suspicion must be maintained, therefore, and adjunct CT imaging is strongly recommended in the case of any work-up. Unfortunately, the published literature on NSFs remains of lower level of evidence and high-quality studies are needed.
Topics: Ankle Injuries; Fractures, Stress; Humans; Return to Sport; Sports; Tarsal Bones
PubMed: 34415421
DOI: 10.1007/s00264-021-05147-6 -
Diabetology & Metabolic Syndrome Aug 2021Diabetes mellitus (DM) causes excess risk of fracture at varied sites. Whereas, the difference between the roles of types 1 DM (T1DM) and 2 DM (T2DM) diabetes in the...
BACKGROUND
Diabetes mellitus (DM) causes excess risk of fracture at varied sites. Whereas, the difference between the roles of types 1 DM (T1DM) and 2 DM (T2DM) diabetes in the risk of fractures remains limited and inconclusive. We, therefore, conducted a meta-analysis to assess the differences for the associations of T1DM and T2DM with the risk of fractures.
METHODS
We systematically searched PubMed, Embase, and the Cochrane library for eligible studies until May 2021. The odds ratios (ORs) with 95% confidence intervals (CIs) were used to calculate the pooled effect estimates for the associations of T1DM and T2DM with the risk of fractures using the random-effects model. An indirect comparison results for the ratio of OR (ROR) with 95% CI were also applied to assess the difference between T1DM and T2DM with the risk of fractures.
RESULTS
Twenty-two cohort studies involving a total of 6,484,851 individuals were selected for meta-analysis. We noted that T1DM was associated with an increased risk of all fractures (OR: 1.72; 95% CI 1.36-2.19; P < 0.001), and fractures at the hip (OR: 4.01; 95% CI 2.90-5.54; P < 0.001), upper arm (OR: 2.20; 95% CI 1.61-3.00; P < 0.001), ankle (OR: 1.97; 95% CI 1.24-3.14; P = 0.004), and vertebrae (OR: 2.18; 95% CI 1.85-2.57; P < 0.001). Moreover, T2DM induced excess risk to all fractures (OR: 1.19; 95% CI 1.09-1.31; P < 0.001), including fractures at the hip (OR: 1.25; 95% CI 1.15-1.35; P < 0.001), upper arm (OR: 1.42; 95% CI 1.20-1.67; P < 0.001), and ankle (OR: 1.15; 95% CI 1.01-1.31; P = 0.029). Furthermore, we noted that T1DM versus T2DM was associated with greater risk to all fractures (ROR: 1.45; 95% CI 1.12-1.87; P = 0.005), including fractures at the hip (ROR: 3.21; 95% CI 2.30-4.48; P < 0.001), upper arm (ROR: 1.55; 95% CI 1.09-2.20; P = 0.015), and ankle (ROR: 1.71; 95% CI 1.06-2.78; P = 0.029).
CONCLUSIONS
This study found that T1DM caused an excess risk to all fractures, including fractures at the hip, upper arm, and ankle than T2DM. Further studies should therefore be conducted to directly compare the differences between T1DM and T2DM with the risk of fractures at various sites.
PubMed: 34399851
DOI: 10.1186/s13098-021-00687-8 -
Medicine Aug 2021Calcaneal fractures are the most common tarsal bone fracture, and are often accompanied by heel pain, local swelling, tenderness, and inability to walk or stand.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Calcaneal fractures are the most common tarsal bone fracture, and are often accompanied by heel pain, local swelling, tenderness, and inability to walk or stand. Surgical intervention results in better reconstruction of the calcaneal anatomy and reduces future complications; however, the optimal incision approach is still controversial. The incision is exposed better with extensile lateral approach (ELA), while the sinus tarsi approach (STA) causes fewer complications. The purpose of this meta-analysis is to compare the outcomes of STA and ELA.
MATERIALS AND METHODS
Published trials comparing ELA and STA in calcaneal fractures were included in our analysis. The quality of each study was assessed using the revised Jadad scale and the Newcastle-Ottawa scale. Two researchers (CP and BY) independently extracted data from all selected studies. Fixed- or random-effects models with mean differences and odds ratios were used to pool the continuous and dichotomous variables to determine the heterogeneity of the included studies.
RESULTS
Calcaneal height and calcaneal width had high heterogeneity. Results showed that the incidence of incision complications in STA was lower than that in ELA (P < .001). There was high heterogeneity in operative time (I2 = 97%), length of hospital stay (I2 = 98%), Böhler angle (I2 = 80%), Gissane angle (I2 = 98%), and American Orthopaedic Foot & Ankle Society scores (I2 = 73%). No source of heterogeneity was found by sensitivity analysis, subgroup analysis, or regression analysis, and the random-effects model was used. STA operative time was significantly shorter than ELA (P < .001). Length of hospital stay after STA was significantly shorter than after ELA (P = .002). There was no statistical difference in the Böhler and Gissane angles between STA and ELA. Postoperative American Orthopaedic Foot & Ankle Society scores after STA were higher than after ELA (P = .01).
CONCLUSIONS
Results show that, compared with ELA, STA is superior for treating calcaneal fractures due to anatomical reduction of the calcaneus, reduction of incision complications incidence, and shortened operative time and postoperative stay.
Topics: Calcaneus; Fractures, Bone; Humans; Length of Stay; Orthopedic Procedures; Postoperative Complications; Treatment Outcome
PubMed: 34397810
DOI: 10.1097/MD.0000000000026717