Risk factors for nonunion following surgically managed, traumatic, diaphyseal fractures: a systematic review and meta-analysis.

Background: There are several studies on nonunion, but there are no systematic overviews of the current evidence of risk factors for nonunion. The aim of this study was to systematically review risk factors for nonunion following surgically managed, traumatic, diaphyseal fractures. Methods: Medline, Embase, Scopus, and Cochrane were searched using a search string developed with aid from a scientific librarian. The studies were screened independently by two authors using Covidence. We solely included studies with at least ten nonunions. Eligible study data were extracted, and the studies were critically appraised. We performed random-effects meta-analyses for those risk factors included in five or more studies. PROSPERO registration number: CRD42021235213. Results: Of 11,738 records screened, 30 were eligible, and these included 38,465 patients. Twenty-five studies were eligible for meta-analyses. Nonunion was associated with smoking (odds ratio (OR): 1.7, 95% CI: 1.2-2.4), open fractures (OR: 2.6, 95% CI: 1.8-3.9), diabetes (OR: 1.6, 95% CI: 1.3-2.0), infection (OR: 7.0, 95% CI: 3.2-15.0), obesity (OR: 1.5, 95% CI: 1.1-1.9), increasing Gustilo classification (OR: 2.2, 95% CI: 1.4-3.7), and AO classification (OR: 2.4, 95% CI: 1.5-3.7). The studies were generally assessed to be of poor quality, mainly because of the possible risk of bias due to confounding, unclear outcome measurements, and missing data. Conclusion: Establishing compelling evidence is challenging because the current studies are observational and at risk of bias. We conclude that several risk factors are associated with nonunion following surgically managed, traumatic, diaphyseal fractures and should be included as confounders in future studies.

Sliding hip screw vs intramedullary nail for AO/OTA31A1-A3: a systematic review and meta-analysis.

OBJECTIVE: to conduct a systematic review with consequent meta-analysis evaluating the best treatment for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 31A1-A3 trochanteric fractures when comparing the sliding hip screw (SHS) to the intramedullary nail (IMN). The outcomes used for comparison are major complications (in total, as well as nonunion and infection specifically), mortality rates, functional outcomes and patient-reported outcome measures (PROM). MATERIALS AND METHODS: Search strings for the Cochrane Library, CINAHL, Medline and Embase databases were developed with the help of a scientific librarian. Two authors screened the studies from the search string independently using Covidence.org and data extraction was performed similarly. Quality assessment was performed using the Cochrane Risk of Bias tool for randomised trials (ROB2) for RCT studies, and Cochrane Risk of Bias in Non-Randomised Studies - of Interventions (ROBINS-I) for non-RCT studies. Meta-analyses were performed using Log Risk Ratio as the primary effect estimate. RESULTS: Of the 2,051 studies screened by the two authors, six RCTs and six non-RCTs were included in this meta-analysis, with a total of 10,402 patients. The results indicated no significant differences in total major complications, nonunion, infection or mortality between SHS and IMN treatments for AO/OTA 31A1, 31A2 and 31A3 trochanteric fractures. Due to a lack of compatible data, we were unable to perform a meta-analysis on function scores and PROM. However, there are trends that favour IMN for 31A1 and 31A2 fractures. CONCLUSION: No significant difference between SHS and IMN was found in the meta-analysis in any of the examined AO/OTA fracture subtypes in terms of primary and secondary outcomes. When assessing function scores and PROM, we found trends favouring IMN for 31A1 and 31A2 fractures that should be explored further.

The ability of comorbidity indices to predict mortality in an orthopedic setting: a systematic review.

BACKGROUND: Several comorbidity indices have been created to estimate and adjust for the burden of comorbidity. The objective of this systematic review was to evaluate and compare the ability of different comorbidity indices to predict mortality in an orthopedic setting. METHODS: A systematic search was conducted in Embase, MEDLINE, and Cochrane Library. The search were constructed around two primary focal points: a comorbidity index and orthopedics. The last search were performed on 13 June 2019. Eligibility criteria were participants with orthopedic conditions or who underwent an orthopedic procedure, a comparison between comorbidity indices that used administrative data, and reported mortality as outcome. Two independent reviewers screened the studies using Covidence. The area under the curve (AUC) was chosen as the primary effect estimate. RESULTS: Of the 5338 studies identified, 16 met the eligibility criteria. The predictive ability of the different comorbidity indices ranged from poor (AUC < 0.70) to excellent (AUC ≥ 0.90). The majority of the included studies compared the Elixhauser Comorbidity Index (ECI) and the Charlson Comorbidity Index (CCI). In-hospital mortality was reported in eight studies reporting AUC values ranging from 0.70 to 0.92 for ECI and 0.68 to 0.89 for CCI. AUC values were generally lower for all other time points ranging from 0.67 to 0.78. For 1-year mortality the overall effect size ranging from 0.67 to 0.77 for ECI and 0.69 to 0.77 for CCI. CONCLUSION: The results of this review indicate that the ECI and CCI can equally be used to adjust for comorbidities when analyzing mortality in an orthopedic setting. TRIAL REGISTRATION: The protocol for this systematic review was registered on PROSPERO, the International Prospective Register of Systematic Reviews on 13 June 2019 and can be accessed through record ID 133,871.