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 use of negative pressure wound therapy for fracture-related infections following internal osteosynthesis of the extremity: A systematic review.

This study aimed to systematically review the current literature on studies using negative pressure wound therapy (NPWT) or dressings following fracture-related infection (FRI) in internal osteosynthesis of the extremity. Articles were analyzed on fracture and wound healing and included when comparing or describing the use of either NPWT or dressings in FRI. We conducted a systematic literature search in four electronic databases: Embase, Medline, the Cochrane Library, and Scopus. The studies were screened by two authors using Covidence.org and evaluated for risk of bias. A total of 8576 records were identified. No articles compared NPWT to dressings. Seven case reports and three case series included a total of 115 patients treated for FRI. Fracture healing was achieved in 21 out of 67 patients treated with NPWT (4 amputations and 46 not described) and all 48 patients in the dressing group (4 patients needed additional sequestrectomy procedures). Five studies did not describe fracture healing. In 57 out of 67 patients treated with NPWT, the wounds were described as healed, closed, or requiring soft tissue reconstruction (4 amputations and six lacking description). The dressing group had complete wound coverage in 18 patients and partial coverage in 30 patients. Studies were generally at high risk of bias because of insufficient descriptions of both patient demographics and outcomes. No studies compared NPWT to dressings, and the existing literature is at high risk of bias. The included studies were of low-level evidence. NPWT can be neither recommended nor advised against to cover infected osteosynthesis.

Low evidence for implementation of well-documented implants regarding risk of early revision: a systematic review on total hip arthroplasty.

When introducing an implant, surgeons are subjected to steep learning curves, which may lead to a heightened revision rate. Stepwise introduction revolutionized implant introduction but lacks a last step.No guidelines exist for the introduction of a well-documented implant not previously used in a department. This is problematic according to the European Union's legislated tendering process, potentially leading to increased revisions. In this systematic review, the introduction of a well-documented total hip arthroplasty implant to experienced surgeons is explored amid concerns of higher revision rate.Literature search strategies were deployed in the Embase and Medline databases, revealing a total of 14,612 articles. Using the Covidence software (Cochrane, London), two reviewers screened articles for inclusion.No articles were found that fulfilled our eligibility criteria. A post hoc analysis retrieved two national register-based studies only missing information about the surgeon's knowledge of the introduced implant. None of the introduced implants decreased the revision rate and around 30% of the introduced implants were associated with a higher revision rate.The review showed that no data exist about revision rates when introducing well-documented implants. In continuation thereof, the introduction of well-documented implants might also be associated with increased revision rates, as has been shown for total knee arthroplasty. We therefore suggest that special attention should be focused on changes of implants in departments, which can be achieved by way of specific registration in national registers. Cite this article: EFORT Open Rev 2021;6:3-8. DOI: 10.1302/2058-5241.6.200047.

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.

Operative versus nonoperative treatment of humeral shaft fractures: a systematic review and meta-analysis.

BACKGROUND: The humeral shaft fracture accounts for 1%-3% of all fractures and occurs in both the young and old population. However, the optimal treatment is still a matter of debate. Even though nonoperative treatment is commonly considered the gold standard, advantages have been described using operative stabilization. This systematic review aims to compare operative and nonoperative treatment in adult patients with humeral shaft fractures. METHOD: We used the following databases: PubMed, Embase, Cochrane, and CINAHL on October 1, 2018, searching for randomized controlled trials (RCTs) and cohort studies. Two reviewers screened the studies using Covidence, followed by systematic data extraction. The primary outcome was defined as posttreatment complications such as nonunion, radial nerve palsy, malunion, and infections. The secondary outcomes were functional scores and patient-reported outcome measures (PROMs). To assess study quality, the risk of bias in nonrandomized studies of interventions and the Cochrane risk of bias tool were used. RESULTS: Twelve studies were included: 1 RCT, 1 prospective cohort, and 10 retrospective cohorts with a total of 1406 patients, of whom 835 were treated operatively and 571 nonoperatively. Mean age ranged from 35 to 64, and 54% of the patients were male. The cohort studies had, in general, moderate bias, whereas the RCT had a low bias. There were statistically significant fewer nonunions in the operative treated group with a risk ratio of 0.49 (0.35-0.67), yielding a number needed to treat = 12. There were more deep infections in the operative group with a risk ratio of 2.76 (1.01-7.53) but otherwise no statistical differences concerning malunion or nerve damage. Only 1 study included PROM data. CONCLUSION: There were fewer nonunions in the operative group but more deep infections. Because of the lack of studies reporting PROMs, the potential positive effect of operative therapy in early aftercare could not be evaluated. Therefore, PROMs should be mandatory in future comparative studies.

Posterior tilt in nondisplaced femoral neck fractures increases the risk of reoperations after osteosynthesis. A systematic review and meta-analysis.

OBJECTIVE: To conduct a systematic review on the effect of posterior tilt on reoperations, patient reported outcome measures (PROM) and functional outcome following osteosynthesis of undisplaced FNFs (uFNF). MATERIAL AND METHODS: A search string was developed with the aid of a scientific librarian and the search was performed in PubMed, CINAHL and Embase. The studies were screened independently by two authors using Covidence. Data were extracted by two authors and quality assessment was performed using Robins-I tool. The meta-analyses were performed in STATA IC 16 using Risk Ratio as the primary effect estimate. RESULTS: In total, 617 studies were screened and ten studies were included with a total of 3,131 patients. The mean age ranged from 68.3 to 85.0 years and the prevalence of posterior tilt ≥20° in the studies ranged from 4.5% to 27.6%. There were 10.3% reoperations when posterior tilt was <20° whereas there were 24.5% when posterior tilt was ≥20° The meta-analysis therefore demonstrated an overall risk ratio of 0.11 (95% confidence interval; 0.04-0.18). Only one study investigated functional outcome, using ADL as measurement, but found no significant difference. No studies investigated PROM. In general, the studies were assessed to be of poor quality mainly due possible bias and confounding. CONCLUSION: A posterior tilt ≥20° leads to a higher risk of reoperations in uFNF. Even though the studies were of poor quality, the results suggest that we should include the measurement of posterior tilt in national guidelines.