Comparison of outcome between nonoperative and operative treatment of medial epicondyle fractures.
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SUBMITTER: Grahn P
PROVIDER: S-EPMC7919892 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:ObjectiveCompare outcomes of operative and nonoperatively managed medial epicondyle fractures in upper-extremity athletes.DesignRetrospective chart review and phone survey.SettingLevel 1, tertiary-referral pediatric hospital.PatientsPropensity scores (probability of operative treatment) were estimated from a logistic regression model that included sex, age, displacement, limb dominance, and injury severity (presence of an additional fracture, nerve injury, or elbow dislocation). These were used to match subjects in the operative group to the nonoperative group.Main outcome measuresReturn to sport, duration of time required to return to sport, pain, range of motion (ROM), need for physical therapy, and complications were recorded for both groups.ResultsTwenty-eight nonoperative subjects were matched to 14 operative subjects. There was no significant difference in the proportion of subjects who returned to the same sport (92.9% in each group), performance at preinjury level of competition, or median time to return to play (P = 0.7106). There was no significant difference in functional limitations in social-/work-related activities (P > 0.9999), pain in the past 30 days (P = 0.0640), need for physical therapy (P = 0.5680), ROM limitations (P = 0.0988), difficulty in sleeping (P = 0.4773), or complications (P = 0.4081).ConclusionsOur study found no statistical difference in outcomes or complications between operative and nonoperatively treated moderately displaced medial epicondyle fractures in adolescent upper-extremity athletes. Our data show that similar outcomes may be achieved with both treatment groups for medial epicondyle fractures in upper-extremity athletes.
| S-EPMC6443487 | biostudies-literature
Project description:Background and purposeTraditionally, clavicle fractures have been treated nonoperatively. However, many recent studies have concentrated on the results of operative treatment. We assessed and compared the outcomes of operative and nonoperative treatment for acute clavicle fractures in adults.MethodsWe performed a systematic search of the medical literature from 1966 until the end of March 2011. We included randomized controlled trials and controlled clinical trials comparing operative and nonoperative treatment and studies comparing different operative and nonoperative treatments. We required that there should be at least 30 adult patients and a follow-up of at least 6 months in each individual trial. We used the GRADE method to assess the quality of evidence.Results6 randomized controlled trials (n = 631) and 7 controlled clinical trials (n = 559) were included. There was moderate-quality evidence (i.e. of grade B) (1) that surgery has considerable effectiveness on better function and less disability at short follow-up, (2) of similar risk of relatively mild complications after operative or nonoperative treatment, (3) that delayed union and nonunion were more common in patients who were treated nonoperatively than in those treated operatively, and (4) that the osteosynthesis method had no effect on the incidence of delayed union or nonunion. Only 1 controlled clinical trial was found on lateral clavicle fractures with very limited (grade D) evidence.InterpretationPatients treated operatively have slightly better function and less disability than those treated nonoperatively at short follow-up, but then the effectiveness diminishes and is weak at 6 months. The different operative techniques may not differ in effectiveness or in adverse effects, but the evidence is very limited or conflicting. Surgery could be considered for active patients who require recovery to the previous level of activity in the shortest possible time.
| S-EPMC3278660 | biostudies-literature
Project description:ImportanceUnstable ankle fractures are routinely managed operatively. However, because of soft tissue and implant-related complications, recent literature has reported on the nonoperative management of well-reduced medial malleolus fractures after fibular stabilization, but with limited evidence supporting the routine application.ObjectiveTo assess the superiority of internal fixation of well-reduced (displacement ≤2 mm) medial malleolus fractures compared with nonfixation after fibular stabilization.Design, setting, and participantsThis superiority, pragmatic, parallel, prospective randomized clinical trial was conducted from October 1, 2017, to August 31, 2021. A total of 154 adult participants (≥16 years) with a closed, unstable bimalleolar or trimalleolar ankle fracture requiring surgery at an academic major trauma center in the UK were assessed. Exclusion criteria included injuries with no medial-sided fracture, open fractures, neurovascular injury, and the inability to comply with follow-up. Data analysis was performed in July 2022 and confirmed in September 2023.InterventionsOnce the lateral (and where appropriate, posterior) malleolus had been fixed and satisfactory intraoperative reduction of the medial malleolus fracture was confirmed by the operating surgeon, participants were randomly allocated to fixation (n = 78) or nonfixation (n = 76) of the medial malleolus.Main outcome and measureOlerud-Molander Ankle Score (OMAS) 1 year after randomization (range, 0-100 points, with 0 indicating worst possible outcome and 100 indicating best possible outcome).ResultsAmong 154 randomized participants (mean [SD] age, 56.5 [16.7] years; 119 [77%] female), 144 (94%) completed the trial. At 1 year, the median OMAS was 80.0 (IQR, 60.0-90.0) in the fixation group compared with 72.5 (IQR, 55.0-90.0) in the nonfixation group (P = .17). Complication rates were comparable. Significantly more patients in the nonfixation group developed a radiographic nonunion (20% vs 0%; P < .001), with 8 of 13 clinically asymptomatic; 1 patient required surgical reintervention for this. Fracture type and reduction quality appeared to influence fracture union and patient outcome.Conclusions and relevanceIn this randomized clinical trial comparing internal fixation of well-reduced medial malleolus fractures with nonfixation, after fibular stabilization, fixation was not superior according to the primary outcome. However, 1 in 5 patients developed a radiographic nonunion after nonfixation, and although the reintervention rate to manage this was low, the future implications are unknown. These results support selective nonfixation of anatomically reduced medial malleolar fractures after fibular stabilization.Trial registrationClinicalTrials.gov Identifier: NCT03362229.
| S-EPMC10797457 | biostudies-literature
Project description:ImportanceNo consensus has been reached to date regarding the optimal treatment for distal radius fractures. The international rate of operative treatment has been increasing, despite higher costs and limited functional outcome evidence to support this shift.ObjectivesTo compare functional, clinical, and radiologic outcomes after operative vs nonoperative treatment of distal radius fractures in adults.Data sourcesThe PubMed/MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched from inception to June 15, 2019, for studies comparing operative vs nonoperative treatment of distal radius fractures.Study selectionRandomized clinical trials (RCTs) and observational studies reporting on the following: acute distal radius fracture with operative treatment (internal or external fixation) vs nonoperative treatment (cast immobilization, splinting, or bracing); patients 18 years or older; and functional outcome. Studies in a language other than English or reporting treatment for refracture were excluded.Data extraction and synthesisData extraction was performed independently by 2 reviewers. Effect estimates were pooled using random-effects models and presented as risk ratios (RRs) or mean differences (MDs) with 95% CIs. Data were analyzed in September 2019.Main outcomes and measuresThe primary outcome measures included medium-term functional outcome measured with the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and the overall complication rate after operative and nonoperative treatment.ResultsA total of 23 unique studies were included, consisting of 8 RCTs and 15 observational studies, that described 2254 unique patients. Among the studies that presented sex data, 1769 patients were women [80.6%]. Overall weighted mean age was 67 [range, 22-90] years). The RCTs included 656 patients (29.1%); observational studies, 1598 patients (70.9%). The overall pooled effect estimates the showed a significant improvement in medium-term (≤1 year) DASH score after operative treatment compared with nonoperative treatment (MD, -5.22 [95% CI, -8.87 to -1.57]; P = .005; I2 = 84%). No difference in complication rate was observed (RR, 1.03 [95% CI, 0.69-1.55]; P = .87; I2 = 62%). A significant improvement in grip strength was noted after operative treatment, measured in kilograms (MD, 2.73 [95% CI, 0.15-5.32]; P = .04; I2 = 79%) and as a percentage of the unaffected side (MD, 8.21 [95% CI, 2.26-14.15]; P = .007; I2 = 76%). No improvement in medium-term DASH score was found in the subgroup of studies that only included patients 60 years or older (MD, -0.98 [95% CI, -3.52 to 1.57]; P = .45; I2 = 34%]), compared with a larger improvement in medium-term DASH score after operative treatment in the other studies that included patients 18 years or older (MD, -7.50 [95% CI, -12.40 to -2.60]; P = .003; I2 = 77%); the difference between these subgroups was statically significant (test for subgroup differences, P = .02).Conclusions and relevanceThis meta-analysis suggests that operative treatment of distal radius fractures improves the medium-term DASH score and grip strength compared with nonoperative treatment in adults, with no difference in overall complication rate. The findings suggest that operative treatment might be more effective and have a greater effect on the health and well-being of younger, nonelderly patients.
| S-EPMC7180423 | biostudies-literature
Project description:PurposeFollowing medial epicondyle fractures, a subset of pediatric patients has persistent limitations in elbow motion. This study soughted to understand the patient characteristics of this group and to assess the effectiveness of intensive therapy and ulnar nerve transposition in improving elbow range of motion and patient-reported outcomes.MethodsA cohort of 31 pediatric patients with stiffness after elbow trauma was narrowed to 8 pediatric patients (7 female) ranging in age from 9 to 14 years, who were diagnosed with medial epicondyle fractures and underwent intensive therapy and ulnar nerve transposition with or without elbow joint release. We collected demographic and objective data as well as subjective data including Patient-Reported Outcome Measurement Information System (PROMIS) scores before and after ulnar nerve transposition.ResultsFollowing initial intensive therapy, elbow range of motion improved by an average of 56°, and 7 of the 8 patients reached a functional motion arc of 100°. Subsequently, following ulnar nerve surgery with or without elbow release, motion improved by an average of 22°, and 5 of the 8 patients demonstrated improvement from this intervention. Surgery led to improvements in subjective outcomes with an improvement in PROMIS mobility scores by an average of 9 points, pain interference by 6 points, and upper extremity scores by 3 points. Based on a previously determined minimally important difference of three points, these indicate significant clinical improvements.ConclusionsA subset of pediatric patients with persistent stiffness following medial epicondyle fractures may benefit from additional interventions, including intensive therapy, transposition of the ulnar nerve, and open capsular release. However, not all patients were improved after ulnar nerve surgery, and the identification and treatment of ulnar nerve irritability may not fully resolve preoperative symptoms in all patients.Type of study/level of evidenceTherapeutic IV.
| S-EPMC10721539 | biostudies-literature
Project description:BackgroundThere are limited data reporting the outcome of patients with non-operatively managed medial malleolus fractures compared to those treated surgically in the presence of fibular stabilisation for unstable fractures of the ankle. Conservative management could result in fewer complications, reduced surgical time and lower cost. The purpose of this study is to determine if any difference exists in patient reported and surgical outcomes 1 year after surgery between operative and non-operative treatment of medial malleolar fractures in combination with stabilisation of the lateral malleolus.Methods/designThis is a single-centre, prospective, randomised controlled trial that aims to randomise 154 participants with an unstable ankle fracture to 'non-fixation' (n = 77) or 'fixation' (n = 77) of an associated well-reduced medial malleolus fracture following fibular stabilisation. The study will include patients ≥ 16 years of age with a closed bimalleolar or trimalleolar ankle fracture who are able to consent, complete questionnaires in the English language, and complete follow-up over a 1-year period. Randomisation will occur intra-operatively when the medial malleolus fracture is deemed 'well-reduced', with 2 mm or less of fluoroscopic displacement. The technique for fixation of both the medial and lateral malleoli is at the discretion of the operating surgeon. Patient-reported, observer-rated, and radiographic assessments will be collected at baseline and then at the following post-operative assessment points: 2 weeks, 6 weeks and 1 year. Postal questionnaire outcome data will be collected at 3 and 6 months. The primary outcome measure will be the Olerud Molander Ankle Score (OMAS) at 1 year following surgery. Secondary outcome measures will include the Manchester-Oxford Foot Questionnaire (MOXFQ), EuroQol-5D (EQ-5D), pain, treatment satisfaction, time to return to activity, operative tourniquet time, and complications.DiscussionThere is only one previous randomised trial comparing non-fixation with fixation of associated medial malleolus fractures but that was limited by the lack of baseline patient-reported outcome data and an inferior sample size. This current prospective trial aims to provide high-quality evidence regarding the requirement for medial malleolar fixation in unstable ankle fractures.Trial registrationClinicalTrials.gov, NCT03362229 . Registered retrospectively on 5 December 2017.
| S-EPMC6739910 | biostudies-literature
Project description:BackgroundFractures of the posterior process of the talus are frequently overlooked, possibly leading to nonunion, arthritis, and chronic pain. Given the rare occurrence, previous case series have been small and without functional outcome scores. Therefore, we aimed to provide evidence on outcomes after nonoperative and operative management of posterior process fractures of the talus.MethodsAll patients treated at a level 1 trauma center between 2012 and 2018 were retrospectively evaluated. Patient, fracture, and treatment characteristics were collected, and functional outcome as well as quality of life were assessed. Twenty-nine patients with posterior process fractures of the talus were identified in our database.ResultsThe most frequently seen mechanism of trauma was fall from height in 13 patients (44.8%). Twenty-two patients underwent primary arthrodesis or operative reduction and fixation of the fracture (75.9%). Eighty-two percent of the patients returned the questionnaires with a mean follow-up of 6 years. The 2 patients with primary arthrodesis were excluded from outcome analysis. The mean Foot Function Index score was 1.8 (range 0.0-10). The mean American Orthopaedic Foot & Ankle Society (AOFAS) score was 78.7 points (range 0-100). The mean quality of life EuroQol-5D (EQ-5D) index score was 0.78 (range -0.26 to 1). The mean visual analog scale (VAS) on overall patient satisfaction was 8.2 (range 1-10).ConclusionOperative management of extended posterior talar fractures was found to provide good functional outcome, quality of life, and patient satisfaction. Although the patients treated nonoperatively were found to have less severe injuries, they demonstrated worse overall outcome, which is supportive of surgical management. Nonoperative treatment is therefore only justified in selected patients.Level of evidenceLevel IV, retrospective case series.
| S-EPMC6900211 | biostudies-literature
Project description:BackgroundThe effectiveness of operative compared with nonoperative treatment at initial presentation (no prior fusion) for adult lumbar scoliosis has not, to our knowledge, been evaluated in controlled trials. The goals of this study were to evaluate the effects of operative and nonoperative treatment and to assess the benefits of these treatments to help treating physicians determine whether patients are better managed operatively or nonoperatively.MethodsPatients with adult symptomatic lumbar scoliosis (aged 40 to 80 years, with a coronal Cobb angle measurement of ≥30° and an Oswestry Disability Index [ODI] score of ≥20 or Scoliosis Research Society [SRS]-22 score of ≤4.0) from 9 North American centers were enrolled in concurrent randomized or observational cohorts to evaluate operative versus nonoperative treatment. The primary outcomes were differences in the mean change from baseline in the SRS-22 subscore and ODI at 2-year follow-up. For the randomized cohort, the initial sample-size calculation estimated that 41 patients per group (82 total) would provide 80% power with alpha equal to 0.05, anticipating 10% loss to follow-up and 20% nonadherence in the nonoperative arm. However, an interim sample-size calculation estimated that 18 patients per group would be sufficient.ResultsSixty-three patients were enrolled in the randomized cohort: 30 in the operative group and 33 in the nonoperative group. Two hundred and twenty-three patients were enrolled in the observational cohort: 112 in the operative group and 111 in the nonoperative group. The intention-to-treat analysis of the randomized cohort found that, at 2 years of follow-up, outcomes did not differ between the groups. Nonadherence was high in the randomized cohort (64% nonoperative-to-operative crossover). In the as-treated analysis of the randomized cohort, operative treatment was associated with greater improvement at the 2-year follow-up in the SRS-22 subscore (adjusted mean difference, 0.7 [95% confidence interval (CI), 0.5 to 1.0]) and in the ODI (adjusted mean difference, -16 [95% CI, -22 to -10]) (p < 0.001 for both). Surgery was also superior to nonoperative care in the observational cohort at 2 years after treatment on the basis of SRS-22 subscore and ODI outcomes (p < 0.001). In an overall responder analysis, more operative patients achieved improvement meeting or exceeding the minimal clinically important difference (MCID) in the SRS-22 subscore (85.7% versus 38.7%; p < 0.001) and the ODI (77.4% versus 38.3%; p < 0.001). Thirty-four revision surgeries were performed in 24 (14%) of the operative patients.ConclusionsOn the basis of as-treated and MCID analyses, if a patient with adult symptomatic lumbar scoliosis is satisfied with current spine-related health, nonoperative treatment is advised, with the understanding that improvement is unlikely. If a patient is not satisfied with current spine health and expects improvement, surgery is preferred.Level of evidenceTherapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
| S-EPMC6738555 | biostudies-literature
Project description:INTRODUCTION:A trend has evolved towards rib fixation for flail chest although evidence is limited. Little is known about rib fixation for multiple rib fractures without flail chest. The aim of this study is to compare rib fixation with nonoperative treatment for both patients with flail chest and patients with multiple rib fractures. METHODS AND ANALYSIS:In this study protocol for a multicentre prospective cohort study, all patients with three or more?rib fractures admitted to one of the five participating centres will be included. In two centres, rib fixation is performed and in three centres nonoperative treatment is the standard-of-care for flail chest or multiple rib fractures. The primary outcome measures are intensive care unit length of stay and hospital length of stay for patients with a flail chest and patients with multiple rib fractures, respectively. Propensity score matching will be used to control for potential confounding of the relation between treatment modality and length of stay. All analyses will be performed separately for patients with flail chest and patients with multiple rib fractures without flail chest. ETHICS AND DISSEMINATION:The regional Medical Research Ethics Committee UMC Utrecht approved a waiver of consent (reference number WAG/mb/17/024787 and METC protocol number 17-544/C). Patients will be fully informed of the purpose and procedures of the study, and signed informed consent will be obtained in agreement with the General Data Protection Regulation. Study results will be submitted for peer review publication. TRIAL REGISTRATION NUMBER:NTR6833.
| S-EPMC6720131 | biostudies-literature
Project description:BackgroundThe popularity of surgery for acute displaced midshaft clavicle fractures has been fuelled by early randomized controlled trials (RCTs) showing improved rates of radiographic union and perceived functional benefits compared with nonoperative approaches. We performed a meta-analysis to determine the effect of operative and nonoperative interventions on the risk of secondary operation and complications and on long-term function.MethodsWe search MEDLINE, Embase and the Cochrane Central Register of Controlled Trials for reports of relevant RCTs published to Mar. 7, 2014. Two reviewers assessed eligibility of potential reports and the risk of bias of included trials. The Grading of Recommendations Assessment, Development and Evaluation approach was used to summarize the quality of evidence for all outcomes.ResultsWe included 15 RCTs (9 trials comparing operative and nonoperative interventions, 5 comparing implants for operative treatment, and 1 comparing nonoperative treatments). Nonoperative treatments did not differ from operative treatments in the risk of secondary operation (risk ratio [RR] 1.16, 95% confidence interval [CI] 0.58 to 2.35) or all complications (RR 0.90, 95% CI 0.55 to 1.50). One in 4 patients had a complication regardless of the treatment approach. Differences in functional outcomes, although smaller than the threshold for minimal important differences at 1 year, favoured operative interventions (standardized mean difference 0.38, 95% CI 0 to 0.75). Evidence for the type of implant or approach to nonoperative treatment remained inconclusive.InterpretationCurrent evidence does not support the routine use of internal fixation for the treatment of displaced midshaft clavicle fractures. Complication rates were high regardless of the treatment approach.
| S-EPMC4701658 | biostudies-literature