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Ao Acetabulo y Supracondilares
Ao Acetabulo y Supracondilares
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Clinical topic
Summary
Closed reduction and percutaneous pinning may be favored slightly when compared
with open reduction in the treatment of supracondylar humeral fractures in
children. Elbow range of motion appears to be better in this group and there is
a suggestion that these patients may have shorter hospitalization times and slightly
shorter healing times. However, it has also been shown that open reduction can
be safe and effective, and the two methods give similar results in humeral-ulnar
angle differences and neurological impairment. Additional studies are recommended
to verify and further clarify these results.
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 1–8
2 | Summary | Supracondylar humeral fractures in children
Sampling Objective
A MEDLINE search was performed to identify studies To critically summarize recently published studies
published from January 1998 to April 2004. comparing open versus closed reduction and pinning
in the treatment of supracondylar humeral fractures
From a list of 102 articles identified from the search in children.
strategy, three cohort studies and one randomized con-
trolled trial that made the desired comparisons were
selected. Case series that did not report a comparison Common outcome measures
group were not included. ■ Cosmetic and functional results according to
Flynn's criteria.
■ Scoring for both the cosmetic results (based on loss
Studies of Baumann angle) and functional results (based
Study 1 on loss of motion) are as follows: excellent (0–5),
de Buys Roessingh AS, Reinberg O (2003) good (6–10), fair (11–15), and poor (> 15). These
Open or closed pinning for distal humerus fractures subscales may be combined.
in children? ■ Humeral-ulnar angle change.
Swiss Surg; 9:76–81. ■ Postoperative neurological impairment.
Study 2
Kaewpornsawan K (2001) Intervention
Comparison between closed reduction with percuta- ■ Open reduction versus closed reduction with
neous pinning and open reduction with pinning percutaneous pinning.
in children with closed totally displaced supracondylar ■ Open reduction through a posteromedial incision,
humeral fractures: a randomized controlled trial. exploring the ulnar nerve and pinning with
J Pediatr Orthop B; 10:131–137. Kirschner wires in a lateral [Oh, Kaewpornsawan]
or crossed fashion [Oh, Ozkoc] (unspecified in
Study 3 [de Buys Roessingh]).
Oh CW, Park BC, Kim PT, et al (2003). ■ Closed reduction and percutaneous pin fixation
Completely displaced supracondylar humerus fractures [de Buys Roessingh, Ozkoc], in a crossed [Ozkoc] or
in children: results of open reduction versus closed lateral fashion [Kaewpornsawan].
reduction. ■ In one study, open reductions were performed
J Orthop Sci; 8:137–141. when an adequate reduction could not be obtained
by closed manipulation [Oh].
Study 4
Ozkoc G, Gonc U, Kayaalp A, et al (2004)
Displaced supracondylar humeral fractures in children:
open reduction vs. closed reduction and pinning.
Arch Orthop Trauma Surg; 124(8):547–551.
Orthop. trauma dir. 2005; 02; 1– 8 AO Journal Club / Evidence from the Literature
Supracondylar humeral fractures in children | Summary | 3
Study design
Demographics of studies comparing open versus closed reduction for supracondylar humeral fractures in children.
open = 20
de Buys retrospective mean age: 6.7 years closed = 18 17.2 months 4
Roessingh cohort male: 63% 100%
(2003) open = 14
Kaewpornsawan randomized open closed = 14 80 months(53–108) 7
(2001) controlled trial mean age: 6.8 years (range 56–120 months)
male: 79% 100%
closed
mean age: 7.9 years
male: 57% open = 14
Oh retrospective mean age: 6.4 years closed = 21 22 months (range 12–50) 3
(2003) cohort male: 54% open = 44 100%
Ozkoc retrospective open closed = 55 open 5
(2004) cohort mean age: 10.7 years 35 months
Male: 57% (range 27–46)
closed 100%
mean age: 7.6 years closed
male: 54% 21 months
(range 16–27)
100%
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 1–8
4 | Appraisal | Supracondylar humeral fractures in children
Reviewer’s evaluation
Orthop. trauma dir. 2005; 02; 1– 8 AO Journal Club / Evidence from the Literature
Supracondylar humeral fractures in children | Results | 5
Results
■ Generally, the average cosmetic (carrying angle) and ■ Loss of mobility, as measured by elbow extension,
functional scores (movement loss), according to the was greater in the open reduction group than in the
Flynn's criteria, were slightly higher in the closed closed reduction group: 6.23° versus 0.6° lost
reduction groups than in the open reduction groups (P=.005) [Ozkoc], 15% versus 11.1% with absence
(Figure 1) [Kaewpornsawan, Oh, Ozkoc]. of total extension (not statistically significant) [de
Buys Roessingh], and 7.14% versus 0% with motion
■ None of the studies showed a statistically significant loss more than 10° (not statistically significant)
difference in the humeral-ulnar angle change as [Kaewpornsawan], respectively.
measured by Bauman's angle (Figure 2); however,
while there was no statistically significant difference ■ Two additional outcomes were also reported to favor
in the incidence of cubitus varus between the open those who received closed reduction compared to
(25%) and closed (27%) reduction groups (P=.16), open reduction in cohort studies.
there was a statistically significant difference in the
incidence of cubitus valgus between the open (20%) ■ Average length of hospitalization: 2.8 days after
and closed (0%) reduction groups (P<.045) [de Buys closed reduction compared with 6.1 days after open
Roessingh]. reduction (P<.018) [de Buys Roessingh].
■ There was no statistically significant difference in ■ Fracture healing time was longer in the open
the percentage of cases with persistent post-operative reduction group (5.3 months) compared with the
neurological impairment in the ulnar nerves between closed reduction group (4.8 months) [Ozkoc].
the open and closed reduction groups (Figure 3).
80
ns P = .036
60
40
20
%
Excellent
Good
Fair
Poor
Excellent
Good
Fair
Poor
Excellent
Good
Fair
Poor
Excellent
Good
Fair
Poor
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 1–8
6 | Results | Supracondylar humeral fractures in children
Degree
of change
10
P = .83
6
P >= .05
P = .8
2
16
P = .47
12
8
ns
Orthop. trauma dir. 2005; 02; 1– 8 AO Journal Club / Evidence from the Literature
Supracondylar humeral fractures in children | Clinical notes | 7
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 1–8
8 | Clinical notes | Supracondylar humeral fractures in children
Orthop. trauma dir. 2005; 02; 1– 8 AO Journal Club / Evidence from the Literature
Posterior wall fractures of the acetabulum | 9
Clinical topic
Summary
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 9–20
10 | Summary | Posterior wall fractures of the acetabulum
Sampling Objective
A MEDLINE search was performed to identify studies To critically summarize recently published studies
published from January 1999 to June 2004 examining that examine prognostic factors for a poor outcome
prognostic factors following posterior wall fractures following posterior wall fractures of the acetabulum.
of the acetabulum. From a list of 23 articles identified
from the search strategy, four articles with similar Prognostic factors evaluated:
outcomes were identified. Two prospective studies ■ Demographics (age, sex).
report on the same overall population, however, ■ Time of injury to hip reduction.
different outcomes measures are assessed. ■ Injury characteristics (fracture comminution).
■ Gap characteristics (width, length, dimension,
area, location).
Studies ■ Bone characteristics (osteonecrosis, heterotopic
Study 1 ossification).
Moed BR, Carr SEW, Watson JT (2002) ■ Loss of joint space.
Results of operative treatment of fractures of the
posterior wall of the acetabulum.
J Bone Joint Surg Am; 84(5):752–758. Outcome measures
■ Merle D'Aubigne-Postel hip score to assess
Study 2 functional outcome (excellent, good, fair, poor).
Moed BR, Carr SEW, Gruson KI, et al (2003) ■ Matta hip rating scale (modification of Merle
Computed tomographic assessment of fractures of D'Aubigne-Postel hip score) to assess functional
the posterior wall of the acetabulum after operative outcome (excellent, very good, good, fair, poor).
treatment. ■ Matta radiographic results (excellent, good, fair,
J Bone Joint Surg Am; 85(3):512–522. poor).
■ Musculoskeletal Function Assessment (MFA)
Study 3 (scores from 0 = minimal dysfunction to
Rommens PM, Gimenez MV, Hessmann M (2001) 100 = severe dysfunction)
Posterior wall fractures of the acetabulum: ■ Complete loss of joint space.
characteristics, management, prognosis.
Acta Chir Belg; 101(6):287–293.
Study 4
Saterbak AM, Marsh JL, Nepola JV, et al (2000)
Clinical Failure after posterior wall acetabular
fractures: the influence of initial fracture patterns.
J Orthop Trauma; 14(4):230–237.
Orthop. trauma dir. 2005; 02; 9–20 AO Journal Club / Evidence from the Literature
Posterior wall fractures of the acetabulum | Summary | 11
Study design
Characteristics of included studies that examine prognostic factors following posterior wall fractures of the acetabulum,
published 1999–2003.
* 108 patients were treated by open reduction and internal fixation; however only 100 patients who were followed for a minimum of two years were included in the
data analysis.
† 114 patients were treated by open reduction and internal fixation; however only 67 patients who were followed for a minimum of two years or had a clearly poor
clinical result after less than two years of follow-up (n = 6) were included in the data analysis.
‡ Mean follow-up does not include the 6 patients who had a poor clinical result after less than two years of follow-up.
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 9–20
12 | Summary | Posterior wall fractures of the acetabulum
* Location of gap deficit was determined by dividing the posterior half of the acetabular surface into thirds: superior (proximal to the middle third),
posterior (the middle third), inferior (distal to the middle third).
Orthop. trauma dir. 2005; 02; 9–20 AO Journal Club / Evidence from the Literature
Posterior wall fractures of the acetabulum | Appraisal | 13
Reviewers’ evaluation
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 9–20
14 | Results | Posterior wall fractures of the acetabulum
Results
■ Overall hip scale ratings indicate that between ■ Factors significantly associated with complete loss
10–30% of patients show a poor-to-fair functional of joint space included posterior wall comminution
outcome (Figure 1). of three fragments or more (P=.001) and depth
of posterior wall fractures just below the roof of the
■ The factors most associated with poor-to-fair acetabulum (P=.045) [Saterbak].
functional and radiographic results were older age
at time of injury (P=.0056) [Moed 2002], a delay ■ Complete loss of joint space as a prognostic factor
of more than 12 hours between time of injury and was associated with a 7-fold increased risk of a
the reduction of the hip dislocation (P=.0018) poor-to-fair functional outcome (P=.002) [Saterbak]
[Moed 2002], and evidence of osteonecrosis of the (Figure 2) and consistently lower scores on the MFA
femoral head (P=.038) [Moed 2003]. subscales compared to those without complete loss
(mean MFA score was 26.1 and 47.3, respectively)
■ Several gap parameters were also significantly (P<.01) (Figure 3). However, there was no association
associated with poor-to-fair functional and between posttraumatic complex articular damage
radiographic outcomes (Table). Overall, 35.8% and functional outcome [Rommens].
(87.5% with a fair-to-poor clinical outcome, and
28.8% with a good or excellent clinical outcome, ■ Several complications were reported: hematomas
P=.002) of hips contained at least one gap with [Moed, Rommens], implant loosening [Rommens],
a dimension of ≥ 10 mm. recurrent dislocation [Rommens], deep-vein
thrombosis [Moed, Rommens], pulmonary embolism
[Rommens], deep infection [Moed, Rommens], and
■ Gap parameters associated with poor-to-fair sciatic nerve injury [Saterbak].
functional and radiographic outcomes*.
Significance (P values)
Orthop. trauma dir. 2005; 02; 9–20 AO Journal Club / Evidence from the Literature
Posterior wall fractures of the acetabulum | Results | 15
Figure 1 | Functional outcomes assessed using hip rating scales (%) after posterior wall fractures of the acetabulum.
Poor Fair
Rommens (2*) 15
15
Saterbak (4*) 0
(no joint space loss)
6
Saterbak 0 P= .002
(joint space loss)
45
% 0 10 20 30 40 50
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 9–20
16 | Results | Posterior wall fractures of the acetabulum
Figure 2 | Relative risks (RR) and 95% confidence intervals of poor-to-fair functional outcomes after posterior wall
fractures of the acetabulum.
100
10
0.1
RR* Posttraumatic complex articular damage versus no damage Complete loss of joint space versus no complete loss
* Crude RRs were calculated from proportions given in the text. The relative risk (represented by the boxes) gives the reader a relative comparison of outcomes between two
groups that have different exposures. For example, patients who have complete loss of joint space are over 7 times more likely to have a poor-to-fair functional outcome
(RR=7.05) compared with those who have no complete loss of joint space. Statistical significance is reached if the 95% confidence intervals (represented by the vertical lines
through the boxes) do not cross the value of 1.
Orthop. trauma dir. 2005; 02; 9–20 AO Journal Club / Evidence from the Literature
Posterior wall fractures of the acetabulum | Results | 17
Mobility
Housework
Sleep/rest
Leisure/recreation
Relationships
Cognition
Emotion/adjustment
Employment
Subscale score 0 10 20 30 40 50 60 70 80
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 9–20
18 | Clinical Notes | Posterior wall fractures of the acetabulum
Orthop. trauma dir. 2005; 02; 9–20 AO Journal Club / Evidence from the Literature
Posterior wall fractures of the acetabulum | Clinical Notes | 19
During surgery
Besides accurate anatomical reduction and high stability
fixation, careful handling of the muscle tissue during the
exposure and debridement of all necrotic muscle tissue at
the end of the operation is mandatory to avoid heterotopic
ossification [3]. When faced with a superior fracture ex-
tension of the posterior wall, an additional trochanteric
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 01; 9–20
20 | Clinical Notes | Posterior wall fractures of the acetabulum
2 Matta JM (1996)
Fracture of the acetabulum: accuracy of reduction and
clinical results in patients managed operatively within
three weeks after the injury.
J Bone Joint Surg Am; 78(11):1632–1645.
Orthop. trauma dir. 2005; 01; 9–20 AO Journal Club / Evidence from the Literature
Implant-related femoral fractures | 21
Clinical topic
Summary
Studies have identified intrinsic and extrinsic risk factors for implant-related
fractures. The intrinsic factors reported to be associated with an increased risk of
implant-related fracture include older age, lower canal flare index and poorer
bone quality. Extrinsic factors include fracture as an indication for the index surgery
compared with all other reasons for the index operation, use of a gamma nail
compared with the compression hip screw or cannulated screw for hip fixation,
and revision hip arthroplasty compared with primary hip arthroplasty for index
surgery.
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 21–28
22 | Summary | Implant-related femoral fractures
Sampling Objective
A MEDLINE search was performed to identify studies To critically summarize recently published studies
published from January 1998 to June 2004 examining that examine risk factors for implant-related fractures
risk factors associated with implant-related fractures of of the femur following hip surgery.
the femur following hip surgery.
From a list of articles identified from the search strate- Prognostic factors evaluated
gy, four studies have been included in this Evidence ■ Demographics (age, sex, body mass index,
Report: two studies (retrospective cohort and case- prefracture residence, history of previous fracture).
control) conducted on the same Finnish population, a ■ Initial diagnosis.
retrospective cohort study from China, and a prospec- ■ Bone characteristics (canal flare index, bone
tive cohort study conducted in the UK. quality).
■ Treatment (type of prosthesis, complications).
Studies
Study 1 Outcome measures
Wu CC, Au MK, Wu SS, et al (1999) ■ Implant-related femoral fracture following hip
Risk factors for postoperative femoral fracture in surgery.
cementless hip arthroplasty.
J Formos Med Assoc; 98(3):190–194.
Study 2
Robinson CM, Adams CI, Craig M, et al (2002).
Implant-related fractures of the femur following hip
fracture surgery.
J Bone Joint Surg Am; 84–A(7):1116–1122.
Study 3
Sarvilinna R, Huhtala HSA, Puolakka TJS,
et al (2003).
Periprosthetic fractures in total hip arthroplasty.
Int Orthop; 27(6):359–361.
Study 4
Sarvilinna R, Huhtala HSA, Sovelius RT,
et al (2004).
Factors predisposing to periprosthetic fracture after
hip arthroplasty: a case (n=31)-control study.
Acta Orthop Scand; 75(1):16–20.
Orthop. trauma dir. 2005; 02; 21–28 AO Journal Club / Evidence from the Literature
Implant-related femoral fractures | Summary | 23
Study design
Characteristics of included studies that examine prognostic factors for implant-related fracture (IRF) following hip
surgery, published 1999–2004.
Author Study design Study Population Type of index Time to implant- Methods score
(year) (out of 6)
procedure/implant* related fracture or
follow-up
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 21–28
24 | Summary | Implant-related femoral fractures
Orthop. trauma dir. 2005; 02; 21–28 AO Journal Club / Evidence from the Literature
Implant-related femoral fractures | Appraisal | 25
Reviewers’ evaluation
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 21–28
26 | Results | Implant-related femoral fractures
Results
■ Although more females tended to have implant- ■ One study observed a 3-fold increased risk of fracture
related fractures, sex was not a significant independ- with use of a Gamma nail compared with the
ent predictor of fracture [Sarvilinna 2003, Sarvilinna compression hip screw or cannulated screw to treat
2004, Wu, Robinson]. extracapsular fractures (RR 3.0, 95% CI 1.5–6.1;
P=.003) [Robinson]. There was a 4-fold increased
■ Older patients tended to have more frequent risk of implant-related fracture with revision to an
implant-related fractures compared with younger arthroplasty with cement (RHA) compared with
patients. In one study, age was significantly higher primary THA with cement (RR 4.0, 95% CI 2.2–7.2;
among cases with implant-related fracture (mean P<.001) [Robinson] (Figure 2). The risk of implant-
65.6 ± 10.9 versus 52.6 ± 16.2 years; P<.001) [Wu] related fracture was not associated with the use of
(Figure 1). In another study, those who were more cement in primary hip arthroplasty [Sarvilinna 2003,
than 70 years were nearly twice as likely to sustain Sarvilinna 2004].
an implant-related fracture compared with those
who were less than 70 years, though this association
did not reach statistical significance (RR = 1.9, 95%
confidence interval = 0.7–5.3) [Sarvilinna 2004].
Orthop. trauma dir. 2005; 02; 21–28 AO Journal Club / Evidence from the Literature
Implant-related femoral fractures | Results | 27
Figure 1 | Prognostic factors for implant-related fracture following uncemented hip arthroplasty (mean ± SD) [Wu]
Subjects Controls
Age
P <.100
Bone quality
P <.01
Mean 0 10 20 30 40 50 60 70 80 90
Figure 2 | Relative risk and 95% confidence intervals of implant-related fractures for three risk factors.
100
10
0.1
RR* Fracture versus other reason for surgery Gamma nail versus CHS RHA (cement) versus primary THA
* Relative risk (RR) or the odds ratio that estimates the relative risk (represented by the boxes) give the reader a relative comparison or risk of a certain outcome between two
groups that have different exposures. For example, patients who receive an implant due to a fracture are over 4 times more likely to have an implant-related fracture
(RR = 4.4) compared with those who receive an implant for other reasons (eg, arthrosis). Statistical significance is reached if the 95% confidence intervals (represented by
the vertical lines through the boxes) do not cross the value of 1.
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 21–28
28 | Clinical notes | Implant-related femoral fractures
Orthop. trauma dir. 2005; 02; 21–28 AO Journal Club / Evidence from the Literature
Classical article review | 29
Author summary
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 29–34
30 | Classical article review
Questionnaire development
The forty-six items selected for the SMFA were
identified from analyses of baseline and follow-up
data on patients who had responded to the original
Musculoskeletal Function Assessment (MFA).
Orthop. trauma dir. 2005; 02; 29–34 AO Journal Club / Evidence from the Literature
Classical article review | 31
prospective mean age: 48.9 ± 16.0 At least 18 years old. Head injury. 3 or 6 months
diagnostic Male: 43% Acute fracture or Fracture of the spine/ (77.6%)
caucasion: 91% soft-tissue injury of an neurological deficit.
N = 420 extremity or the spine. Neuromuscular
A repetitive- diseases.
motion disorder. Amputation secondary
Osteoarthritis or to systemic disease.
rheumatoid arthritis. History of a stroke or
cardiovascular disease.
End-stage renal disease.
Cancer or AIDS.
Serious psychiatric
or cognitive limitation.
Inability to speak
or understand English.
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 29–34
32 | Classical article review
Results
■ Both indexes demonstrated excellent reliability with ■ The dysfunction and bother indexes were not
intraclass correlation coefficients of 0.93 and 0.88 significantly related to the physicians' ratings of
for the dysfunction index and the bother index, mobility of the lower extremities or mobility of the
respectively. upper extremities (rho = 0.10–0.36).
Cronbach's alpha values for baseline and follow-up The SMFA indexes were found to be significantly
data, measuring internal consistency, were 0.95 related to walking speed and grip strength and
and 0.96 for the dysfunction index and 0.92 and the dysfunction index alone correlated with range of
0.95 for the bother index. motion of the ankle and wrist (r = 0.40).
■ Both indexes displayed good score ranges, distribu- The SMFA indexes were found to be significantly
tions with little skew, no floor effects and few ceiling related to all comparable SF-36 subscales (P=.000).
effects. Changes in both indexes from baseline to follow-up
was significantly different (P=.01) for patients who
■ The SMFA indexes were highly correlated with reported that their health was “worse” or “much
physicians' ratings for activities of daily living, worse” and for those who reported that their health
recreational and leisure activities, and emotional was “better” or “much better” (Figure 2).
function (rho ≥ 0.40).
Standardized response means for patients who
reported health changes ranged from 0.76 (patients
who reported “better” or “much better” on the
bother index) to 1.14 (patients who reported “worse”
or “much worse” on the dysfunction index).
Orthop. trauma dir. 2005; 02; 29–34 AO Journal Club / Evidence from the Literature
Classical article review | 33
Allow patients to assess how much they are ■ Amount of difficulty one has performing certain functions (25 items)
bothered by problems in the following broad ■ How often one has difficulty when performing certain functions (9 items)
functional areas:
■ Recreation and leisure Functions are divided into the following 4 categories
■ Mobility
Responsiveness of the SMFA According to the Patient’s Reports of Changes in Health Status
60
40
20
SMFA Score Whorse health Health the same Better health Whorse health Health the same Better health
AO Journal Club / Evidence from the Literature Orthop. trauma dir. 2005; 02; 29–34
34 | Classical article review
Orthop. trauma dir. 2005; 02; 29–34 AO Journal Club / Evidence from the Literature