Cargando…

Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms

BACKGROUND: A comprehensive overview of treatments of common fractures is missing, although it would be important for shared decision-making in clinical practice. The aim was to determine benefits and harms of surgical compared to non-surgical treatments for traumatic skeletal fractures. METHODS: We...

Descripción completa

Detalles Bibliográficos
Autores principales: Skou, Søren T., Juhl, Carsten B., Hare, Kristoffer B., Lohmander, L. Stefan, Roos, Ewa M.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2020
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7425058/
https://www.ncbi.nlm.nih.gov/pubmed/32792014
http://dx.doi.org/10.1186/s13643-020-01424-4
_version_ 1783570422511435776
author Skou, Søren T.
Juhl, Carsten B.
Hare, Kristoffer B.
Lohmander, L. Stefan
Roos, Ewa M.
author_facet Skou, Søren T.
Juhl, Carsten B.
Hare, Kristoffer B.
Lohmander, L. Stefan
Roos, Ewa M.
author_sort Skou, Søren T.
collection PubMed
description BACKGROUND: A comprehensive overview of treatments of common fractures is missing, although it would be important for shared decision-making in clinical practice. The aim was to determine benefits and harms of surgical compared to non-surgical treatments for traumatic skeletal fractures. METHODS: We searched Medline, Embase, CINAHL, Web of Science, and CENTRAL until November 2018, for randomized trials of surgical treatment in comparison with or in addition to non-surgical treatment of fractures in adults. For harms, only trials with patient enrollment in 2000 or later were included, while no time restriction was applied to benefits. Two reviewers independently assessed studies for inclusion, extracted data from full-text trials, and performed risk of bias assessment. Outcomes were self-reported pain, function, and quality of life, and serious adverse events (SAEs). Random effects model (Hedges’ g) was used. RESULTS: Out of 28375 records screened, we included 61 trials and performed meta-analysis on 12 fracture types in 11 sites: calcaneus, clavicula, femur, humerus, malleolus, metacarpus, metatarsus, radius, rib, scaphoideum, and thoraco-lumbar spine. Seven other fracture types only had one trial available. For distal radius fractures, the standardized mean difference (SMD) was 0.31 (95% CI 0.10 to 0.53, n = 378 participants) for function, favoring surgery, however, with greater risk of SAEs (RR = 3.10 (1.42 to 6.77), n = 436). For displaced intra-articular calcaneus fractures, SMD was 0.64 (0.13 to 1.16) for function (n = 244) and 0.19 (0.01 to 0.36) for quality of life (n = 506) favoring surgery. Surgery was associated with a smaller risk of SAE than non-surgical treatment for displaced midshaft clavicular fractures (RR = 0.62 (0.42 to 0.92), n = 1394). None of the other comparisons showed statistical significance differences and insufficient data existed for most of the common fracture types. CONCLUSIONS: Of 12 fracture types with more than one trial, only two demonstrated a difference in favor of surgery (distal radius fractures and displaced intra-articular calcaneus fractures), one of which demonstrated a greater risk of harms in the surgical group (distal radius fractures). Our results highlight the current paucity of high-quality randomized trials for common fracture types and a considerable heterogeneity and risk of bias in several of the available trials. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015020805
format Online
Article
Text
id pubmed-7425058
institution National Center for Biotechnology Information
language English
publishDate 2020
publisher BioMed Central
record_format MEDLINE/PubMed
spelling pubmed-74250582020-08-16 Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms Skou, Søren T. Juhl, Carsten B. Hare, Kristoffer B. Lohmander, L. Stefan Roos, Ewa M. Syst Rev Research BACKGROUND: A comprehensive overview of treatments of common fractures is missing, although it would be important for shared decision-making in clinical practice. The aim was to determine benefits and harms of surgical compared to non-surgical treatments for traumatic skeletal fractures. METHODS: We searched Medline, Embase, CINAHL, Web of Science, and CENTRAL until November 2018, for randomized trials of surgical treatment in comparison with or in addition to non-surgical treatment of fractures in adults. For harms, only trials with patient enrollment in 2000 or later were included, while no time restriction was applied to benefits. Two reviewers independently assessed studies for inclusion, extracted data from full-text trials, and performed risk of bias assessment. Outcomes were self-reported pain, function, and quality of life, and serious adverse events (SAEs). Random effects model (Hedges’ g) was used. RESULTS: Out of 28375 records screened, we included 61 trials and performed meta-analysis on 12 fracture types in 11 sites: calcaneus, clavicula, femur, humerus, malleolus, metacarpus, metatarsus, radius, rib, scaphoideum, and thoraco-lumbar spine. Seven other fracture types only had one trial available. For distal radius fractures, the standardized mean difference (SMD) was 0.31 (95% CI 0.10 to 0.53, n = 378 participants) for function, favoring surgery, however, with greater risk of SAEs (RR = 3.10 (1.42 to 6.77), n = 436). For displaced intra-articular calcaneus fractures, SMD was 0.64 (0.13 to 1.16) for function (n = 244) and 0.19 (0.01 to 0.36) for quality of life (n = 506) favoring surgery. Surgery was associated with a smaller risk of SAE than non-surgical treatment for displaced midshaft clavicular fractures (RR = 0.62 (0.42 to 0.92), n = 1394). None of the other comparisons showed statistical significance differences and insufficient data existed for most of the common fracture types. CONCLUSIONS: Of 12 fracture types with more than one trial, only two demonstrated a difference in favor of surgery (distal radius fractures and displaced intra-articular calcaneus fractures), one of which demonstrated a greater risk of harms in the surgical group (distal radius fractures). Our results highlight the current paucity of high-quality randomized trials for common fracture types and a considerable heterogeneity and risk of bias in several of the available trials. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015020805 BioMed Central 2020-08-13 /pmc/articles/PMC7425058/ /pubmed/32792014 http://dx.doi.org/10.1186/s13643-020-01424-4 Text en © The Author(s) 2020 Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
spellingShingle Research
Skou, Søren T.
Juhl, Carsten B.
Hare, Kristoffer B.
Lohmander, L. Stefan
Roos, Ewa M.
Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms
title Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms
title_full Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms
title_fullStr Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms
title_full_unstemmed Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms
title_short Surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms
title_sort surgical or non-surgical treatment of traumatic skeletal fractures in adults: systematic review and meta-analysis of benefits and harms
topic Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7425058/
https://www.ncbi.nlm.nih.gov/pubmed/32792014
http://dx.doi.org/10.1186/s13643-020-01424-4
work_keys_str_mv AT skousørent surgicalornonsurgicaltreatmentoftraumaticskeletalfracturesinadultssystematicreviewandmetaanalysisofbenefitsandharms
AT juhlcarstenb surgicalornonsurgicaltreatmentoftraumaticskeletalfracturesinadultssystematicreviewandmetaanalysisofbenefitsandharms
AT harekristofferb surgicalornonsurgicaltreatmentoftraumaticskeletalfracturesinadultssystematicreviewandmetaanalysisofbenefitsandharms
AT lohmanderlstefan surgicalornonsurgicaltreatmentoftraumaticskeletalfracturesinadultssystematicreviewandmetaanalysisofbenefitsandharms
AT roosewam surgicalornonsurgicaltreatmentoftraumaticskeletalfracturesinadultssystematicreviewandmetaanalysisofbenefitsandharms