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Meta-Analysis
. 2020 Aug 13;9(1):179.
doi: 10.1186/s13643-020-01424-4.

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

Søren T Skou  1   2 , Carsten B Juhl  3   4 , Kristoffer B Hare  5   6   7 , L Stefan Lohmander  8 , Ewa M Roos  3
Affiliations
Meta-Analysis

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

Søren T Skou et al. Syst Rev. .

Abstract

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.

Keywords: Fracture; Orthopedics; Randomized, controlled trial; Systematic review; Therapeutics.

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Conflict of interest statement

EMR is deputy editor of Osteoarthritis and Cartilage, the developer of the Knee injury and Osteoarthritis Outcome Score (KOOS) and several other freely available patient-reported outcome measures and co-founder of Good Life with Osteoarthritis in Denmark (GLA:D), a not-for-profit initiative hosted at the University of Southern Denmark aimed at implementing clinical guidelines for osteoarthritis in clinical practice.

STS is an associate editor of the Journal of Orthopaedic & Sports Physical Therapy, has received grants from The Lundbeck Foundation, personal fees from Munksgaard, all outside the submitted work. He is co-founder of GLA:D. GLA:D is a not-for-profit initiative hosted at the University of Southern Denmark aimed at implementing clinical guidelines for osteoarthritis in clinical practice.

The authors report no other conflict of interest.

Figures

Fig. 1
Fig. 1
Selection of trials of surgical and non-surgical treatment of fractures
Fig. 2
Fig. 2
Results of the analysis of effects of surgical and non-surgical treatment on pain. Fracture sites are in alphabetic order
Fig. 3
Fig. 3
Results of the analysis of effects of surgical and non-surgical treatment on function. Fracture sites are in alphabetic order
Fig. 4
Fig. 4
Results of the analysis of effects of surgical and non-surgical treatment on quality of life. Fracture sites are in alphabetic order
Fig. 5
Fig. 5
Results of the analysis of effects of surgical and non-surgical treatment on serious adverse events. Fracture sites are in alphabetic order
See this image and copyright information in PMC

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References

    1. Donaldson LJ, Reckless IP, Scholes S, Mindell JS, Shelton NJ. The epidemiology of fractures in England. J Epidemiol Community Health. 2008;62(2):174–180. - PubMed
    1. Curtis EM, van der Velde R, Moon RJ, van den Bergh JP, Geusens P, de Vries F, et al. Epidemiology of fractures in the United Kingdom 1988-2012: variation with age, sex, geography, ethnicity and socioeconomic status. Bone. 2016;87:19–26. - PMC - PubMed
    1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(8):691–697. - PubMed
    1. Global Burden of Disease Study 2013 Collaborators Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(9995):743–800. - PMC - PubMed
    1. Leal J, Gray AM, Prieto-Alhambra D, Arden NK, Cooper C, Javaid MK, et al. Impact of hip fracture on hospital care costs: a population-based study. Osteoporos Int. 2016;27(2):549–558. - PMC - PubMed

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