Surgical rib fracture fixation : systematic review of effectiveness, assessment of current UK practice, and development of a core outcome set

AimTo synthesise contemporary evidence for rib fracture fixation, and thereby to fill the gaps in the knowledge required to inform a trial and provide recommendations for future study.MethodA systematic review of systematic reviews and a meta-analysis of primary research were the methods used to examine the effectiveness of rib fracture fixation. Delphi consensus methods were used to survey three international stakeholder groups so as to define a core outcome set and a consensus on indications for and timing of rib fracture fixation. A United Kingdom (UK) survey assessed the provision of rib fracture care and analysis of a UK trauma database assessed the factors that predict rib fixation and the outcomes experienced by rib fracture patients.ResultsThe systematic reviews and meta-analysis suggest that rib fracture fixation shortens the duration of mechanical ventilation, reduces critical care and hospital stay as well as overall mortality. UK clinical data suggests that rib fracture fixation improves these outcomes, and that early intervention confers an advantage over late fixation. With regard to which patients receive an intervention; fracture pattern, pulmonary contusion, admission to a major trauma centre, injury severity and age are all important predictors of undergoing surgery. A core outcome set was derived to include 23 outcomes. Consensus was achieved on 20 indications and 7 timings of surgery. Care of rib fracture patients in England and Wales is delivered in a variety of centres with different care protocols, referral pathways, lead specialties and rehabilitation services.ConclusionFurther evidence is required to assess the effectiveness of rib fracture fixation. A feasibility trial is required to understand more clearly if clinicians have equipoise, patients are willing to be randomised and whether comparative care can be delivered. A trial will need to be stratified for surgical indication and further study is required to define outcome instruments

Systematic Review of Systematic Reviews for Effectiveness of Internal Fixation for Flail Chest and Rib Fractures in Adults

Objectives Multiple systematic reviews have reported on the impact of rib fracture fixation in the presence of flail chest and multiple rib fractures, however this practice remains controversial. Our aim is to synthesise the effectiveness of surgical fixation of rib fractures as evidenced by systematic reviews. Design A systematic search identified systematic reviews comparing effectiveness of rib fracture fixation with non-operative management of adults with flail chest or multiple rib fractures. MEDLINE, EMBASE, Cochrane Database of Systematic Reviews (CDSR) and Science Citation Index were last searched 17th March 2017. Risk of bias was assessed using the ROBIS tool. The primary outcome was duration of mechanical ventilation. Results Twelve systematic reviews were included, consisting of 3 unique randomised controlled trials, 19 non-randomised studies). Length of mechanical ventilation was shorter in the fixation group compared to the non–operative group in flail chest; pooled estimates ranged from -4.52 days, 95% CI [-5.54, -3.5] to -7.5 days, 95% CI [-9.9, -5.5]. Pneumonia, length of hospital and ICU stay all showed a statistically significant improvement in favour of fixation for flail chest; however, all outcomes in favour of fixation had substantial heterogeneity. There was no statistically significant difference between groups in mortality. Two systematic reviews included one non-randomised studies of multiple rib fracture population; due to limited evidence the benefits with surgery are uncertain. Conclusions Synthesis of the reviews has shown some potential improvement in patient outcomes with flail chest after fixation. For future review updates, meta-analysis for effectiveness may need to take into account indications and timing of surgery as a subgroup analysis to address clinical heterogeneity between primary studies. Further robust evidence isrequired before conclusions can be drawn of the effectiveness of surgical fixation for flail chest and in particular, multiple rib fractures

Removal of a below knee plaster cast worn for 28 months: a case report

<p>Abstract</p> <p>Introduction</p> <p>An unusual situation in which a below knee cast was removed after 28 months is reported. To the best of our knowledge no similar cases have been reported in the literature.</p> <p>Case presentation</p> <p>The cast was removed from the leg of a 45-year-old Caucasian woman. Significant muscle atrophy and dense skin scales were present but the underlying skin surface was relatively healthy with only small pitted 1-2 mm ulcers. No pathogenic organisms were cultured from this environment.</p> <p>Conclusion</p> <p>It seems likely that skin can tolerate cast immobilization for prolonged duration.</p

Effectiveness of surgical fixation for lateral compression type one (LC-1) fragility fractures of the pelvis: a systematic review

Objectives: To undertake a systematic review of the evidence base for the effectiveness of surgical fixation of lateral compression (LC-1) fragility fractures of the pelvis compared to non-surgical approaches. Searches: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and two international trials registers were searched up to January 2017 (Medline to February 2019) for studies of internal or external fixation of fragility fractures of the pelvis. Participants: Patients with lateral compression pelvic fractures (LC-1 fractures), sustained as the result of a low energy mechanism, defined as a fall from standing height or less. Interventions: Surgery using either external or internal fixation devices. Conservative non-surgical treatment was the defined comparator. Outcome measures: Outcomes of interest were patient mobility and function, pain, quality of life, fracture union, mortality, hospital length of stay and complications (additional operative procedures, number and type of adverse events and serious adverse events). Quality assessment and synthesis: The Joanna Briggs Institute Checklist for Case Series was used to assess the included studies. Results were presented in a narrative synthesis. Results: Of 3421 records identified, four retrospective case series met the inclusion criteria. Fixation types were not consistent between studies or within studies and most patients had more than one type of pelvic fixation. Where reported, mobility and function improved post-surgery, and a reduction in pain was recorded. Length of hospital stay ranged from four days to 54 days for surgical fixation of any type. Reported complications and adverse outcomes included: infections, implant loosening, pneumonia and thrombosis. Use of analgesia was not reported, Conclusions: There is insufficient evidence to support guidance on the most effective treatment for patients who fail to mobilise after sustaining an LC-1 fragility fracture. Registration: PROSPERO registration number: CRD4201705587

Supplementary Table 1 -Supplemental material for Scoping review: Diagnosis and management of periprosthetic joint infection in shoulder arthroplasty

<p>Included Studies</p

Supplementary Table 8 -Supplemental material for Scoping review: Diagnosis and management of periprosthetic joint infection in shoulder arthroplasty

<p>Surgical Management of PSI</p

Supplementary Table 6 -Supplemental material for Scoping review: Diagnosis and management of periprosthetic joint infection in shoulder arthroplasty

<p>Prophylaxis</p

Supplementary Table 3 -Supplemental material for Scoping review: Diagnosis and management of periprosthetic joint infection in shoulder arthroplasty

<p>Incidence of PSI</p