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Meta-analysis
ACE Report #6244

Antegrade intramedullary nailing the favoured procedure for fifth metacarpal neck fracture


Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:2

Antegrade intramedullary nailing for fifth metacarpal neck fractures: a systematic review and meta-analysis

Eur J Orthop Surg Traumatol. 2014 Apr;24(3):273-8. doi: 10.1007/s00590-013-1344-5. Epub 2013 Oct 27.

Contributing Authors: K Yammine A Harvey

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Synopsis

4 studies (3 quasi-randomized trials and 1 randomized controlled trial) comparing antegrade intramedullary nailing (AIMN) with other surgical interventions for fifth metacarpal neck fractures were included in this review to compare treatment efficacy. Pooled data demonstrated trends favouring AIMN for pain scores, the incidence of complications and mean residual angulation at the site of fracture. Additionally, AIMN yielded significantly greater grip strength at 12 months and improved range of motion of the metacarpophalangeal joint. When compared to transverse pinning (TP) with K-wires, AIMN yielded significantly better total active motion and greater patient satisfaction.

Publication Funding Details +
Funding:
Not Reported
Conflicts:
None disclosed

Risk of Bias

7.5/10

Reporting Criteria

18/20

Fragility Index

N/A

Were the search methods used to find evidence (original research) on the primary question or questions stated?

Was the search for evidence reasonably comprehensive?

Were the criteria used for deciding which studies to include in the overview reported?

Was the bias in the selection of studies avoided?

Were the criteria used for assessing the validity of the included studies reported?

Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?

Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?

Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?

Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?

How would you rate the scientific quality of this evidence?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.

4/4

Introduction

4/4

Accessing Data

4/4

Analysing Data

3/4

Results

3/4

Discussion

Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65

The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now?

Fractures of the neck of the fifth metacarpal, also known as boxer's fractures, are common and may require surgical intervention. The clinical recommendations regarding the optimal conditions for surgical intervention, however, are inconsistent in the literature. Operative procedures to treat this type of fracture include antegrade intramedullary nailing (AIMN), retrograde pinning (RP) or transverse pinning (TP) using intramedullary K-wires, external fixation, and standard plates. Although AIMN is less invasive and is commonly used in clinical practice, evidence is conflicted regarding the superiority of its efficacy over other surgical treatment approaches.

What was the principal research question?

When treating fifth metacarpal neck fractures, is antegrade intramedullary nailing (AIMN) more efficacious than other surgical interventions?

Study Characteristics -
Data Source:
The following databases were searched: The Cochrane Central Register of Controlled Trials (CENTRAL) - The Cochrane Library (up to May 2013), Ovid MEDLINE (from 1985 to week 22 of 2013), Ovid EMBASE (from 1974 to week 22 of 2013), Ovid CINAHL (from 1982 to week 22 of 2013), and the Centre for Reviews and Dissemination (up to May 2013). A manual search of reference lists was also performed.
Index Terms:
Search terms included: "metacarpal fractures" OR "boxer's fracture" OR "fifth metacarpal fracture" OR "little finger fracture".
Study Selection:
Study selection was performed independently by two reviewers, with disagreements being resolved through discussion. Studies were included if they: (1) were quasi- or fully-randomized studies, (2) included an adult population with fifth metacarpal neck fractures, (3) compared antegrade intramedullary nailing (AIMN) to another surgical treatment.
Data Extraction:
Data extraction was performed by one independent author, and results were reviewed by another independent author. Any disagreement was resolved through discussion. The primary extracted outcome was the number of patients with an uncomplicated, pain-free fifth metacarpal joint with acceptable radiological and aesthetic outcomes. As such, the functional outcomes consisted of pain, the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) scores, grip strength, total active motion and range of motion of the fifth metacarpal joint. Clinical outcomes included complications (i.e. head necrosis, material issues, neurological lesions, aesthetic issues, revision surgery, stiffness and tendon rupture), as well as patient satisfaction. Lastly, secondary outcomes included radiological outcomes (i.e. anatomical restoration, delayed union, malunion).
Data Synthesis:
Data was pooled using a fixed effects model when possible. Statistical heterogeneity was assessed by computing the Q Cochrane and I-squared statistics. Clinical heterogeneity was also assessed.

What were the important findings?

  • 4 studies (3 quasi-randomized trials and one randomized controlled trial) were included in this meta-analysis. In total, 163 patients were included (mean age 29.1 years [range 18-65]).
  • There was no significant difference between groups with respect to pooled pain scores from 3 studies (n=133; MD -0.18; 95% CI -0.528 to 0.154; p=0.2; I-squared 0%).
  • Quick DASH scores were reported in one study, demonstrating no significant difference between AIMN and plates.
  • Although there was no significant difference between AIMN and plates in grip strength at 3-6 months (2 studies; MD -0.28; 95% CI -0.773 to 0.204; p=0.2), AIMN yielded significantly greater grip strength at 12 months compared to either plates or transverse pinning (3 studies; MD 0.84; 95% CI 0.468 to 1.206; p<0.0001; I-squared 54.5%).
  • When compared to transverse pinning (TP) with K-wires, AIMN resulted in significantly greater total active motion at 12 months (2 studies; pooled effect size 0.5; 95% CI 0.087 to 0.904; p=0.01; Q: p=0.316). In the only study reporting patient satisfaction following TP and AIMN, 15/16 patients (94%) in the AIMN group were either "satisfied" or "very satisfied", which was likewise displayed by 13/17 patients (76.5%) in the TP group.
  • With respect to range of motion of the metacarpophalangeal joint, one study, at a follow-up of <6 months, reported a significant difference in favour of AIMN (p=0.001). At 12 months, pooled data from three studies also found a significant difference in favour of AIMN (pooled effect size 1.45; 95% CI 0.787 to 2.106; p<0.0001; I-squared 55.9%).
  • The incidence of complications was lower with AIMN compared to all other surgical interventions, with this difference being borderline-significant (OR 0.4; 95% CI 0.155 to 1.028; p=0.05; I-squared 0%).
  • Pooled data on mean residual angulation at the site of fracture from 3 studies favoured AIMN, with the difference being borderline significant (pooled effect size -0.4; 95% CI -0.779 to 0.000042; p=0.05; I-squared 0%).

What should I remember most?

Trends favouring antegrade intramedullary nailing (AIMN) were found for pain scores, the incidence of complications and mean residual angulation at the site of fracture. Additionally, AIMN yielded significantly greater grip strength at 12 months and range of motion of the metacarpophalangeal joint. When compared to transverse pinning (TP) with K-wires, AIMN yielded significantly better total active motion and greater patient satisfaction.

How will this affect the care of my patients?

Results from this study suggest antegrade intramedullary nailing (AIMN) may provide additional clinical benefits when compared to other forms of surgical intervention for patients with fifth metacarpal neck fractures. Future studies are needed to conduct head-to-head comparisons between various surgical interventions and AIMN, as opposed to grouping surgical approaches as one comparison group.

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