Meta-Analysis of Pinning in Supracondylar Fracture of The

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ORIGINAL ARTICLE Meta-Analysis of Pinning in Supracondylar Fracture of the Humerus in Children Patarawan Woratanarat, MD, PhD,* Chanika Angsanuntsukh, MD,* Sasivimol Rattanasiri, PhD,† John Attia, MD, PhD, FRCPC, FRACP,‡ Thira Woratanarat, MD, MMedSc,§ and Ammarin Thakkinstian, PhD† Key Words: supracondylar, humerus, children, pinning, metaanalysis (J Orthop Trauma 2012;26:48–53) Objectives: The purpose of this study was to compare the outcomes of lateral pinning versus cross pinning in pediat
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  O RIGINAL  A RTICLE Meta-AnalysisofPinninginSupracondylarFractureoftheHumerus in Children  Patarawan Woratanarat, MD, PhD,* Chanika Angsanuntsukh, MD,* Sasivimol Rattanasiri, PhD,†  John Attia, MD, PhD, FRCPC, FRACP,‡ Thira Woratanarat, MD, MMedSc,§ and Ammarin Thakkinstian, PhD†  Objectives:  The purpose of this study was to compare the outcomesof lateral pinning versus cross pinning in pediatric supracondylar humerus fractures. Data Sources:  The Cochrane library, MEDLINE, CINAHL,specific orthopaedic journals, abstracts/papers from conferencesand meetings, and reference lists of articles were searched frominception to September 2007. Study Selection:  All randomized controlled trials and cohort studies comparing outcomes (ie, loss of fixation, iatrogenic ulnar nerve injury, and Flynn criteria) between crossed and lateral pinningwere identified. Data Extraction:  Two authors independently assessed methodo-logical quality and extracted data by using a standardized dataextraction form. Data Synthesis:  Heterogeneity among studies was assessed usingthe Q test. Pooled relative risk was estimated using the Mantel-Haenszel method. Eighteen of 1829 studies were included with 1615supracondylar fractures (837 and 778 children with cross and lateral pinning, respectively). The average age was 6.1 6 0.9 years. The risk of iatrogenic ulnar nerve injury was 4.3 (95% confidence interval,2.1–9.1) times higher in cross pinning compared with lateral pinning.Therewas no significant difference for loss of fixation, late deformity,or Flynn criteria between the two types of pinning. Conclusions:  Lateral pinning is preferable to cross pinning for fixation of pediatric supracondylar humerus fractures as a result of decreased risk of ulnar nerve injury. Key Words:  supracondylar, humerus, children, pinning, meta-analysis(  J Orthop Trauma  2012;26:48–53) INTRODUCTION Supracondylar fractures of the humerus are the most common elbow fractures in children 1,2 and the decision to treat operatively depends on the quality of reduction, ability tomaintain reduction, the degree of displacement, and fracturestability. 3–6 Cross pinning is biomechanically superior tolateral pinning. 7–9 Although some authors have proposed that divergent lateral pins are comparable in extension, varus, and valgus stability to cross pins, the axial torsional strength wasfar less. 9 However, the primary drawback of cross pinning isiatrogenic ulnar nerve injury. 10,11 Various surgical techniques(eg, mini-open approach to the ulnar nerve, 12–15 elbowextension, 14,16  preoperative nerve stimulator, 17 or Dorgan’stechnique) 18 have been used to prevent this complication withlimited success.Previous debates led to a systematic review that concluded there was a 42% reduction in fixation failure and deformity with cross pinning, but at the cost of five timeshigher risk of iatrogenic ulnar nerve injury. 19 However,heterogeneity was not addressed in the review nor werestandard meta-analysis methods used to combine studies. 20 Thus, variance in pooling might be biased. In addition, therehave been three further studies published since the 2007review. 11,12,15 To fill former methodological gaps and obtain the best available evidence, we conducted a new systematic review and formal meta-analysis specifically comparing rates of iatro-genic ulnar nerve injury, loss of fixation, late deformity, and Flynn criteria between the two types of pinning. MATERIALS AND METHODSSearch Strategies We searched the Cochrane library, MEDLINE (1966 toSeptember 2007), and CINAHL (1982 to September 2007)using both PubMed and OVID. In addition, specificorthopaedic journals (eg,  Journal of Bone and Joint Surgery, Journal of Pediatric Orthopaedics, Clinical Orthopaedics and  Accepted for publication February 4, 2011.From the *Department of Orthopaedics and   † Clinical Epidemiology Unit,Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok,Thailand;  ‡ Centre for Clinical Epidemiology and Biostatistics, TheUniversity of Newcastle, Newcastle, NSW, Australia; and §Department of Preventive and Social Medicine, Faculty of Medicine, ChulalongkornUniversity, Bangkok, Thailand.Each author certifies that he or she has no commercial associations (eg,consultancies, stock ownership, equity interest, patent/licensing arrange-ments, etc) that might pose a conflict of interest in connection with thesubmitted article.Each author certifies that his or her institution has approved the protocol for this investigation and that all investigations were conducted in conformitywith ethical principles of research.Reprints: Patarawan Woratanarat, MD, PhD, Department of Orthopaedics,Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok,Thailand (e-mail: rapwo@mahidol.ac.th).Copyright     2012 by Lippincott Williams & Wilkins 48  |  www.jorthotrauma.com  J Orthop Trauma     Volume 26, Number 1, January 2012   Related Research, Journal of Orthopaedics Trauma, Ortho- paedics Clinic of North America ), abstracts/papers fromconferences and meetings (eg, Pediatric Orthopaedic Societyof North America (POSNA), International Pediatric Ortho- paedic Symposium (IPOS), European Pediatric OrthopaedicSociety (EPOS), American Academyof Orthopaedic Surgeons(AAOS), The Royal College of Orthopaedic Surgeons of Thailand (RCOST)), and reference lists from articles were alsoexplored. The search strategies included combinations of thefollowing terms: supracondylar fracture*, humerus, child*,treatment, operative treatment, pin*, neurovascular injury,results, nerve injury. Search hits were limited to ‘‘child’’ and ‘‘age 0–18 years.’’ Inclusion Criteria Follow-up studies, ie, randomized controlled trials(RCTs) and cohort studies, comparing outcomes betweencross and lateral pinning in supracondylar humerus fractureswere included if they met the following criteria: children aged 0 to 18 years; had at least one of the following outcomes:iatrogenic ulnar nerve injury, loss of fixation, late deformity,and/or Flynn criteria 21 ; and sufficient results for dataextraction, ie, number of subjects for each outcome groupwas provided. If eligible papers had insufficient information,we contacted the authors for additional information.The most complete and/or recent results were selected if there were multiple publications from the same study group. Outcomes of Interest The outcomes of interest were iatrogenic ulnar nerveinjury, loss of fixation, late deformity, and Flynn criteria for cosmetic and functional outcomes. 21 Iatrogenic ulnar nerveinjury was defined as ulnar nerve injury caused by surgery.Other iatrogenic nerve injuries (anterior interosseous nerve,median nerve, posterior interosseous nerve, and radial nerve)were also collected. Loss of fixation was defined asdisplacement of the fracture by more than 2 mm, angulationof more than 5  , or fracture needing revision surgery. Latedeformity would be documented if there were cubitus varus of more than 5   after complete fracture healing 3 to 4 weeks postoperatively. Flynn criteria were categorized as excellent/ good and fair/poor. Data Extraction We used a standardized data extraction form, whichincluded outcomes and baseline patient characteristics (ie, age,gender, study setting [country], extension type, completelydisplaced fracture [Gartland classification; Type III], and ulnar nerve injury before surgery). Two authors independentlyextracted data. Any disagreement was adjudicated by a third author. Quality Assessment Two authors independently assessed quality of studies.Jadad’s scale forquality rating of randomized control trialswasapplied. 22 Observational studies were assessed based onGRADE (Grading of Recommendations Assessment, De-velopment and Evaluation). 23 Data Analysis Characteristics of studies were described using fre-quency and mean. Only cohort studies were pooled in the mainanalyses, because the majority of designs were cohort studieswith a limited number of RCTs. The risk ratio (RR) and 95%confidence interval (CI) were estimated for each study. Acontinuity correction was performed by adding 0.5 to thosestudies that had at least one zero cell. Heterogeneity of RRswas assessed using the Q test and I 2 . 24 If heterogeneity was present (as judged by a Q-test   P   ,  0.1 or I 2 $  50%), therandom effect model was used for pooling. Otherwise, thefixed effect model using Mantel-Haenzel was applied. 20 Tosecure the validity of analytical process, sensitivity analysiswas also performed with or without including the randomized control trials or very small studies (ie, less than 10 patients).Furthermore, publication bias was assessed using the Egger test. All analyses were performed by using STATA Version10.0 (StataCorp 2007, College Station, TX). A  P   value , 0.05was considered statistically significant, except for the test of heterogeneity in which 0.10 was used. RESULTS Using multiple databases, 1829 articles were identified,of which 869 were duplicates (Fig. 1). This left 960 abstracts,whichweregathered and reviewed; 935 articles were excluded,leaving 25 abstracts for which full papers were retrieved.Seven of the 25 had inadequate reporting of data (eg, number of patients in each type of pinning and/or outcomes were not reported), leaving 18 studies eligible for review. 10–16,25–35 These 18 studies, representing 1615 children, aredescribed in Table 1. Study designs were largely cohorts FIGURE 1.  Study flow diagram demonstrated methods of dataretrieval and reasons for exclusion until gathered eligiblearticles. q 2012 Lippincott Williams & Wilkins  www.jorthotrauma.com  |  49  J Orthop Trauma     Volume 26, Number 1, January 2012  Meta-Analysis of Supracondylar Fracture   (n = 16) and twowere randomized controlled trials. Ten studieswere conducted in the United States (55.6%), four in Europe,and four in Asia. Average age ranged from 4.3 to 8.6 years and 31.0% to 72.9% of participants were male. Extension type was between 77% and 100%, and Gartland classification Type IIIwas from 58.1% to 100.0%. Ulnar nerve injury before surgerywas 0% to 4.9%.Cross pinning was performed in 837 children, and 778children underwent fixation with lateral pins. The standard cross pinning technique was performed by engaging each pinat the lateral and medial column, respectively, whereas lateral pinning technique engaged each pin at the lateral and centralcolumns. At least two pins were used for each pinningtechnique to achieve fracture stability. Fixation using less thantwo pins was considered substandard treatment and thereforeexcluded from review. Dorgan’s technique was considered asa subgroup of the cross pinning technique; however, it is not included in this review because it was not included in thesurgical methods section of any of the eligible articles.Quality of studies ranged from low to moderate for cohort studies. For RCTs, the Jadad scale for description of randomization, double-blinded, withdrawal, and dropouts was100 25 and 101. 11 Ulnar Nerve Injury Among the eligible 16 cohort studies, 10,12–16,26–35 13studies 10,12–14,16,26,27,29,31–35 had sufficient data for poolingulnar nerve injury outcomes (Table 2). There were 716 participants in the cross pinning group and 576 participants inthe lateral pinning group. Average age of included studiesvaried from 4.3 to 6.8 years. Thirty one percent to 72.9% of  participants were male and Gartland Type III ranged from58.8% to 100%.As shown in Figure 2, estimated RRs across studies werequite similar and there was no evidence of heterogeneity (chi-square = 10.6, df = 12,  P   = 0.566, I 2 = 0). The pooled RR,estimated using the Mantel-Haenzel method, was 4.5 (95% CI,2.1–9.7). There was no evidence of publication bias (Egger test: coefficient = –2.5, standard error = 1.6,  P   = 0.136; Fig. 3).After exclusion of the smallest study, 26 sensitivityanalysis showed similar results (RR, 4.2; 95% CI, 1.9–9.4).Pooling the two RCT studies yielded a risk ratio of 2.0 (95% TABLE 1.  Characteristics of Included Studies Year Author Design SettingMean Age(years)PercentMalePercentExtension TypePercentGartlandType IIIPercentUlnar Nerve InjuryBefore SurgeryNo. of PinningsCross Lateral 1978 Gjerloff  26 Cohort Denmark — — — — — 2 61992 Cramer  27 Cohort USA 5.8 31.0 100.0 86.2 3.5 24 51992 France 28 Cohort USA 6.9 34.8 — 67.2 — 33 141995 Cheng 29 Cohort Hong Kong 6.0 65.9 100.0 100.0 1.1 8 741995 Topping 10 Cohort USA 6.6 61.7 100.0 100.0 4.3 27 201996 Mehlman 16 Cohort USA 6.1 43.5 99.1 81.7 3.5 69 351998 Onwuanyi 30 Cohort Saudi Arabia 8.6 68.2 — — — 19 252000 Davis 31 Cohort USA 5.8 — 77.0 77.8 4.9 68 132001 Gordon 14 Cohort USA 6.1 50.0 — 65.0 1.5 95 432001 Mazda 32 Cohort France 5.7 60.3 100.0 74.1 0 26 822001 Shamsuddin 33 Cohort Malaysia 6.8 52.5 100.0 76.8 — 28 282001 Skaggs 13 Cohort USA 4.3 — 100.0 59.1 0 220 1252003 Solak  34 Cohort Turkey 5.0 72.9 — 100.0 0 35 242004 Foead  25 RCT Malaysia 5.8 — — — 1.8 28 272004 Ponce 35 Cohort USA 5.7 41.3 — 63.5 0 49 552006 Sibinski 12 Cohort UK 6.0 55.7 — 58.8 0 65 662007 Sankar  15 Cohort USA 5.8 — — 58.1 — 17 1082007 Kocher  11 RCT USA 5.9 44.2 100.0 100.0 0 24 28 TABLE 2.  Distribution of Ulnar Nerve Injury and EstimatedRisk Ratios (RRs) AuthorCrossPinningLateralPinningRR (95% CI)NJ+ NJ– NJ+ NJ–  Cheng 29 1 7 0 74 25 (1.1–569.1)Cramer  27 0 24 0 5 0.2 (0–10.9)Davis 31 1 67 0 13 0.6 (0–14.2)Gjerloff  26 2 0 0 6 11.7 (0.8–176.8)Gordon 14 0 95 0 43 0.5 (0–22.7)Mazda 32 0 26 0 82 3.1 (0.1–151.2)Mehlman 16 0 69 0 35 0.5 (0–25.4)Ponce 35 1 48 0 55 3.4 (0.1–80.6)Shamsuddin 33 3 25 0 28 7 (0.4–129.6)Skaggs 13 17 203 0 125 20.0 (1.2–329.0)Solak  34 2 33 1 23 1.4 (0.1–14.3)Topping 10 1 26 0 20 2.3 (0.1–52.5)Sibinski 12 4 61 0 66 9.1 (0.5–166.4)Summary 35 703 1 584 4.5 (2.1–9.7)  NJ, nerve injury; NJ+, presence of iatrogenic ulnar nerve injury; NJ–, absence of iatrogenic ulnar nerve injury; CI, confidence interval. 50  |  www.jorthotrauma.com  q 2012 Lippincott Williams & WilkinsWoratanarat et al   J Orthop Trauma     Volume 26, Number 1, January 2012  CI, 0.5–7.6), which was not significant. In the lateral pinninggroup, there were two radial nerve and one anterior interosseous nerve 34 injuries (Table 3). 25,33 However, the pooled relative risk could not be estimated for these injuries asa result of insufficient data (ie, no postoperative nerve injuries,other than ulnar nerve, in the cross pinning group). Loss of Fixation Ten cohorts 10,12–15,28,31,32,34,35 had sufficient data toassess loss of fixation as an outcome (Table 4). No evidenceof heterogeneity was found (chi-square = 8.7, df = 9,  P   =0.470, I 2 = 0) and thus the fixed effect model was applied for  pooling. The pooled relative risk was 0.6 (95% CI, 0.4–1.0) asshown in Figure 4. There was only one RCT; therefore, thedata could not be pooled. Late Deformity Seven studies were included for pooling of latedeformity 10,13,15,30–32,34 (Table 5). They were homogeneous(chi-square = 8.6, df = 7,  P   = 0.285, I 2 = 0.2) and the pooled relative risk using a fixed effects model was 1.1 (95% CI, 0.6– 2.1). Pooling two RCT studies yielded the RR of 0.6 (95% CI,0.1–4.3). Flynn Function Four studies were pooled for Flynn criteria 12,28,32,34 (Table 6). With no evidence of heterogeneity (chi-square = 2.9,df = 3,  P   = 0.398, I 2 = 0), the pooled relative risk was 0.9 (95%CI, 0.8–1.0). There were insufficient RCTs to pool data. DISCUSSION The purpose of this study was to find the most appropriate type of pinning for fixation of pediatric FIGURE2.  A forest plot showed pooling risk ratio of ulnar nerveinjury between cross and lateral pinning. FIGURE 3.  Funnel plot of pooling ulnar nerve injury. TABLE 3.  Distribution of Iatrogenic Nerve Injuries StudyIatrogenic Nerve InjuriesMedian Radial Ulnar Overall Cheng 29 0 0 1 1Cramer  27 0 0 0 0Davis 31 0 0 1 1Foead  25 0 1 7 8France 28  NA NA NA NAKocher  11 0 0 0 0Gerloff  26 0 0 2 2Gordon 14 0 0 0 0Mazda 32 0 0 0 0Mehlman 16 0 0 0 0Onwuanyi 30  NA NA NA NAPonce 35 0 0 1 1Sankar  15  NA NA NA NAShamsuddin 33 0 1 3 4Skaggs 13  NA NA 17 17Solak  34 1 0 3 4Topping 10 0 0 1 1Sibinski 12 0 0 4 4Total 1 2 40 43(lateral pin) lateral pin) (2 lateral 25 , 38 cross pin)  NA, not available. TABLE 4.  Distribution of Loss of Fixation and Estimated RiskRatios (RRs) AuthorCross Pinning Lateral PinningRR (95% CI)N LoF+ LoF– N LoF+ LoF–  Davis 31 68 1 67 13 2 11 0.1 (0–1.0)France 28 33 1 32 14 0 14 1.3 (0.1–30.7)Gordon 14 95 0 95 43 0 43 0.5 (0–22.7)Mazda 32 26 1 25 82 3 79 1.1 (0.1–9.7)Ponce 35 49 0 49 55 0 55 1.1 (0–55.4)Sankar  15 171 1 170 108 7 101 0.1 (0–0.7)Skaggs 13 220 5 215 125 4 121 0.7 (0.2–2.6)Solak  34 35 9 26 24 7 17 0.9 (0.4–2.0)Topping 10 27 1 26 20 0 20 2.3 (0.1–52.5)Sibinski 12 65 3 62 66 2 64 1.5 (0.3–8.8)Summary 811 22 789 559 25 534 0.6 (0.4–1.0) LoF, loss of fixation; LoF+, presence of loss of fixation; LoF–, absence of loss of fixation; CI, confidence interval. q 2012 Lippincott Williams & Wilkins  www.jorthotrauma.com  |  51  J Orthop Trauma     Volume 26, Number 1, January 2012  Meta-Analysis of Supracondylar Fracture 
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