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      Operative versus conservative treatment of apophyseal avulsion fractures of the pelvis in the adolescents: a systematical review with meta-analysis of clinical outcome and return to sports

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          Abstract

          Background

          Avulsion fractures of the pelvic apophyses typically occur in adolescent athletes due to a sudden strong muscle contraction while growth plates are still open. The main goals of this systematic review with meta-analysis were to summarize the evidence on clinical outcome and determine the rate of return to sports after conservative versus operative treatment of avulsion fractures of the pelvis.

          Methods

          A systematic search of the Ovid database was performed in December 2016 to identify all published articles reporting outcome and return to preinjury sport-level after conservative or operative treatment of avulsion fractures of the pelvis in adolescent patients. Included studies were abstracted regarding study characteristics, patient demographics and outcome measures. The methodological quality of the studies was assessed with the Coleman Methodology Score (CMS).

          Results

          Fourteen studies with a total of 596 patients met the inclusion criteria. The mean patient age was 14.3 ± 0.6 years and 75.5% of patients were male. Affected were the anterior inferior iliac spine (33.2%), ischial tuberosity (29.7%), anterior superior iliac spine (27.9%), iliac crest (6.7%) lesser trochanter (1.8%) and superior corner of the pubic symphysis (1.2%). Mean follow-up was 12.4 ± 11.7 months and most of the patients underwent a conservative treatment (89.6%). The overall success rate was higher in the patients receiving surgery (88%) compared to the patients receiving conservative treatment (79%) ( p = 0,09). The rate of return to sports was 80% in conservative and 92% in operative treated patients ( p = 0,03). Overall, the methodological quality of the included studies was low, with a mean CMS of 41.2.

          Conclusion

          On the basis of the present meta-analysis, the overall success and return to sports rate was higher in the patients receiving surgery. Especially in patients with fragment displacement greater 15 mm and high functional demands, surgical treatment should be considered.

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          Most cited references28

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          Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group.

          Carrie Coleman, Adam J L Cook, Riaz Khan … (2000)
          Patellar tendinopathy is often treated surgically after failure of conservative treatment but clinical experience suggests that results are not uniformly excellent. The aim of this review was to (i) identify the different surgical techniques that have been reported and compare their success rates, and (ii) critically assess the methodology of studies that have reported surgical outcomes. Twenty-three papers and two abstracts were included in the review. Surgical procedures were categorized and outcomes summarized. Using ten criteria, an overall methodology score was derived for each paper. Criteria for which scores were generally low (indicating methodological deficiency) concerned the type of study, subject selection process and outcome measures. We found a negative correlation between papers' reported success rates and overall methodology scores (r= -0.57, P<0.01). There was a positive correlation between year of publication and overall methodology score (r=0.68, P<0.001). We conclude that study methodology may influence reported surgical outcome. We suggest practical guidelines for improving study design in this area of clinical research, as improved study design would provide clinicians with a more rigorous evidence-base for treating patients who have recalcitrant patellar tendinopathy.
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            Level of evidence in orthopaedic journals.

            William Obremskey, Nick Pappas, Emad S Attallah-Wasif … (2005)
            The American edition of The Journal of Bone and Joint Surgery (JBJS-A) has included a level-of-evidence rating for each of its clinical scientific papers published since January 2003. The purpose of this study was to assess the type and level of evidence found in nine different orthopaedic journals by applying this level-of-evidence rating system. We reviewed all clinical articles published from January through June 2003 in nine orthopaedic journals. Studies of animals, studies of cadavera, basic-science articles, review articles, case reports, and expert opinions were excluded. The remaining 382 clinical articles were randomly assigned to three experienced reviewers and two inexperienced reviewers, who rated them with the JBJS-A grading system. Each reviewer determined whether the studies were therapeutic, prognostic, diagnostic, or economic, and each rated the level of evidence as I, II, III, or IV. Reviewers were blinded to the grades assigned by the other reviewers. According to the reviewers' ratings, 70.7% of the articles were therapeutic, 19.9% were prognostic, 8.9% were diagnostic, and 0.5% were economic. The reviewers graded 11.3% as Level I, 20.7% as Level II, 9.9% as Level III, and 58.1% as Level IV. The kappa values for the interobserver agreement between the experienced reviewers and the inexperienced reviewers were 0.62 for the level of evidence and 0.76 for the study type. The kappa values for the interobserver agreement between the experienced reviewers were 0.75 for the level of evidence and 0.85 for the study type. The kappa values for the agreement between the reviewers' grades and the JBJS-A grades were 0.84 for the level of evidence and 1.00 for the study type. All kappa values were significantly different from zero (p < 0.0001 for all). The percentage of articles that were rated Level I or II increased in accordance with the 2003 journal impact factors for the individual journals (p = 0.0061). Orthopaedic journals with a higher impact factor are more likely to publish Level-I or II articles. The type and level of information in orthopaedic journals can be reliably classified, and clinical investigators should pursue studies with a higher level of evidence whenever feasible.
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              Acute avulsion fractures of the pelvis in adolescent competitive athletes: prevalence, location and sports distribution of 203 cases collected.

              F. Rossi, S. Dragoni (2001)
              To describe the prevalence, location and sports distribution of pelvic avulsion fractures in adolescent competitive athletes. One thousand two hundred and thirty-eight radiographs of the pelvis taken for focal traumatic symptoms in athletes with an age range of 11-35 years over a period of 22 years were reviewed. One hundred and ninety-eight adolescent athletes were affected by 203 avulsion fractures of the pelvic apophyses (five cases presented multiple locations). The localisation was the ischial tuberosity (IT) in 109 cases, anterior inferior iliac spine (AIIS) in 45 cases, anterior superior iliac spine (ASIS) in 39 cases, superior corner of pubic symphysis (SCPS) in 7 cases and iliac crest (IC) in 3 cases. Soccer (74 cases) and gymnastics (55 cases) were the sports with the highest number of avulsion fractures documented. Apophyseal avulsion fractures of the pelvis in adolescent competitive athletes are most common in soccer and gymnastics. The lesions are usually the consequence of sudden and forceful muscle-tendon contractions during sport activities. Plain radiographs, are determinant for the diagnosis.
              Article 0 comments Cited 50 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                H. Eberbach: + 49 761 270 24010 , helge.eberbach@uniklinik-freiburg.de
                L. Hohloch: lisa.hohloch@uniklinik-freiburg.de
                M.J. Feucht: matthias.feucht@uniklinik-freiburg.de
                L. Konstantinidis: lukas.konstantinidis@uniklinik-freiburg.de
                N.P. Südkamp: norbert.suedkamp@uniklinik-freiburg.de
                J. Zwingmann: joern.zwingmann@uniklinik-freiburg.de
                Journal
                Journal ID (nlm-ta): BMC Musculoskelet Disord
                Journal ID (iso-abbrev): BMC Musculoskelet Disord
                Title: BMC Musculoskeletal Disorders
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1471-2474
                Publication date (Electronic): 19 April 2017
                Publication date PMC-release: 19 April 2017
                Publication date Collection: 2017
                Volume: 18
                Electronic Location Identifier: 162
                Affiliations
                ISNI 0000 0000 9428 7911, GRID grid.7708.8, Department of Orthopaedic and Trauma Surgery, , University of Freiburg Medical Center, ; Hugstetter Straße 55, Freiburg, 79106 Germany
                Article
                Publisher ID: 1527
                DOI: 10.1186/s12891-017-1527-z
                PMC ID: 5395880
                PubMed ID: 28420360
                SO-VID: dccd1a94-c81b-4d3d-8bbd-b191ccba237f
                Copyright © © The Author(s). 2017
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. 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.

                History
                Date received : 7 January 2017
                Date accepted : 7 April 2017
                Categories
                Subject: Research Article
                Custom metadata
                issue-copyright-statement © The Author(s) 2017

                ScienceOpen disciplines: Orthopedics
                Keywords: avulsion fractures,pelvis,treatment,outcome,return to sports
                Data availability:
                ScienceOpen disciplines: Orthopedics
                Keywords: avulsion fractures, pelvis, treatment, outcome, return to sports

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