Background Vertebral compression fractures are common and result in significant pain and loss of function. Treatment strategy, however, remains controversial. We conducted a meta-analysis of randomized trials to elucidate the impact of bracing on these injuries. Methods A comprehensive literature review utilizing Embase, OVID MEDLINE, and the Cochrane Library was performed to identify randomized trials evaluating brace therapy for adult patients with thoracic and lumbar compression fractures. Two independent reviewers assessed the eligibility of studies and risk of bias. The primary assessed outcome was pain after injury. Secondary outcomes were function, quality of life, opioid use, and kyphotic progression [anterior vertebral body compression percentage (AVBCP)]. Continuous variables were analyzed using mean differences and standardized mean differences, and dichotomous variables were analyzed using odds ratios in random-effects models. GRADE criteria were applied. Results Of 1,502 articles, a total of 3 studies with 447 patients (96% female) were included. Fifty-four patients were managed without a brace, and 393 with a brace (195 rigid, 198 soft). At 3 to 6 months post-injury, rigid bracing resulted in significantly less pain compared to no brace (SMD =−1.32, 95% CI: −1.89 to −0.76, P<0.05, I 2 =41%), though this diminished at long-term follow-up of 48 weeks. Radiographic kyphosis, opioid use, function, or quality of life were not significantly different at any timepoint. Conclusions Moderate quality evidence demonstrates rigid bracing of vertebral compression fractures may decrease pain up to 6 months post-injury, though there is no difference in radiographic parameters, opioid use, function, or quality of life at short- or long-term follow-up. No difference was found between rigid and soft bracing; therefore, soft bracing may be an adequate alternative.
Background:First described by Soule in 1910, arthrodesis of the proximal interphalangeal joint is a common operative method of treatment of hammer toe, or fixed-flexion deformity of the proximal interphalangeal joint of the lesser toes1. The deformity is often caused by imbalance in intrinsic and extrinsic muscle function across the interphalangeal joint and metatarsophalangeal joint2,3, which can be effectively addressed through proximal interphalangeal joint straightening and arthrodesis in conjunction with soft-tissue balancing of the metatarsophalangeal joint.Description:Following longitudinal skin incision over the joint, a transverse extensor tenotomy and capsulotomy reveal the proximal interphalangeal joint and provide appropriate exposure of the head of the proximal phalanx. With the soft tissues protected, the proximal and middle phalanges undergo resection of the articular surfaces to allow osseous apposition. This step can be performed with a rongeur sagittal saw or with osteotomes4,5. The head of the proximal phalanx is resected proximal to the head-neck junction, and the proximal portion of the middle phalanx is removed to expose the subchondral bone. Often, there is a dorsal contracture of the metatarsophalangeal joint that is elevating the toe, which is addressed with use of a longitudinal incision over the metatarsophalangeal joint, a Z-lengthening of the long extensor tendon to the toe, and a subsequent capsulectomy. If there is an angular component to the deformity, the collateral ligaments are released from the metatarsal neck, and the toe can be balanced. If there is residual subluxation of the joint that is incompletely corrected by soft-tissue procedures, a metatarsal osteotomy should be considered. Fixation is then performed with use of a smooth Kirschner wire. The wire is inserted from the middle phalanx out the tip of the toe and subsequently inserted retrograde across the proximal interphalangeal joint, often into the metatarsal head and neck, holding the metatarsophalangeal joint in appropriate position. This step can also be completed with use of novel methods including screws, bioabsorbable pins, or intramedullary implants6-8.Alternatives:Nonoperative treatments for hammer toe deformity are generally pursued prior to surgery and include shoe modifications such as a wide toe-box, soft uppers, and padding of osseous prominences3,9,10. Alternative surgical treatments include proximal interphalangeal arthroplasty, soft-tissue capsulotomy, extensor tendon lengthening, and amputation11.Rationale:Although nonoperative treatment can alleviate symptoms temporarily, surgical treatment is often necessary for definitive treatment of hammer toe. Soft-tissue procedures such as tendon lengthening can provide a stabilizing benefit, but the degenerative bone changes associated with hammer toe are better addressed with use of resection of the proximal interphalangeal joint3. Arthroplasty allows for some retained motion; however, this motion may lead to deformity and pain over time2. Arthrodesis provides...
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