Orthopedics

Review Article Supplemental Data

Surgical Management for Olecranon Fractures in Adults: A Systematic Review and Meta-analysis

Alex Koziarz, MSc; Taylor Woolnough, BSc; Colby Oitment, MD; Siddharth Nath, BSc; Herman Johal, MD, MPH, FRCSC

Abstract

Olecranon fractures are common upper-extremity fractures amenable to various surgical techniques. The authors conducted a systematic review and meta-analysis to evaluate surgical management strategies for olecranon fractures in adult patients. Two investigators independently screened articles from records obtained from MEDLINE, Embase, SPORTDiscus, CINAHL, and the Cochrane Library databases. The authors compared tension-band wiring (TBW) with plate fixation (PF) for the outcomes of complications and hardware removal. Subgroup analyses were conducted comparing randomized controlled trials with observational studies for each outcome. In addition, the authors evaluated novel fixation techniques other than TBW and PF. Twenty-four studies were included in the systematic review and 10 studies were included in the meta-analysis of TBW vs PF. Compared with TBW (n=270), patients who underwent PF (n=369) had a significantly lower complication rate (relative risk, 0.48; 95% confidence interval, 0.36–0.64; P<.01; I2=16%). Plate fixation (41 of 332) also had less hardware removal compared with TBW (79 of 236; relative risk, 0.36; 95% confidence interval, 0.25–0.50; P<.01; I2=0%). Subgroup analyses showed no difference when comparing randomized controlled trials with observational studies for the outcomes of complication rate (P=.45) and hardware removal (P=.54). Qualitative analysis revealed novel methods of olecranon fixation: a modified cable pin system, tension banding through 2 cannulated screws, olecranon memory connector fixation, and cancellous screw TBW. This meta-analysis revealed significantly lower complication and hardware removal rates for PF compared with TBW. Several novel methods of olecranon fixation may represent viable alternatives. [Orthopedics. 2019; 42(2):75–82.]

Abstract

Olecranon fractures are common upper-extremity fractures amenable to various surgical techniques. The authors conducted a systematic review and meta-analysis to evaluate surgical management strategies for olecranon fractures in adult patients. Two investigators independently screened articles from records obtained from MEDLINE, Embase, SPORTDiscus, CINAHL, and the Cochrane Library databases. The authors compared tension-band wiring (TBW) with plate fixation (PF) for the outcomes of complications and hardware removal. Subgroup analyses were conducted comparing randomized controlled trials with observational studies for each outcome. In addition, the authors evaluated novel fixation techniques other than TBW and PF. Twenty-four studies were included in the systematic review and 10 studies were included in the meta-analysis of TBW vs PF. Compared with TBW (n=270), patients who underwent PF (n=369) had a significantly lower complication rate (relative risk, 0.48; 95% confidence interval, 0.36–0.64; P<.01; I2=16%). Plate fixation (41 of 332) also had less hardware removal compared with TBW (79 of 236; relative risk, 0.36; 95% confidence interval, 0.25–0.50; P<.01; I2=0%). Subgroup analyses showed no difference when comparing randomized controlled trials with observational studies for the outcomes of complication rate (P=.45) and hardware removal (P=.54). Qualitative analysis revealed novel methods of olecranon fixation: a modified cable pin system, tension banding through 2 cannulated screws, olecranon memory connector fixation, and cancellous screw TBW. This meta-analysis revealed significantly lower complication and hardware removal rates for PF compared with TBW. Several novel methods of olecranon fixation may represent viable alternatives. [Orthopedics. 2019; 42(2):75–82.]

Olecranon fractures represent 1% to 10% of upper-extremity fractures and typically result from direct trauma to the elbow or falling on an outstretched hand.1–3 Several different classification systems are frequently used, including AO, Mayo, and Schatzker-Schmeling.4–6 These classifications guide treatment through description of fracture morphology, displacement, and comminution; however, many other factors, including bone quality and patient age, also inform treatment.7,8 Stable fractures with less than 2 mm of articular surface step deformity and an intact extensor mechanism (ie, Mayo 1) are typically treated conservatively.9,10 When surgical management is indicated, anatomical reduction facilitates union and allows for improved range of motion.11 Most current surgical constructs can be divided into 2 broad categories, tension-band wiring (TBW) and plate and screw fixation (PF), with TBW being the most common method of fixation for simple transverse fractures.8 Many variations of TBW have been described (eg, intramedullary screw TBW, biodegradable wire TBW), but traditional Kirschner wire TBW remains the most frequently used technique.8,12–16 Alternatively, PF is often the method of choice for fractures that are oblique, comminuted, or associated with dislocation.1,5,8,9,17,18 Other methods of fixation have also been described, including figure-of-8 wiring and intramedullary nailing, but these alternatives have yet to see widespread use.8,19,20 In certain cases, such as elderly, low-demand patients with poor bone quality, fracture excision and triceps advancement may be preferable to internal fixation.9

Although both TBW and PF have been associated with good functional outcomes, TBW has been associated with shorter surgical times and lower cost.8,21,22 However, TBW has been suggested to lead to striking rates of hardware irritation, possibly as high as 80%.23–25 Accordingly, for comminuted fractures, PF is suggested over TBW owing to increased stability.8 Plate fixation may also be used regularly for noncomminuted fractures in older patients with poor bone quality.21,26 Concern arises from PF because it has been associated with longer surgical times and greater cost.21,25–28

Small samples and conflicting outcomes have prevented a clear consensus in the literature favoring TBW or PF, particularly in non-elderly adults experiencing fractures with mild or no comminution.29 In 2014, a Cochrane review reported uncertainty in treatment outcomes in TBW and PF, largely due to limited, low-quality studies.29 Since then, several higher-quality randomized controlled trials (RCTs) have been conducted comparing TBW with PF as well as other interventions for the management of olecranon fractures.16,30,31 In 1 high-quality RCT evaluating TBW vs PF, a trend toward increased complication rates in TBW was shown.31 However, few outcomes reached statistical significance, likely due to small samples in trial arms. Overall, many of these trials were underpowered to evaluate important patient functional outcomes and significant complications such as hardware removal. Therefore, the authors conducted a systematic review and meta-analysis to compare TBW with PF and to evaluate alternative surgical management strategies for patients with olecranon fractures.

Materials and Methods

The authors conducted a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement32,33 and the Cochrane Collaboration's handbook for systematic reviews of interventions.34

Literature Review

The authors conducted a detailed search to identify studies examining surgical management strategies for fractures of the olecranon. Their electronic search included 5 databases: MEDLINE, Embase, SPORTDiscus, CINAHL, and the Cochrane Library. Search strategies were developed collaboratively by all of the authors and were conducted without any restrictions on type of publication or time using key words and medical subject heading terms such as “olecranon,” “elbow fracture,” “tension-band wiring,” and “plate fixation” (Table A, available in the online version of the article). The search is current to November 20, 2018. The authors hand searched the references of included studies and reviews to identify articles not captured by electronic search criteria.

Search strategy for the Medline database

Table A:

Search strategy for the Medline database

Data Extraction and Definition of Outcomes

Three of the authors (A.K., T.W., C.O.) served as reviewers and independently evaluated studies for eligibility. Articles were included if they were RCTs, prospective cohort studies, or retrospective cohort studies evaluating surgical management strategies for olecranon fractures. Disagreements were resolved through discussion and consensus among the reviewers. Case reports, case series, letters to the editor, narrative reviews, and conference abstracts were excluded. The quality of individual RCTs, prospective cohort studies, and retrospective cohort studies was evaluated using the Cochrane Collaboration's risk of bias assessment tool,34 the Newcastle-Ottawa scale,35 and the methodological index for non-randomized studies,36 respectively.

Three of the authors (A.K., T.W., S.N.) independently abstracted data from the included studies using data abstraction forms. Disagreements were resolved by consensus and, if necessary, by consultation with an additional reviewer (C.O.). Meta-analyzed outcomes included complication rate and hardware removal rate between TBW and PF. Other outcomes included Disabilities of the Arm, Shoulder and Hand score, Mayo Elbow Performance Score, elbow arc flexion, operation time, time to union, and pain. The authors defined complications as including infection, symptomatic (ie, painful) hardware, loss of reduction, or hardware migration or failure that resulted in patient complaint or nonunion.

Statistical Analysis

The authors analyzed dichotomous outcomes by calculating the relative risks and corresponding 95% confidence intervals. They considered P<.05 statistically significant. The authors used the DerSimonian and Laird model with random effects to conduct their meta-analysis.37 Heterogeneity was evaluated by Cochran's Q test and quantified using the I2 statistic.38 Meta-analysis was conducted using R version 3.5.1 software (R Foundation for Statistical Computing, Vienna, Austria).

Results

The initial literature search yielded 3760 articles. After de-duplication and title and abstract screening, 100 articles remained. After full-text screening, 24 articles were included in the systematic review12–17,19–22,30,31,39–50 and 10 were included in the meta-analysis21,31,39,42,43,45–47,49,50 (Figure 1; Table B, available in the online version of the article). Cochrane risk of bias for RCTs indicated that studies were of relatively low to moderate quality, with recent RCTs15,16,30,31 having moderate quality (Tables CE, available in the online version of the article). All studies showed high risk of bias for patient blinding.

Search strategy.

Figure 1:

Search strategy.

Characteristics of included studiesCharacteristics of included studiesCharacteristics of included studiesCharacteristics of included studiesCharacteristics of included studiesCharacteristics of included studiesCharacteristics of included studiesCharacteristics of included studiesCharacteristics of included studiesCharacteristics of included studiesCharacteristics of included studies

Table B:

Characteristics of included studies

Cochrane risk of bias for randomized controlled trialsCochrane risk of bias for randomized controlled trialsCochrane risk of bias for randomized controlled trialsCochrane risk of bias for randomized controlled trials

Table C:

Cochrane risk of bias for randomized controlled trials

Newcastle-Ottawa for prospective cohort studies

Table D:

Newcastle-Ottawa for prospective cohort studies

MINORS for retrospective cohort studies

Table E:

MINORS for retrospective cohort studies

A systematic review of PF vs TBW, involving 639 patients across 7 observational studies42,43,45–47,49,50 and 3 RCTs,21,31,39 showed some clinical heterogeneity regarding reporting of outcomes. Patients had a mean age of 40.7 years at presentation and 32.6% were female. Functional outcomes were reported in 6 observational studies and 1 RCT (Table 1). Average functional outcome after both TBW and PF was either good or excellent in all studies according to Mayo Elbow Performance Scores, with all but 1 study reporting a mean elbow flexion arc greater than 130°.42 One cohort study (n=48) found significantly less terminal extension (−8.6º±7º vs −3.5º±9.3º) after hook-plate fixation49; no other studies reported functional differences between TBW and PF.

Functional Outcomes

Table 1:

Functional Outcomes

Complication rate was reported in 7 cohort studies and 3 RCTs. There were 155 of 270 (57%) patients with complications who underwent TBW and 81 of 369 (22%) patients with complications who underwent PF (Table 2). The meta-analysis revealed significantly lower complication rates with PF compared with TBW (relative risk, 0.48; 95% confidence interval, 0.36–0.64; P<.01; I2=16%; Figure 2). These results were robust to subgroup analysis for complication rate comparing RCTs with observational studies (P=.45).

List of Complications

Table 2:

List of Complications

Forest plot of tension-band wiring vs plate fixation for outcome of complications. Abbreviations: CI, confidence interval; MH, Mantel–Haenszel.

Figure 2:

Forest plot of tension-band wiring vs plate fixation for outcome of complications. Abbreviations: CI, confidence interval; MH, Mantel–Haenszel.

Hardware removal was reported in 7 cohort studies and 1 RCT. There were 41 of 332 (12%) patients with hardware removal who underwent PF and 79 of 236 (33%) patients with hardware removal who underwent TBW (Table 2). The meta-analysis revealed lower hardware removal with PF compared with TBW (relative risk, 0.36; 95% confidence interval, 0.25–0.50; P<.01; I2=0%; Figure 3). In addition, these results were robust to subgroup analysis for complication rate comparing RCTs with observational studies (P=.54).

Forest plot of tension-band wiring vs plate fixation for outcome of hardware removal. Abbreviations: CI, confidence interval; MH, Mantel–Haenszel.

Figure 3:

Forest plot of tension-band wiring vs plate fixation for outcome of hardware removal. Abbreviations: CI, confidence interval; MH, Mantel–Haenszel.

Three RCTs and 1 quasi-RCT reported outcomes following other methods of fixation (Table 3).14–16,30 An RCT by Liu et al15 compared a modified cable pin system tension band (n=30) with standard TBW (n=32) and found that the modified cable pin system tension band was associated with significantly shorter fracture healing time (9.73±2.02 vs 11.13±2.21 weeks), significantly fewer complications (1 vs 7), and significantly greater Mayo Elbow Performance Score (88.67±6.42 vs 80.78±11.99). Lu et al16 published an RCT comparing TBW through 2 cannulated screws (n=42) with standard TBW (n=46). They reported that cannulated screw use was associated with significantly shorter fracture healing time (11.4±1.2 vs 12.6±1.8 weeks), significantly less hardware removal (0 of 42 vs 10 of 46), and significantly greater Mayo Elbow Performance Score (87.9±6.0 vs 83.67±6.6).16 An RCT by Chen et al30 comparing novel olecranon memory connector fixation (n=20) with locking PF (n=20) reported that olecranon memory connector fixation was associated with greater Mayo Elbow Performance Score (86.7±12.5 vs 79.8±12.3) and no difference in complication rate. Finally, the quasi-RCT by Ahmed et al14 examining cancellous screw TBW (n=15) vs standard K-wire TBW (n=15) found that screw TBW was associated with fewer re-operations for removal of prominent hardware (0 of 15 vs 8 of 15) and no functional differences.

Other Elbow Fixation Techniques

Table 3:

Other Elbow Fixation Techniques

Discussion

This systematic review and meta-analysis found that among patients who have olecranon fractures and are eligible for surgery, those who undergo PF show significantly fewer complications and hardware removals compared with those who undergo TBW. The current analysis focused on TBW and PF because they represent the most common methods of olecranon fixation; however, several novel treatment options appear promising. These findings were gathered from meta-analyses of approximately 600 patients combined for both outcomes and were robust to subgroup analyses comparing RCTs with observational studies.

With an extensive history and perceived ability to produce compression across fracture sites, TBW remains the most commonly used method of fixation for transverse noncomminuted olecranon fractures.8,51 However, biomechanical studies have highlighted several weaknesses in TBW, including less compression across fractures relative to precontoured olecranon-specific plates.21,52,53 Despite biomechanical superiority, the authors found that the functional outcomes (Disabilities of the Arm, Shoulder and Hand score, Mayo Elbow Performance Score, and flexion arc) of TBW and PF are similar in most of the studies. This lack of difference may be the result of studies being underpowered to evaluate functional differences between TBW and PF. However, some authors have shown similar results between TBW and PF in comminuted fractures as well.34,45,49 Accordingly, there is a lack of consensus in the literature and clinical expert opinion.8 Tension-band wiring is favored by some for reasons related to initial implant cost and duration of surgery. One retrospective cohort study using data gathered in the United States reported that TBW was approximately 50% less costly than PF when hospital stay was not accounted for ($6598.36 vs $14,333.46).47 Other benefits of TBW may include reduced surgical time.21,47,49,50

Although the 2 methods lead to similar functional outcomes, this analysis showed that TBW is associated with significantly more complications and more frequent reoperations for hardware removal. Symptomatic (ie, painful or irritating) hardware was the most common complication of both TBW and PF. It would be imprudent to consider symptomatic hardware as trivial because it was also found to be the most common cause of hardware removal. Hardware removal, found to be significantly more likely after TBW, increases patient morbidity through exposure to a second operation and should carry considerable weight in initial implant decision.54,55 The cost of additional operating room time and hospital admissions associated with removal must also be considered.31,46 Two recent cost-analyses, 1 cohort study and 1 RCT, both from the United Kingdom, questioned the TBW cost-efficacy dogma; these analyses found that PF was less expensive than TBW ($8374 vs $7812) when all treatment- and admission-related costs were considered.31,49 However, the difference in implant cost reported between studies was substantial, suggesting cost-efficacy may largely depend on institution-specific implant pricing and protocols.

Patient age should also be taken into consideration when interpreting the current findings. Across the current literature, elderly patients are poorly represented. In the elderly or those with poor bone stock, precontoured olecranon-specific plates have an advantage of increased stability, although screw pullout may still occur.56,57 Limited soft tissue coverage may also influence application of the current findings to elderly populations. Evidence suggests that nonoperative management or fragment excision may yield equivalent or superior outcomes in elderly, low-demand populations.10

Several novel treatment methods appear to represent promising alternatives to traditional K-wire TBW, including cable pin system TBW, TBW with cannulated cancellous screws, and the olecranon memory connector. Lu et al16 suggest that the lower rate of implant removal in patients with TBW plus screw fixation is due to the additional fixation that screws provide, which reduces K-wire migration and is thus less likely to irritate skin and subcutaneous tissues. Potentially, added compression across the fracture site with olecranon screws reduces tension in the figure-of-8 fixation around the triceps tendon, reducing the rates of symptomatic tendonitis. Although all 3 novel methods supported by randomized data appear promising, they have each only been studied in 1 relatively small randomized trial to date. Further evidence comparing these novel methods with PF is required before their use can be advocated for in place of the more common fixation techniques.

This systematic review had several strengths. First, the authors conducted an in-depth literature search of 5 databases in duplicate to ensure all relevant studies were included. The quality of all studies was assessed independently and in duplicate using appropriate quality assessment scales. In addition, the authors conducted subgroup analyses comparing randomized and nonrandomized data to ensure their main outcomes were robust to potential differences in the methodological quality of included studies.

Nevertheless, this systematic review and meta-analysis had several limitations. Studies included in the meta-analysis were of low to moderate quality, with all studies having lack of patient blinding. In addition, the meta-analysis included 3 RCTs. Although the authors were able to support their conclusions with nonrandomized data via subgroup analysis, their primary analyses involved the inherent risks of bias common in observational studies.

Conclusion

Plate fixation yields significantly lower rates of complication as well as hardware removal compared with TBW. This article highlights the need to consider the increased complications associated with TBW before deciding on a method of fixation in adults with olecranon fractures.

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Functional Outcomes

Study, YearNo. of PatientsDASH Score, Mean (SD)MEPS, Mean (SD)Elbow Arc Flexion, Mean (Range or SD)




TBWPFTBWPFTBWPFTBWPF
Observational
  Aslam et al,42 20032019130° (100°–140°)119° (60°–150°)
  Tarallo et al,45 2014334512.4 (12)10.7 (12.5)88.3 (10.9)9.1 (11.1)
  Schliemann et al,22 2014131312.5 (8.7)14 (13.6)141° (5.6°)144° (6.7°)
  Amini et al,47 201510101010.59795132°132°
  DelSole et al,49 2016232597 (5.8)93.6 (7.1)135.4° (6.7°)134° (11.2°)
  Powell et al,50 2018481612.915
Randomized
  Hume et al,21 1992192212.8 (20)8.5 (10)90 (14)96 (6.8)137° (15°)131° (15°)

List of Complications

Study, YearTotalNo. (%)

ComplicationHardware RemovalSymptomatic HardwareInfectionNonunionHardware Migration or FailureOther Complications








TBWPFTBWPFTBWPFTBWPFTBWPFTBWPFTBWPFTBWPF
Observational
  Aslam et al,42 2003201912 (60)5 (26)11 (55)2 (11)7 (35)NR1 (5)1 (5)NRNR4 (20)2 (11)NRNR
  von Rüden et al,43 201129516 (21)1 (2)4 (14)1 (2)NRNR2 (7)NRNRNR3 (10)NR1 (3)NR
  Tarallo et al,45 2014334514 (42)10 (22)10 (30)4 (9)2 (6)1 (2)NRNR3 (9)3 (7)4 (12)NR4 (12)6 (13)
  Snoddy et al,46 20144313423 (53)41 (31)20 (47)25 (19)15 (35)17 (13)6 (14)8 (6)NR4 (3)1 (2)NR2 (5)14 (10)
  Amini et al,47 201510109 (90)3 (30)4 (40)1 (10)7 (70)3 (30)NRNRNRNR1 (10)NR1 (10)NR
  DelSole et al,49 201623257 (30)5 (20)2 (9)1 (4)7 (30)5 (20)NRNR1 (4)NRNRNR5 (22)2 (8)
  Powell et al,50 2018481619 (40)0 (0)13 (27)0 (0)15 (31)NRNRNR1 (2)NR2 (4)NRNRNR
  Subtotal20630090656434532699571521322
Randomized
  Hume et al,21 199219229 (47)1 (5)NRNR8 (42)1 (5)2 (11)NR2 (11)NRNRNR1 (5)NR
  Duckworth et al,10 2017303219 (63)12 (38)15 (50)7 (22)NRNRNR4 (13)NRNR8 (27)4 (13)NR3 (9)
  Khanna et al,39 2012151510 (67)3 (20)NRNR5 (33)1 (7)3 (20)1 (7)NR1 (7)2 (13)NRNRNR
  Subtotal64693816157132552110413
Total27036912881794166281414782561425

Other Elbow Fixation Techniques

Study, YearType of StudyInterventionNo. of PatientsMEPS, Mean±SDElbow Function (MEPS), No.Complications, No. (%)Hardware Removal, No. (%)
Liu et al,15 2012RCTCable pin system TBW3088.67±6.4220 excellent 9 good 1 fair 0 poor1 (3)0 (0)
Standard TBW3280.78±11.9912 excellent 12 good 5 fair 3 poor7 (22)5 (16)
Chen et al,30 2013RCTMemory connector fixation2086.7±12.510 excellent 7 good 3 fair 0 poor0 (0)NR
Locking plate2079.8±12.35 excellent 10 good 4 fair 1 poor1 (5)NR
Lu et al,16 2015RCTDouble screw TBW4287.9±6.029 excellent 12 good 1 fair 0 poor0 (0)0 (0)
Standard TBW4683.67±6.616 excellent 26 good 4 fair 0 poor21 (46)10 (22)
Ahmed et al,14 2008Quasi-RCTIntramedullary screw + TBW150 (0)0 (0)
TBW159 (60)8 (53)

Search strategy for the Medline database

DatabaseSearch Terms
MEDLINE 1946 - present1. olecranon process/ or olecranon/ or olecranon.mp.
2. elbow*.mp.
3. proximal ulna.mp.
4. (tension-band wiring or tension band wiring).mp.
5. (plate fixation or plating).mp.
6. locking compression plate*.mp.
7. cancellous screw*.mp.
8. (figure-of-eight or figure of eight or figure-of-8 or figure of 8).mp.
9. hook plate*.mp.
10. 1 or 2 or 3
11. 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11
12. 10 and 11

Characteristics of included studies

Randomized controlled trials
Study author, yearBaseline characteristicsOutcomes
Larsen, 1987

Study design: quasi-randomized controlled trial

Country of patient recruitment: Denmark

Multi-centre: no

Study interventions: modified TBW with non-sliding Netz pins, standard TBW

Fracture type:

Modified TBW: 14 transverse, 3 oblique, 4 comminuted

Standard TBW: 12 transverse, 2 oblique, 11 comminuted

Sample size: modified TBW: 21, standard TBW: 25

Female: 32/46

Mean age: 64.87 years

Follow-up:

13 (range: 4–30 weeks)

13 (range: 4–54 weeks)

Complications:

Modified TBW: 11

Standard TBW: 6

Implant removal:

Modified TBW: 17

Standard TBW: 11

Time to union:

Modified TBW: 6 (range: 4–12) weeks

Standard TBW: 7 (range: 4–12) weeks

Hume, 1992

Study design: randomized controlled trial

Country of patient recruitment: USA

Multi-centre: no

Study interventions: plate fixation, standard TBW

Fracture type: 3 simple reverse oblique, 11 simple transverse, 15 simple oblique, 12 comminuted

Sample size:

Plate fixation: 22

Standard TBW: 19

Female: 11/41

Mean age: 30.9 (range: 18–67) years

Follow-up: 28.5 (range: 16–86) weeks

Operation time:

Plate fixation: 120 (range 85–150) min

Standard TBW: 94.5 (range: 75–120) min

Complications:

Plate fixation: 1 patient

Standard TBW: 9 patients

Implant removal: 13.02 (range: 8.68–26.04) weeks

Time to union: 13.02 (range: 8.68–26.04) weeks

Juutilainen, 1995

Study design: randomized controlled trial

Country of patient recruitment: Finland

Multi-centre: no

Study interventions: biodegradable wire and screw TBW, standard TBW

Fracture type: transverse, oblique (numbers not reported)

Sample size:

Biodegradable wire and screw TBW: 15

Standard TBW: 10

Female:

Biodegradable wire and screw TBW: 9/15

Standard TBW: 8/10

Mean age:

Biodegradable wire and screw TBW: 47.2 (range: 22–77)

Standard TBW: 53.8 (range: 17–85)

Follow-up:

Biodegradable wire and screw TBW: 93.6 (range: 25–104)

Standard TBW: 72.8 (range: 25–104)

Pain:

Biodegradable wire and screw TBW: 1/15

Standard TBW: 2/10

Ahmed, 2008

Study design: quasi-randomized controlled trial

Country of patient recruitment: Egypt

Multi-centre: no

Study interventions: intramedullary screw and TBW, standard TBW

Fracture type:

Intramedullary screw and TBW: 10 transverse, 5 oblique

Standard TBW: 6 transverse, 9 oblique

Sample size:

Intramedullary screw and TBW: 15

Standard TBW: 15

Female:

Intramedullary screw and TBW: 4/15

Standard TBW: 5/15

Mean age:

Intramedullary screw and TBW: 37.9 (SD: 18.5, range: 17–70) years

Standard TBW: 28.8 (SD: 7.4, range: 18–42) years

Follow-up:

Intramedullary screw and TBW: 32.55 (SD: 9.1) weeks

Standard TBW: 38.2 (SD: 11.7) weeks

Complications:

Intramedullary screw and TBW: 0

Standard TBW: 9

Implant removal:

Intramedullary screw and TBW: 0

Standard TBW: 8

Time to union:

Intramedullary screw and TBW: 7.1 (SD: 1.7) weeks

Standard TBW: 7 (SD: 1.6) weeks

Khanna, 2012

Study design: quasi-randomized controlled trial

Country of patient recruitment: India

Multi-centre: no

Study interventions: TBW, reconstruction plating

Sample size:

TBW: 15

Reconstruction plating: 15

Female: 5/30

Mean age: 40 (range: 20–70) years

Complications:

TBW: 10/15

Reconstruction plating: 3/15

Time to union: 14 weeks

Liu, 2012

Study design: randomized controlled trial

Country of patient recruitment: China

Multi-centre: yes

Study interventions: modified TBW with cable pin system, standard TBW

Fracture type:

Modified TBW with cable pin system: 25 Mayo IIA, 5 Mayo IIIA

Standard TBW: 25 Mayo IIA, 7 Mayo IIIA

Sample size:

Modified TBW with cable pin system: 30

Standard TBW: 32

Female:

Modified TBW with cable pin system: 14/30

Standard TBW: 18/32

Mean age:

Modified TBW with cable pin system: 47.8 (SD: 12.83, range: 21–69) years

Standard TBW: 46.4 (SD: 13.93, range: 20–70) years

Follow-up:

Modified TBW with cable pin system: 92.31 (SD: 36.4) weeks

Standard TBW: 90.62 (SD: 36.3) years

Mayo elbow performance score:

Modified TBW with cable pin system: 88.67 (SD: 6.42, range: 70–100)

Standard TBW: 80.78 (SD: 11.99, range: 55–95)

Operation time:

Modified TBW with cable pin system: 34.83 (SD: 4.64) min

Standard TBW: 35.56 (SD: 3.78) min

Complications:

Modified TBW with cable pin system: 1

Standard TBW: 7

Implant removal:

Modified TBW with cable pin system: 0

Standard TBW: 5

Time to union:

Modified TBW with cable pin system: 9.73 (SD: 2.02, range: 8–12)

Standard TBW: 11.13 (SD: 2.21, range: 8–16)

Chen, 2013

Study design: randomized controlled trial

Country of patient recruitment: China

Multi-centre: no

Study interventions: olecranon memory connector fixation, locking plate fixation

Fracture type:

Olecranon memory connector fixation: 13 Mayo II, 7 Mayo III

Locking plate fixation: 14 Mayo II, 6 Mayo III

Sample size:

Olecranon memory connector fixation: 20

Locking plate fixation: 20

Female:

Olecranon memory connector fixation: 8/20

Locking plate fixation: 10/20

Mean age:

Olecranon memory connector fixation: 47.85 (SD: 17.6, range: 21–77) years

Locking plate fixation: 48.9 (SD: 15.5, range: 28–64) years

Follow-up:

Olecranon memory connector fixation: 158.4 (SD: 32.1) years

Locking plate fixation: 158.8 (SD: 40.4) years

Disabilities of the arm, shoulder, hand score

Olecranon memory connector fixation: 3.3 (SD: 4)

Locking plate fixation: 4 (SD: 6.9)

Mayo elbow performance score:

Olecranon memory connector fixation: 86.7 (SD: 12.5)

Locking plate fixation: 79.8 (SD: 12.3)

Complications:

Olecranon memory connector fixation: 0

Locking plate fixation: 1

Lu, 2015

Study design: randomized controlled trial

Country of patient recruitment: China

Multi-centre: yes

Study interventions: double screw TBW, standard TBW

Fracture type:

Double screw TBW: 18 transverse, 24 oblique

Standard TBW: 21 transverse, 25 oblique

Sample size:

Double screw TBW: 42

Standard TBW: 46

Female:

Double screw TBW: 16/42

Standard TBW: 15/46

Mean age:

Double screw TBW: 39.81 (SD: 12.7) years

Standard TBW: 43.74 (SD: 11.6) years

Follow-up: 141.92 (range: 104.2–173.6) weeks

Mayo elbow performance score:

Double screw TBW: 87.9

Standard TBW: 83.67

Operation time:

Double screw TBW: 48.71 (SD: 10.1) min

Standard TBW: 48.42 (SD: 9.7) min

Complications:

Double screw TBW: 0

Standard TBW: 21

Implant removal:

Double screw TBW: 0

Standard TBW: 10

Time to union:

Double screw TBW: 11.38 (SD: 1.2) weeks

Standard TBW: 12.6 (SD: 1.8) weeks

Duckworth, 2017

Study design: randomized controlled trial and cost-analysis

Country of patient recruitment: United Kingdom

Multi-centre: no

Study interventions: TBW, plate fixation

Fracture type: isolated displaced Mayo type IIA

Sample size:

TBW: 34

Plate fixation: 33

Female:

TBW: 13/34

Plate fixation: 16/33

Mean age:

TBW: 43 (SD: 15, range: 19–73)

Plate fixation: 52 (SD: 17, range: 18–74)

Follow-up: 1-year follow-up 85%

Disabilities of the arm, shoulder, hand score:

TBW: 12.8 (SD: 20, range: 0–79)

Plate fixation: 8.5 (SD: 10, range: 0–41)

Mayo elbow performance score:

TBW: 90 (SD: 14, range: 40–100)

Plate fixation: 96 (SD: 6.8, range: 85–100)

Complications:

TBW: 19/30

Plate fixation: 12/32

Implant removal:

TBW: 15/30

Plate fixation: 7/32

Prospective cohort study
StudyBaseline characteristicsOutcomes
Johnson, 1986

Study design: prospective cohort

Country of patient recruitment: USA

Multi-centre: no

Study interventions: AO cancellous screw alone, TBW plus AO cancellous screw

Fracture type: 17 transverse, 4 oblique, 2 dislocations, 5 fractures with associated elbow injuries

Sample size:

AO cancellous screw alone: 16

TBW plus AO cancellous screw: 12

Female: 12/28

Mean age: 36.4 (range: 16–78) years

Follow-up: 13 weeks

Complications: 4 total

Pain:

AO cancellous screw alone: 6

TBW plus AO cancellous screw: 8

Revision: 6 total

Retrospective cohort studies
StudyBaseline characteristicsOutcomes
Gartsman, 1981

Study design: Retrospective comparative cohort

Country of patient recruitment: USA

Multi-centre: no

Study interventions: primary excision, open reduction and internal fixation (using various methods)

Sample size:

Primary excision: 53

Open reduction and internal fixation: 54

Female: 65/107

Mean age: 57 (range: 19–92) years

Follow-up: 187.2 (range: 104–780) weeks

Complications:

Primary excision: 2

Open reduction and internal fixation: 13

Implant removal:

Primary excision: 0

Open reduction and internal fixation: 13

Revision:

Primary excision: 0

Open reduction and internal fixation: 13

Murphy, 1986

Study design: Retrospective comparative cohort

Country of patient recruitment: USA

Multi-centre: no

Study interventions: intramedullary screw, TBW, intramedullary screw and wire, figure-of-eight wire, Rusk rod with figure-of-eight wire

Fracture type: 26 transverse, 12 oblique, 7 comminuted

Sample size:

Intramedullary screw: 13

TBW: 10

Intramedullary screw and wire: 10

Figure-of-eight wire: 2

Rusk rod with figure-of-eight wire: 2

Female: 27/45

Mean age: 43.3 (range: 17–81) years total

Intramedullary screw: 56.4 years

TBW: 35.4 years

Intramedullary screw and wire: 46.4 years

Figure-of-eight wire: not reported

Rusk rod with figure-of-eight wire: not reported

Follow-up: 141.9 (range: 26–403.6) weeks

Complications:

Intramedullary screw: 2

TBW: 10

Intramedullary screw and wire: 3

Figure-of-eight wire: not reported

Rusk rod with figure-of-eight wire: not reported

Mullett, 2000

Study design: Retrospective comparative cohort

Country of patient recruitment: Ireland

Multi-centre: no

Study interventions: transcortical TBW, intramedullary TBW

Fracture type: displaced closed transverse

Sample size:

Transcortical TBW: 35

Intramedullary TBW: 45

Mean age:

Transcortical TBW: 58.2 years

Intramedullary TBW: 54.7 years

Follow-up:

Transcortical TBW: 169.3 weeks

Intramedullary TBW: 186.6 weeks

Complications:

Transcortical TBW: 9

Intramedullary TBW: 50

Implant removal:

Transcortical TBW: 4

Intramedullary TBW: 19

Karlsson, 2002

Study design: Retrospective comparative cohort

Country of patient recruitment: Sweden

Multi-centre: no

Study interventions: TBW, figure-of-eight wiring

Fracture type: 51 displaced >2mm, 16 comminuted

Sample size:

TBW: 32

Figure-of-eight wiring: 35

Female: 41/67

Mean age:

TBW: 47.3

Figure-of-eight wiring: 42.1

Follow-up: 946.4 (range: 728–1300) weeks

Complications:

TBW: 0

Figure-of-eight wiring: 1

Implant removal:

TBW: 26

Figure-of-eight wiring: 15

Aslam, 2003

Study design: Retrospective comparative cohort

Country of patient recruitment: United Kingdom

Multi-centre: no

Study interventions: AO TBW, plate fixation

Sample size:

AO TBW: 25

Plate fixation: 23

Mean age:

AO TBW: 50 (range: 27–42)

Plate fixation: 58 (range: 23–77)

Complications:

AO TBW: 12

Plate fixation: 5

Implant removal:

AO TBW: 11

Plate fixation: 2

Revision:

AO TBW: 11

Plate fixation: 2

Ruden, 2011

Study design: Retrospective comparative cohort

Country of patient recruitment: Germany

Multi-centre: no

Study interventions: TBW figure-of-eight, posterior plating +/− intramedullary screw

Fracture type: Mayo II, Mayo III

Sample size:

TBW figure-of-eight: 29

Posterior plating +/− intramedullary screw: 51

Female: 36/80

Complications:

TBW figure-of-eight: 6

Posterior plating +/− intramedullary screw: 1

Revision:

TBW figure-of-eight: 4

Posterior plating +/− intramedullary screw: 1

Lan, 2013

Study design: Retrospective comparative cohort

Country of patient recruitment: Taiwan

Multi-centre: no

Study interventions: pre-shaped non-locking plating, locking plate

Fracture type: comminuted

Sample size:

Pre-shaped non-locking plating: 10

Locking plate: 13

Female:

Pre-shaped non-locking plating: 6/10

Locking plate: 7/13

Mean age:

Pre-shaped non-locking plating: 36.5 years

Locking plate: 43.4 years

Follow-up:

Pre-shaped non-locking plating: 160.6 weeks

Locking plate: 60.8 weeks

Mayo elbow performance score:

Pre-shaped non-locking plating: 95

Locking plate: 94

Complications:

Pre-shaped non-locking plating: 3

Locking plate: 0

Implant removal:

Pre-shaped non-locking plating: 3

Locking plate: 3

Time to union:

Pre-shaped non-locking plating: 13.45 weeks

Locking plate: 12.59 weeks

Tarallo, 2014

Study design: Retrospective comparative cohort

Country of patient recruitment: Italy

Multi-centre: no

Study interventions: TBW, plate fixation

Fracture type:

TBW: 21 Mayo IIA, 12 Mayo IIB

Plate fixation: 10 Mayo IIA, 35 Mayo IIB

Sample size:

TBW: 33

Plate fixation: 45

Female:

TBW: 20

Plate fixation: 28

Mean age:

TBW: 51.82 (SD: 10.05)

Plate fixation: 49.38 (SD: 12.7)

Follow-up: 143.2 (range: 52.1–386.3) weeks

Disabilities of the arm, shoulder, hand score:

TBW: 12.4 (SD: 12)

Plate fixation: 10.7 (SD: 12.5)

Mayo elbow performance score:

TBW: 88.3 (SD: 10.9)

Plate fixation: 9.1 (SD: 11.1)

Complications:

TBW: 14

Plate fixation: 10

Implant removal:

TBW: 4

Plate fixation: 0

Non-union:

TBW: 3

Plate fixation: 3

Revision:

TBW: 5

Plate fixation: 8

Pain:

TBW: 4

Plate fixation: 4

Snoddy, 2014

Study design: Retrospective comparative cohort

Country of patient recruitment: USA

Multi-centre: no

Study interventions: plate fixation, TBW

Fracture type:

Plate fixation: 2 OTA class 21-A1, 131 OTA class 21-B1

TBW: 1 OTA class 21-A1, 41 OTA 21-B1, 1 OTA class 21-C1

Sample size:

TBW: 134

Plate fixation: 43

Female:

TBW: 70

Plate fixation: 26

Mean age:

TBW: 45.8 (SD: 20.3, range: 27-61)

Plate fixation: 43.27 (SD: 21.8, range: 22–54)

Complications:

TBW: 41

Plate fixation: 23

Implant removal:

TBW: 25

Plate fixation: 10

Non-union:

TBW: 4

Plate fixation: 0

Time to union:

TBW: 25 weeks

Plate fixation: 20 weeks

Schliemann, 2014

Study design: Retrospective comparative cohort

Country of patient recruitment: Germany

Multi-centre: no

Study interventions: plate fixation, TBW

Fracture type: Mayo IIA

Sample size:

Plate fixation: 13

TBW: 13

Female:

Plate fixation: 7

TBW: 6

Mean age:

Plate fixation: 48.6 (range: 18–67)

TBW: 38.1 (range: 18–67)

Follow-up:

Plate fixation: 118.92 (range: 56.4–173.6) weeks

TBW: 264.31 (range 82.5–520.8) weeks

Disabilities of the arm, shoulder, hand score

Plate fixation: 14 (SD: 13.6, range: 0–45)

TBW: 12.5 (SD: 8.7, range: 0–37)

Complications:

Plate fixation: 12

TBW: 16

Implant removal:

Plate fixation: 7

TBW: 12

Pain:

Plate fixation: 2

TBW: 5

Revision:

Plate fixation: 7

TBW: 12

Amini, 2015

Study design: Retrospective comparative cohort and cost analysis

Country of patient recruitment: USA

Multi-centre: no

Study interventions: TBW, locking plate

Fracture type: isolated, transverse, non-comminuted

Sample size:

TBW: 10

Locking plate: 10

Mean age:

TBW: 51.7 years

Locking plate: 55.2 years

Follow-up:

TBW: 265.2 weeks

Locking plate: 182 weeks

Disabilities of the arm, shoulder, hand score:

TBW: 97

Locking plate: 95

Complications:

TBW: 7

Locking plate: 3

Implant removal:

TBW: 4

Locking plate: 1

Non-union:

TBW: 0

Locking plate: 0

Chan, 2015

Study design: Retrospective comparative cohort

Country of patient recruitment: United Kingdom

Multi-centre: no

Study interventions: Transcortical K-wire TBW, intramedullary K-wire TBW

Fracture type:

48 Mayo IIA, 15 Mayo IIB

Sample size:

Intramedullary: 47

Transcortical: 16

Female: 35/63

Mean age: 58 years (range 20–95)

Follow-up: 56 (range 20-116) weeks

Complications:

Transcortical K-wire: 4

Intramedullary K-wire: 9

Implant removal:

Transcortical K-wire: 4

Intramedullary K-wire: 9

DelSole, 2016

Study design: Retrospective comparative cohort

Country of patient recruitment: USA

Multi-centre: no

Study interventions: TBW, hook plate

Fracture type:

TBW: 1 Mayo IA, 18 Mayo IIA, 3 Mayo IIB, 1 Mayo IIIB

Hook plate: 0 Mayo IA, 15 Mayo IIA, 10 Mayo IIB, 0 Mayo IIIB

Sample size:

TBW: 23

Hook plate: 25

Female:

TBW: 18

Hook plate: 19

Mean age:

TBW: 64.5 (SD: 20)

Hook plate: 65.76 (SD: 17.2)

Follow-up:

TBW: 58.59 (SD: 42.1)

Hook plate: 62.5 (SD: 50.3)

Mayo elbow performance score:

TBW: 97 (SD: 5.8)

Hook plate: 93.6 (SD: 7.1)

Complications:

TBW: 7

Hook plate: 5

Implant removal:

TBW: 2

Hook plate: 0

Non-union:

TBW: 1

Hook plate: 0

Time to union:

TBW: 12.2 (SD: 5.5)

Hook plate: 19.1 (SD: 7.7)

Revision:

TBW: 2

Hook plate: 0

Powell, 2018

Study design: Retrospective comparative cohort and cost analysis

Country of patient recruitment: United Kingdom

Multi-centre: no

Study interventions: TBW, locking plate

Fracture type: 64 Mayo IIA

Sample size:

TBW: 48

Locking plate: 16

Female:

TBW: 28

Locking plate: 12

Mean age:

TBW: 57 (range 15–93)

Locking plate: 60 (range 22–80)

Follow-up:

TBW: 42 (range 28–78) months

Locking plate: 32 (range 28–54) months

QuickDASH:

TBW: 12.9

Locking plate: 15.0

Complications:

TBW: 19

Locking plate: 0

Non-union:

TBW: 1

Locking plate: 0

Implant removal:

TBW: 13

Locking plate: 0

Revision:

TBW: 2

Locking plate: 0

Cost per patient:

TBW: £480.33

Locking plate: £244.00

Cochrane risk of bias for randomized controlled trials

Larsen et al, 1987
Risk of bias domainAuthor's judgmentEvidence or support for judgment
Random sequence generationhigh“Patients were selected for the two methods according to whether they were admitted on even or odd days”
Allocation concealmenthighQuasi-randomization suggests no allocation concealment implemented.
Blinding of patientshighNo mention of blinding of patients.
Blinding of outcome assessorhighNo mention of blinding of outcome assessor.
Incomplete outcome datalowAll patients included in analysis.
Selective reportinglowOutcomes specified in methods were reported in results.
Other bias (industry sponsorship)lowNo mention of industry sponsorship.
Hume et al, 1991
Risk of bias domainAuthor's judgmentEvidence or support for judgment
Random sequence generationunclear“patients with displaced olecranon fractures requiring open reduction and internal fixation were randomized”
Allocation concealmentunclearUnclear whether allocation concealment was implemented.
Blinding of patientshighNo mention of blinding of patients.
Blinding of outcome assessorhighNo mention of blinding of outcome assessor.
Incomplete outcome datalowAll patients included in analysis.
Selective reportinglowOutcomes specified in methods were reported in results.
Other bias (industry sponsorship)lowNo mention of industry sponsorship.
Juutilainen et al, 1995
Risk of bias domainAuthor's judgmentEvidence or support for judgment
Random sequence generationunclear“patients with closed olecranon (transverse/oblique) or patella fractures were randomized to SR-PLLA wire and SR-PGA screw or SR-PLLA plug fixation or to metallic cerclage wire and two Kirschner wires fixation”
Allocation concealmentunclearUnclear whether allocation concealment was implemented.
Blinding of patientshighNo mention of blinding of patients.
Blinding of outcome assessorhighNo mention of blinding of outcome assessor.
Incomplete outcome datalowPatients eligible for trial were included in analysis.
Selective reportinglowOutcomes specified in methods were reported in results.
Other bias (industry sponsorship)lowNo mention of industry sponsorship.
Ahmed et al, 1995
Risk of bias domainAuthor's judgmentEvidence or support for judgment
Random sequence generationhigh“patients were randomly divided into two groups of equal number where patients with odd numbers were treated using AO tension band wiring and those with even numbers by intramedullary screw plus tension band”
Allocation concealmenthighQuasi-randomization suggests no allocation concealment implemented.
Blinding of patientshighNo mention of blinding of patients.
Blinding of outcome assessorhighNo mention of blinding of outcome assessor.
Incomplete outcome datalowAll patients included in analysis.
Selective reportinglowOutcomes specified in methods were reported in results.
Other bias (industry sponsorship)low“No funds were received in support of this study”
Liu et al, 2012
Risk of bias domainAuthor's judgmentEvidence or support for judgment
Random sequence generationlow“patients were then randomly divided into two groups for treatment with open reduction and different types of internal fixation, using an adaptive biased coin design”
Allocation concealmentlow“randomization was carried out by a research assistant whenever an eligible patient was admitted and the grouping result was placed in a sealed envelope”
Blinding of patientshighPatients were unblinded after allocated to treatment group.
Blinding of outcome assessorlow“an independent group of physicians (not involved in the initial fracture treatment and blinded to the fixation method) evaluated the clinical outcomes of all patients”
Incomplete outcome datalowAll patients included in analysis.
Selective reportinglowOutcomes specified in methods were reported in results.
Other bias (industry sponsorship)low“authors had no conflicts of interest to declare in relation to this article”
Chen et al, 2013
Risk of bias domainAuthor's judgmentEvidence or support for judgment
Random sequence generationunclearRandomization conducted but random sequence generation unclear.
Allocation concealmentlow“all reviewers were blinded to evaluate the postoperative function by means of a randomised block design”
Blinding of patientshighNo mention of blinding of patients.
Blinding of outcome assessorlow“all reviewers were blinded to evaluate the postoperative function by means of a randomised block design”
Incomplete outcome datalow“no loss to follow-up”
Selective reportinglowOutcomes specified in methods were reported in results.
Other bias (industry sponsorship)low“authors declare no conflict of interest”
Lu et al, 2015
Risk of bias domainAuthor's judgmentEvidence or support for judgment
Random sequence generationunclearRandomization conducted but random sequence generation unclear.
Allocation concealmentunclearUnclear whether allocation concealment was implemented.
Blinding of patientshighNo mention of blinding of patients.
Blinding of outcome assessorlow“all digital radiographics were assessed by an independent senior radiologist”
Incomplete outcome datalowAll patients included in analysis.
Selective reportinglowOutcomes specified in methods were reported in results.
Other bias (industry sponsorship)low“no conflicts declared”
Duckworth et al, 2017
Risk of bias domainAuthor's judgmentEvidence or support for judgment
Random sequence generationunclearRandomization conducted but random sequence generation unclear.
Allocation concealmentlow“performed by block randomization using sequential closed opaque envelopes”
Blinding of patientshighNo mention of blinding of patients.
Blinding of outcome assessorlow“a full clinical outcome assessment was completed by a blinded research physiotherapist or research fellow not involved in the patient's management”
Incomplete outcome datalow“1-year follow-up rate was 85%”; loss to follow-up <20%
Selective reportinglowOutcomes specified in methods were reported in results.
Other bias (industry sponsorship)lowSponsorship was not industry-related.
Khanna et al, 2012
Risk of bias domainAuthor's judgmentEvidence or support for judgment
Random sequence generationhigh“patients with closed olecranon fractures were taken who were distributed alternatively to two groups”
Allocation concealmenthighQuasi-randomization suggests no allocation concealment implemented.
Blinding of patientshighNo mention of blinding of patients.
Blinding of outcome assessorhighNo mention of blinding of outcome assessor.
Incomplete outcome datalow“every patient of each group then is graded during his follow-up for clinical and radiological results”
Selective reportinglowOutcomes specified in methods were reported in results.
Other bias (industry sponsorship)lowNo mention of industry sponsorship.

Newcastle-Ottawa for prospective cohort studies

StudySelectionComparabilityOutcome
12341123
Johnson et al, 1986**-*--**

MINORS for retrospective cohort studies

StudyMINORS Scale Domain
123456789101112Total
Gartsman et al, 198102010220220011
Murphy et al, 198622110200220012
Mullett et al, 200022210020222015
Karlsson et al, 200222212200220217
Aslam et al, 200322010200220112
Ruden et al, 201122010000221010
Lan et al, 201322010220221216
Tarallo et al, 201422210220221218
Snoddy et al, 201422210221222220
Schliemann et al, 201422110201221216
Amini et al, 201521110220222217
Chan et al, 201522110220221217
Del Sole et al, 201620210222222219
Powell et al, 201822210220222219
Authors

The authors are from the Department of Surgery (AK, CO, SN, HJ) and the Department of Health Research Methods, Evidence, and Impact (AK, TW, HJ), McMaster University, Hamilton, Ontario, Canada.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Alex Koziarz, MSc, Department of Surgery, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada ( koziaa@mcmaster.ca).

Received: December 28, 2018
Accepted: February 12, 2019
Posted Online: February 27, 2019

10.3928/01477447-20190221-03

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