Abstract
Background
Multiple rib fractures are common in trauma patients, who are prone to trauma-associated complications. Surgical or nonsurgical interventions for the aforementioned conditions remain controversial.
Questions/purposes
The purpose of our study was to perform a meta-analysis to evaluate the clinical prognosis of surgical fixation of multiple rib fractures in terms of (1) hospital-related endpoints (including duration of mechanical ventilation, ICU length of stay [LOS] and hospital LOS), (2) complications, (3) pulmonary function, and (4) pain scores.
Methods
We screened PubMed, Embase, and Cochrane databases for randomized and prospective studies published before January 2018. Individual effect sizes were standardized; the pooled effect size was calculated using a random-effects model. Primary outcomes were duration of mechanical ventilation, intensive care unit length of stay (ICU LOS), and hospital LOS. Moreover, complications, pulmonary function, and pain were assessed.
Results
The surgical group had a reduced duration of mechanical ventilation (weighted mean difference [WMD], -4.95 days; 95% confidence interval [CI], -7.97 to -1.94; p = 0.001), ICU LOS (WMD, -4.81 days; 95% CI, -6.22 to -3.39; p < 0.001), and hospital LOS (WMD, -8.26 days; 95% CI, -11.73 to -4.79; p < 0.001) compared with the nonsurgical group. Complications likewise were less common in the surgical group, including pneumonia (odds ratio [OR], 0.41; 95% CI, 0.27–0.64; p < 0.001), mortality (OR, 0.24; 95% CI, 0.07–0.87; p = 0.030), chest wall deformity (OR, 0.02; 95% CI. 0.00–0.12; p < 0.001), dyspnea (OR, 0.23; 95% CI, 0.09–0.54; p < 0.001), chest wall tightness (OR, 0.11; 95% CI, 0.05–0.22; p < 0.001) and incidence of tracheostomy (OR, 0.34; 95% CI, 0.20–0.57; p < 0.001). There were no differences between the surgical and nonsurgical groups in terms of pulmonary function, such as forced vital capacity (WMD, 6.81%; 95% CI: -8.86 to 22.48; p = 0.390) and pain scores (WMD, -11.41; 95% CI: -42.09 to 19.26; p = 0.470).
Conclusions
This meta-analysis lends stronger support to surgical fixation, rather than conservative treatment, for multiple rib fractures. Nevertheless, additional trials should be conducted to investigate surgical indications, timing, and followup for quality of life.
Level of Evidence
Level I, therapeutic study.
Introduction
Multiple rib fractures are common in trauma patients, occurring in up to 39% of patients after blunt chest trauma and accounting for 10% of all trauma admissions [16]. Trauma-associated complications and pain worsen patients’ pulmonary function and long-term recovery. Moreover, flail chest is a condition in which three or more contiguous ribs fracture at multiple locations, with paradoxical chest movements causing severe acute respiratory failure [20]. Historically, multiple rib fractures are managed conservatively with analgesia, mechanical ventilation, and pulmonary hygiene [13]. The surgical management of multiple rib fractures to achieve stability remains controversial [5]. However, patients experiencing severe pain because of progressive rib displacement may take longer to return to normal activity, have a lower quality of life, and even have an increased risk of pneumonia, septicemia, and mortality [10, 27].
In recent years, surgical stabilization of multiple rib fractures has become increasingly popular worldwide [8]. Fixation plates and intramedullary stabilization are the principles of osteosynthesis [13]. Furthermore, a titanium device with biodynamic qualities considered similar to ribs, minimally invasive plates, and other materials have been used for rib fixation [2]. These protocols may restore chest wall integrity, prevent permanently damaging sequelae [10], and improve respiratory function [26].
The efficacy of surgical stabilization of rib fractures has recently been investigated by several randomized controlled trials (RCTs) [10, 20, 26, 30] and prospective studies [8, 13, 21, 27]. However, surgical indications varied among the studies and management for multiple rib fractures remains controversial.
Several systematic reviews and meta-analyses have summarized the surgical outcomes of chest injuries [3, 4, 17, 23]. However, they included limited RCTs that focused on only the surgical outcomes of flail chest. Schulte et al. [22] and Swart et al. [25] have systematically reviewed trials with varied surgical indications for rib fractures, which were mostly retrospective without meta-analyses.
Therefore, we conducted a systematic review and meta-analysis of randomized and prospective studies to evaluate the clinical prognosis of surgical fixation of multiple rib fractures in terms of (1) hospital-related endpoints (including duration of mechanical ventilation, ICU length of stay [LOS], and hospital LOS) (2) complications, (3) pulmonary function, and (4) pain scores.
Patients and Methods
Search Strategy and Criteria
We included RCTs and prospective studies comparing surgical and nonsurgical outcomes in patients with multiple rib fractures. We excluded studies that met any of the following criteria: (1) lack of a nonsurgical group and (2) examined patients who underwent rib fixation in the chronic phase (ie, rib nonunion after more than 3 months).
Relevant studies published before January 2018 were identified from the PubMed, EMBASE, and Cochrane Library databases. We used the following medical subject headings terms: “rib fractures” or “flail chest” or “surgery”; “surgical procedures” or “operative” or “fracture fixation”; “internal” or “fracture fixation”; and “intramedullary” or “conservative treatment” or “respiration”; or “artificial.” Various combinations of these terms were used to search for potential studies. We used the “Related Articles” option in PubMed to broaden the search scope, and all retrieved abstracts, studies, and citations were reviewed. Moreover, we identified other studies by using the bibliographies of included studies and reference sections of relevant papers and by corresponding with subject experts. Finally, unpublished studies were collected from the ClinicalTrials.gov registry (http://clinicaltrials.gov/). The search was not restricted to papers published in English. Our systematic review has been accepted by PROSPERO, an online international prospective register of systematic reviews, which is curated by the National Institute for Health Research (CRD42017072633).
Data Extraction
Baseline and outcome data were independently abstracted by two reviewers (Y-SL and K-CY). Study designs, population characteristics, inclusion criteria, surgical procedures, complications, and postoperative parameters were extracted. The decisions individually recorded by the reviewers were compared, and disagreements were resolved by consulting a third reviewer (K-WT).
Methodological Quality Appraisal
The two reviewers (Y-SL and K-CY) independently assessed the methodological quality of each study by using the revised Cochrane Risk of Bias tool (RoB 2.0, Bristol, United Kingdom) [12] for RCTs and Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I, Bristol, United Kingdom and Boston, MA, USA) [24] for prospective studies. Several domains were assessed, including selection, performance, detection, attrition, reporting, and other biases in RCTs, as well as preintervention, at-intervention, postintervention, and overall biases in prospective studies.
Outcomes
The primary outcomes were the duration of mechanical ventilation, intensive care unit (ICU) length of stay (LOS), and hospital length of stay (LOS). The secondary outcomes included complications, namely pneumonia, mortality, dyspnea, chest wall deformity and tightness and incidence of tracheostomy. Other outcomes included pulmonary function, pain, and medication use.
Statistical Analyses
Data were entered and analyzed using Review Manager, Version 5.3 (Cochrane Collaboration, Oxford, England). The meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [18]. We estimated SDs from the reported confidence intervals (CIs), standard errors, or interquartile ranges divided by 1.35. Continuous and dichotomous variables were analyzed using the weighted mean difference (WMD) and odds ratio (OR). The precision of the effect sizes was reported as 95% CIs. Furthermore, a pooled estimate was computed using the DerSimonian and Laird random-effect model [7]. The Cochran Q tests were calculated to evaluate the statistical heterogeneity and the I2 statistics were calculated to evaluate the inconsistency of treatment effects across studies. Statistical significance was set at p < 0.10 for the Cochran Q tests [18], according to PRISMA guidelines. Subgroup analysis was performed by pooling the estimates of similar study designs across trials.
Trial Characteristics
The initial search yielded 363 citations, of which 232 were ineligible based on the criteria used for screening titles and abstracts. Subsequently, we retrieved the full text of 131 studies. However, we also excluded 55 retrospective studies, 29 studies lacking a nonsurgical group, 21 case reports, 11 reviews, five guidelines, one study discussing rib nonunion, and one study comparing patients with different pain scores [15]. Thus, four RCTs [10, 20, 26, 30] and four prospective studies [8, 13, 21, 27] were included in this meta-analysis (Fig. 1).
Fig. 1.
The flowchart shows the search strategy we used for this study.
Among the included studies, eight were published between 2002 and 2016; the patient numbers ranged from 20 to 276, with a total of 608 participants. All studies included patients with multiple rib fractures; three RCTs [10, 20, 26] and two prospective studies [13, 27] only included patients with flail chest. Additionally, all studies compared the prognosis of the surgical fixation and conservative treatment of multiple rib fractures. The mean injury severity score (ISS) was 16.8–35.0, and the number of rib fractures ranged from 4.4 to 11.3. Except in two studies that reported a lower ISS in the surgical group [10, 27], the baseline characteristics in other studies were fairly balanced. Surgical interventions included Kirschner and stainless-steel wires [10], resorbable plates and bicortical screws [20], Judet struts [26], Stracos plates (Strasbourg Costal Osteosynthesis System, MedXpert GmbH, Germany) [13], and MatrixRIB™ Fixation System (DePuy Synthes, Raynham, MA, USA) [8, 27] (Table 1).
Table 1.
Characteristics of studies that fulfilled the inclusion criteria for meta-analysis
Two RCTs had selection bias because of differences in the ISS of patients (surgical group, 18.0 ± 5.1 patients and nonsurgical group, 16.8 ± 3.5 patients; p = 0.043) [10] and lack of concealment [30]. Patients in the two groups were treated equally in all trials; therefore, no performance bias was found. In Wu et al. [30] there were some concerns regarding detection bias because the authors did not clearly define the acute and chronic phases [30]. In Marasco et al. [20], 23% of the patients in the nonsurgical group were lost to followup 3 months after receiving patient care, raising some attrition bias concerns. No other biases were found in the RCTs (Table 2).
Table 2.
Assessment of methodological quality of included trials
During the preintervention period, two prospective studies had a moderate risk of confounding bias because of historical control groups [8, 27]. During the at-intervention period, one study had a moderate risk of bias in the classification of interventions among patients, considering different caregivers [8] in the nonsurgical group. Furthermore, during the postintervention period, two studies had a moderate risk of bias due to missing data [8, 27]. Considering bias in the measurement or selection of reported results, all studies reported appropriate methods. Overall, two prospective studies had moderate bias [8, 27] (Table 2).
Results
Hospital-related Endpoints
Duration of Mechanical Ventilation
Seven studies recorded the duration of mechanical ventilation with 553 patients being analyzed [10, 13, 20, 21, 26, 27, 30]. The surgical group had a shorter duration of mechanical ventilation (WMD, -4.95 days; 95% CI, -7.97 to -1.94; p = 0.001) than did the nonsurgical group. In subgroup analysis, both RCTs (WMD, -6.22 days; 95% CI, -9.64 to -2.79; p < 0.001) and prospective studies (WMD, -1.91 days; 95% CI, -3.69 to -0.13; p = 0.040) showed a shorter duration of mechanical ventilation in the surgical group than in the nonsurgical group (Fig. 2).
Fig. 2.
The forest plot shows the duration of mechanical ventilation, ICU length of stay, and hospital length of stay after surgical versus nonsurgical management. The size of the squares reflects the weight of the trial in pooled analysis. The horizontal bars represent the 95% CI; IV = inverse variance; df = degrees of freedom.
Intensive Care Unit Length of Stay
Seven studies recorded the ICU LOS for 553 patients [10, 13, 20, 21, 26, 27, 30]. The ICU LOS was shorter in the surgical group (WMD, -4.81 days; 95% CI, -6.22 to -3.39; p < 0.001) than in the nonsurgical group. In subgroup analysis, both RCTs (WMD, -5.77 days; 95% CI, -6.99 to -4.55; p < 0.001) and prospective studies (WMD, -2.58 days; 95% CI, -4.45 to -0.72; p = 0.007) had a shorter ICU LOS (Fig. 2).
Hospital Length of Stay
Six studies analyzed the hospital LOS of 516 patients [10, 13, 20, 21, 27, 30]. The hospital LOS was shorter in the surgical group (WMD, -7.25 days; 95% CI, -10.76 to -3.73; p < 0.001). Subgroup analysis demonstrated a shorter LOS in the surgical group (WMD, -11.00 days, 95% CI, -12.60 to -9.40; p < 0.001) in RCTs but not in prospective studies (WMD, -2.73 days, 95% CI, -5.55 to 0.09; p = 0.06; Fig. 2).
Complications
Pneumonia
Seven studies recorded the incidence of pneumonia in 553 patients [10, 13, 20, 21, 26, 27, 30]. Tanaka et al. [26] reported pneumonia 7 and 21 days after injury and analyzed data at 7 days [8]. Granetzny et al. [10] reported outcomes as chest infection. The surgical group had a lower incidence of pneumonia (OR, 0.41; 95% CI, 0.27, 0.64; p < 0.001) than did the nonsurgical group. Both RCTs (OR, 0.25, 95% CI, 0.13–0.51; p < 0.001) and prospective studies (OR, 0.57; 95% CI, 0.32–1.00; p = 0.05) showed a lower incidence of pneumonia in the surgical group (Fig. 3).
Fig. 3.
The forest plot shows the incidence of pneumonia and mortality after surgical versus nonsurgical management. The size of the squares reflects the weight of the trial in pooled analysis. The horizontal bars represent the 95% CI; M-H = Mantel-Haenszel; df = degrees of freedom.
Mortality
Four studies analyzed mortality in 426 patients [10, 20, 27, 30]; only Marasco et al. [20] recorded in-hospital mortality, Wu et al. [30] recorded mortality during the acute phase, and the other two studies [10, 27] recorded mortality without a clear definition. The surgical group had a lower incidence of mortality (OR, 0.24; 95% CI, 0.07–0.87; p = 0.030) than the nonsurgical group. Subgroup analysis revealed a lower mortality rate (OR, 0.07; 95% CI, 0.02–0.31; p < 0.001) in prospective studies but not in RCTs (OR, 0.55; 95% CI, 0.14–2.13; p = 0.38; Fig. 3).
Chest Wall Deformity
Two RCTs investigated the incidence of chest wall deformity in 204 patients [10, 30]. Of the two trials, Granetzny et al. [10] reported deformity after management, whereas Wu et al. [30] reported the condition in the chronic phase (without a clear definition of time). The surgical group had a lower incidence of chest wall deformity than the nonsurgical group (OR, 0.02; 95% CI, 0.00–0.12; p < 0.001; Fig. 4).
Fig. 4.
The forest plot shows the incidence of complications including chest wall deformity, dyspnea, chest wall tightness, and tracheostomy after surgical versus nonsurgical management. The size of the squares reflects the weight of the trial in pooled analysis. The horizontal bars represent the 95% CI; M-H = Mantel-Haenszel; df = degrees of freedom.
Dyspnea
Two RCTs recorded the incidence of dyspnea in 201 patients [26, 30]. Of the two trials, Tanaka et al. [26] reported dyspnea 12 months after injury, and Wu et al. [30] reported the condition in the chronic phase; however, they did not clearly define the timing of the chronic phase. The surgical group had a lower incidence of dyspnea than the nonsurgical group (OR, 0.23; 95% CI, 0.09–0.54; p < 0.001; Fig. 4).
Chest Wall Tightness
Two trials determined the incidence of chest wall tightness in 201 patients [26, 30]. Of the two trials, Tanaka et al. [26] reported chest wall tightness 12 months after injury, and Wu et al. [30] reported the condition in the chronic phase, without a clear definition of time. The surgical group had a lower incidence of chest wall tightness than the nonsurgical group (OR, 0.11; 95% CI, 0.05–0.22; p < 0.001; Fig. 4).
Incidence of Tracheostomy
Five studies determined the incidence of tracheostomy in 493 patients [20, 21, 26, 27, 30]. Tanaka et al. [26] reported the incidence of tracheostomy at 7 and 21 days after injury, and we analyzed data at 7 days. The surgical group showed a lower incidence of tracheostomy (OR, 0.34; 95% CI, 0.20–0.57; p < 0.001). Subgroup analysis revealed a lower incidence of tracheostomy in both RCTs (OR, 0.36; 95% CI, 0.15–0.90; p = 0.03) and prospective studies (OR, 0.32; 95% CI. 0.16–0.63; p < 0.001; Fig. 4).
Pulmonary Function
Forced Vital Capacity
Four studies determined the forced vital capacity (FVC) [8, 10, 20, 26] of 184 patients. In contrast to three other studies, Fagevik Olsén et al. [8] reported the results as a percentage of the predicted value. There were no differences in FVC between the surgical and the nonsurgical groups in the overall pooled analysis (WMD, 6.81%; 95% CI, -8.86 to 22.48; p = 0.390) and in subgroup analysis (RCTs: WMD, 11.24%; 95% CI, -6.95 to 29.43; p = 0.23; prospective studies: WMD, -8.00%; 95% CI, -20.54 to 4.54; p = 0.21; Fig. 5).
Fig. 5.
The forest plot shows the pulmonary function test including forced vital capacity (FVC), peak expiratory flow rate (PEFR), forced expiratory volume in 1 second (FEV1), and total lung capacity (TLC) after surgical versus nonsurgical management. The size of the squares reflects the weight of the trial in pooled analysis. The horizontal bars represent the 95% CI; IV = inverse variance; df = degrees of freedom.
Peak Expiratory Flow Rate
Three studies recorded the peak expiratory flow rate [8, 10, 20]. A total of 147 patients were analyzed. Peak expiratory flow rate showed no differences between the surgical and the nonsurgical groups in the overall pooled analysis (WMD, 0.39%; 95% CI, -0.75 to 1.54; p = 0.50) and in subgroup analysis (RCTs: WMD, 0.38%; 95% CI: -0.77 to 1.53; p = 0.52; prospective studies: WMD, 3.00%; 95% CI: -11.81 to 17.81; p = 0.69; Fig. 5).
Forced Expiratory Volume in 1 Second (FEV1)
Two RCTs determined the forced expiratory volume in 1 second (FEV1) in 86 patients [10, 20]. FEV1 showed no differences between the surgical and the nonsurgical group (WMD, -1.09%; 95% CI, -6.52 to 4.33; p = 0.69; Fig. 5).
Total Lung Capacity
Two RCTs recorded the total lung capacity (TLC) of 43 patients [10, 20]. They demonstrated no differences in TLC between the surgical and nonsurgical groups (WMD, 2.68%; 95% CI, -4.98 to 10.34; p = 0.49; Fig. 5).
Pain Scores and Pain Medication
Pain Scores
Two RCTs with 210 patients assessed thoracic pain scores [20, 30]. Marasco et al. [20] used bodily pain scores ranging from 0 to 100, whereas Wu et al. [30] scored pain from 0 to 10. Therefore, we multiplied the results of Wu et al. [30] by 10. Pain scores showed no difference between the surgical and nonsurgical groups (WMD, -11.41; 95% CI, -42.09 to 19.26; p = 0.470; Fig. 6).
Fig. 6.
The forest plot shows the pain score and pain medications after surgical versus nonsurgical management. The size of the squares reflects the weight of the trial in pooled analysis. The horizontal bars represent the 95% CI; IV = inverse variance; M-H = Mantel-Haenszel; df = degrees of freedom.
Tanaka et al. [26] reported a lower incidence of pain in the surgical group compared with the nonsurgical group (p < 0.05), whereas Fagevik Olsén et al. [8] revealed no differences between surgical and nonsurgical groups (p = 0.253) [10].
Pain Medication
Two prospective studies recorded pain medications used by 131 patients [8, 21]. Of the two studies, Fagevik Olsén et al. [8] reported pain medications used 12 months after injury, whereas Pieracci et al. [21] reported pain medications used daily. No differences were found between surgical and nonsurgical groups (OR, 0.93; 95% CI, 0.31–2.79; p = 0.90; Fig. 6).
Discussion
Our meta-analysis reveals that patients who underwent surgical fixation of multiple rib fractures had a shorter duration of mechanical ventilation, shorter ICU LOS and hospital LOS, a lower incidence of tracheostomy, and fewer complications compared with those who did not undergo surgery. No differences were found in pain scores, medication use, and pulmonary function tests. We believe these results, which are based on the best-available evidence, lend some support for stronger consideration of surgical management when caring for patients with multiple rib fractures.
This meta-analysis has several limitations. First, in the included studies, the percentage of women was lower than that of men. More studies are needed to determine the clinical outcomes of women. In addition, the injury severity and surgical management of patients varied, and not all included studies restricted surgical timing to a specific period after trauma. However, all patients in the included studies had multiple rib fractures or flail chest with paradoxical chest movement, most with respiratory insufficiency. In addition, loss to followup may have influenced the results in several included studies, especially for those with milder symptoms [8]. More trials are necessary to determine an appropriate surgical condition, such as the number of rib fractures for surgical fixation. Considerable heterogeneity was observed across all studies in this meta-analysis. First, we observed a 6-month difference between pain measurements [20, 30]. Moreover, some studies only recorded incidence of pain rather than scores and medications [8, 26] or even had no record on pain [10, 13, 21, 27]. Finally, in the pulmonary function test, according to Marasco et al. [20] the heterogeneous favoring of the nonsurgical group was attributed to the different distribution of smoking habits between patients and controls. Such diversities among studies resulted in heterogeneity.
Our findings are in concordance with the results of several previous retrospective studies. Wada et al. [29] examined 420 patients with traumatic rib fractures and reported that the surgical group had a shorter duration of mechanical ventilation and a lower risk of mortality than the nonsurgical group [29]. Althausen et al. [1] and Uchida et al. [28] found shorter ICU LOS and hospital LOS, lower incidence of pneumonia and tracheostomy, and more desirable pulmonary function with surgical fixation than with conservative management. However, two other retrospective studies reported contrasting results. Defreest et al. [6] and Farquhar et al. [9] found a longer duration of mechanical ventilation and longer ICU LOS and hospital LOS in the surgical group than in the nonsurgical group. This result may be attributed to the failure of standard conservative treatments in patients in the surgical group, resulting in selection bias. Moreover, one practice management guideline from the Eastern Association for the Surgery of Trauma also recommended rib fixation for flail chest to decrease mortality, shorten mechanical ventilation duration, hospital LOS, and ICU LOS, as well as to decrease the incidence of pneumonia and need for tracheostomy [14]. Based on the results of our meta-analysis, we concur with these recommendations.
Rib-fracture surgery seems to benefit patients with multiple rib fractures under many circumstances, regardless of different medical environments, techniques used, or patient populations. The included studies were conducted in various countries, including the United States [21, 27], Australia [20], China [30], Egypt [10], France [13], Japan [26], and Sweden [8]. Despite the diversity of countries of origin and the varied surgical approaches, data from our pooled analyses in this meta-analysis seems to support to surgical stabilization of multiple rib fractures compared with conservative management. Clinically, we suggest the development of more-specific and less-invasive fixation techniques for the surgical stabilization of rib fractures.
Surgical fixation of rib fractures may be associated with cost savings, but there was insufficient high-quality published evidence on this point for us to meta-analyze it. Majercik et al. [19] conducted a large retrospective study in America and investigated hospital and professional charges in 95 mechanically ventilated patients who underwent surgical or nonsurgical management; they reported that the cost of surgery was not higher than that of conservative treatment. Granhed et al. [11] and Zhang et al. [31] reported similar results in retrospective studies conducted in Sweden and China, respectively. Despite different medical insurance systems, lower costs associated with surgery than nonsurgical approaches may be attributed to shorter ICU LOS and hospital LOS, and fewer ventilator-associated complications, but we caution the reader that the evidence on cost savings is not robust.
One relevant protocol of RCT focusing on surgical fixation of flail chest is available on clinicaltrials.gov (NCT01308697), but the results have not yet been published. Five trials evaluating surgical fixation of multiple rib fractures are ongoing, and most of them aim to compare ICU LOS, pain scores, hospitalization costs, and quality of life between surgical and nonsurgical groups (NCT01367951, NCT03221595, NCT02635165, NCT02094807, NCT02595593). These trials will provide additional evidence on the efficacy of rib fixation.
We believe these results, which are based on the best-available evidence, lend some support for stronger consideration of surgical management when caring for patients with multiple rib fractures. This meta-analysis reveals a shorter duration of mechanical ventilation, shorter ICU LOS and hospital LOS, and fewer trauma-associated complications in the surgical group than in the nonsurgical group. This meta-analysis lends stronger support to surgical fixation, rather than conservative treatment, for patients with multiple rib fractures. However, additional RCTs should be conducted to investigate correct surgical indications, timing, and followup for quality of life.
Acknowledgments
We thank Wallace Academic Editing for editing this manuscript.
Footnotes
Each author certifies that neither he or she, nor any member of his or her immediate family, have funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.
Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.
Each author certifies that his or her institution approved the reporting of this investigation and that all investigations were conducted in conformity with ethical principles of research.
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