Management Of Femoral Neck Fractures Research Articles

Management of a Proximal Femoral Central Physeal Bar in a 3-Year-Old Child Using a Novel Surgical Technique: A Case Report.

We present a proximal femoral central physeal bar secondary to femoral neck fracture management, in a 3-year-old boy. He presented with progressive femoral neck deformity and limb length discrepancy. He was managed with a novel technique of bar resection by drilling and polymethylmethacrylate interposition. After 5 years of follow-up, the hip score by Ratliff criteria was good. Screw penetration across physis during management of femoral neck fracture can cause growth arrest in a young child. Our technique is useful when physeal bar is central and linear. It can allow sufficient growth and remodeling to restore a near-normal hip both radiologically and clinically.

Application of digital orthopaedics in the management of femoral neck fractures

Application of digital orthopaedics in the management of femoral neck fractures

Surgical management of femoral neck fracture in dog with trans-articular pinning: A case report

Surgical management of femoral neck fracture in dog with trans-articular pinning: A case report

Management of femoral neck fracture on prolonged steroid

Management of femoral neck fracture on prolonged steroid

Management of Femoral Neck Fractures in Patients Age ≥50 Years by American Board of Orthopaedic Surgery Part II Examination Candidates.

Assess associations between fellowship training, procedure, and performance in femoral neck fracture (FNF) surgery on adults by American Board of Orthopaedic Surgery (ABOS) Part II Examination candidates. ABOS SCRIBE database exam years 2007-2020. 6,777 candidates performing 39,283 FNF surgeries on adults age ≥ 50 years. Fellowship training. Case volume; procedure performed: internal fixation (IF), hemiarthroplasty (HA), or total hip arthroplasty (THA); complications; readmission; reoperation. Over the observation period, fewer candidates reported FNF surgery (68% overall, -0.6%/year, R2=0.80) while more candidates reported fellowship training (87% overall, +1.4%/year, R2=0.81). The rate of any complication was significantly associated with fellowship training (32% overall, p<0.001). Readmission (12%, p=0.080) and reoperation (5%, p=0.531) were not significantly associated with fellowship training. The odds of any complication (odds ratio [OR]=-0.03 [95% CI -0.07 to -0.001] per 10 cases) and surgical complication (OR=-0.12 [95% CI -0.17 to -0.07] per 10 cases) were negatively associated with candidate FNF case volume. 3,396 THA for FNF were performed (8% of cases). THA use increased 25 cases/year (R2=0.83) and was associated with adult reconstruction (p<0.001) and oncology (p<0.001) fellowship training. Any complication of THA for FNF (32%, p=0.261), readmission (9% overall, p=0.321), and reoperation (5%, p=0.200) were not significantly associated with fellowship training. Between 2007-2020, femoral neck fracture surgery was performed by fewer ABOS Part II Examination candidates and there was greater use of THA. Over this time period there was a greater prevalence of fellowship training but complications were not associated with fellowship training. Complications were associated with FNF case volume. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reduced mortality associated to cementless total hip arthroplasty in femoral neck fracture

Mortality related to femoral neck fractures remains a challenging health issue, with a high mortality rate at 1 year of follow-up. Three modifiable factors appear to be under control of the surgeon: the choice of the implant, the use of cement and the timing before surgery. The aim of this research project was to study the impact on mortality each of these risk factors play during the management of femoral neck fractures. A large retrospective epidemiological study was performed using a national database of the public healthcare system. The inclusion criteria were patients who underwent joint replacement surgery after femoral neck fracture during the years 2015 to 2017. All data points were available for at least 2 years after the fracture. The primary outcome was mortality within 2 years following the surgery. We evaluated the association between mortality and the type of the implant hemiarthroplasty (HA) versus total hip arthroplasty (THA), cemented versus non cemented femoral stem as well as the timing from fracture to surgical procedure. A multivariate analysis was performed including age, gender, comorbidities/autonomy scores, social category, and obesity. We identified 96,184 patients who matched the inclusion criteria between 2015 and 2017. 64,106 (66%) patients underwent HA and 32,078 (33.4%) underwent THA. After multivariate analysis including age and comorbidities, patients who underwent surgery after 72 h intra-hospital had a higher risk of mortality: Hazard Ratio (HR) = 1.119 (1.056–1.185) p = 0.0001 compared to the group who underwent surgery within 24 h. THA was found to be a protective factor HR = 0.762 (0.731–0.795) p < 0.0001. The use of cement was correlated with higher mortality rate: HR = 1.107 (1.067–1.149) p < 0.0001. Three key points are highlighted by our study in the reduction of mortality related to femoral neck fracture: the use of hemiarthroplasty a surgery performed after 48 h and the use of cement for femoral stem fixation adversely affect mortality risk.

Treatment of Femoral Neck Fractures in the Elderly: A Survey of the Korean Hip Society Surgeons.

This study examined the methods for treatment of femoral neck fracture (FNF) preferred by members of the Korean Hip Society (KHS) and identified factors that influence decisions regarding the surgical intervention of choice. A total of 97 members of the KHS responded to the 16-question survey which included questions about the mean number of surgeries performed each month for treatment of femoral neck fractures, the cut-off age for deciding between internal fixation and arthroplasty, the implant used most often, usage of cement, and factors influencing each decision. The mean cut-off age used when deciding between internal fixation and arthroplasty was 64 years old. Hemiarthroplasty (HA) (70%) was the most preferred option for treatment of displaced FNFs in cases where arthroplasty was indicated (total hip arthroplasty [THA] 19% and dual mobility THA 11%). The main reasons for selection of arthroplasty over reduction with internal fixation were age and pre-fracture ambulatory status. Pre-trauma ambulatory status and/or sports activity were the main factors in selection of HA over THA. Cement was used by 33% of responders. Poor bone quality and a broad femoral canal were factors that influenced the usage of cement. Management of FNFs in the elderly is a major health problem worldwide; thus, remaining alert to current trends in treatment is essential for surgeons. The mean cut-off age used in deciding between internal fixation and arthroplasty was 64 years old. HA is the preferred method for treatment of displaced FNFs for members of the KHS.

Comparing the volume of vascular intersection of two femoral neck fracture fixation implants using an In silico technique.

Three dimensional (3D) µCT angiograms of 9 cadaveric proximal femora were produced. Three segmented volumes-porous or cancellous bone, filled or cortical bone, and intraosseous vasculature-were converted to surface files. 3D in silico models of the fixation systems were sized and implanted in silico without visibility of the vascular maps. The volume of vasculature that overlapped with the devices was determined. The ratio of the vascular intersection to the comparator device was calculated, and the mean ratio was determined. A paired design, noninferiority test was used to compare the devices. Results indicate both significant (P < 0.001) superiority and noninferiority of the hip screw with an integrated antirotation screw when compared with a dynamic hip screw and antirotation screw for the volume of vasculature that overlapped with each device in the femoral neck. Combining established methods of vascular visualization with newer methods enables an implant's impact on vascular intersection to be assessed in silico. This methodology suggests that when used for femoral neck fracture management, the new device intersects fewer blood vessels than the comparator. Comparative clinical studies are needed to investigate whether these findings correlate with the incidence of avascular necrosis and clinical outcomes.

Reducing complications of femoral neck fracture management: a retrospective study on the application of multidisciplinary team

BackgroundFemoral neck fractures are associated with substantial morbidity and mortality for older adults. Multi-system medical diseases and complications can lead to long-term care needs, functional decline and death, so patients sustaining hip fractures usually have comorbid conditions that may benefit from application of multidisciplinary team(MDT).MethodsThis is a retrospective cohort study that incorporates medical record review with an outcomes management database. 199 patients were included who had surgery for a new unilateral femoral neck fracture from January 2018 to December 2021 (96 patients in usual care (UC) model and 103 patients in MDT model. High-energy, pathological, old and periprosthetic femoral neck fracture were excluded. Age, gender, comorbidity status, time to surgery, and postoperative complication, length of stay, in-hospital mortality, 30-day readmission rate, 90-day mortality data were collected and analyzed.ResultsPreoperative general data of sex, age, community dwelling and charlson comorbidity score of MDT group (n = 103) have no statistically significant difference with that of usual care (UC) group. Patients treated in the MDT model had significantly shorter times to surgery (38.5 vs. 73.4 h;P = 0.028) and lower lengths of stay (11.5 vs. 15.2 days;P = 0.031). There were no significant differences between two models in In-hospital mortality (1.0% vs. 2.1%; P = 0.273), 30-day readmission rate (7.8% vs. 11.5%; P = 0.352) and 90-day mortality (2.9% vs. 3.1%; P = 0.782). The MDT model had fewer complications overall (16.5% vs. 31.3%; P = 0.039), with significantly lower risks of delirium, postoperative infection, bleeding, cardiac complication, hypoxia, and thromboembolism.ConclusionApplication of MDT can provide standardized protocols and a total quality management approach, leading to fewer complications for elderly patients with femoral neck fracture.Trial registrationNo.

A 7-year perspective on femoral neck fracture management in New York State—Do Level 1 trauma centers provide better care?

IntroductionPatients with femoral neck fractures are at a substantial risk for medical complications and all-cause mortality. Given this trend, our study aims to evaluate postoperative outcomes and the economic profile associated with femoral neck fractures managed at level-1 (L1TC) and non-level-1-trauma centers (nL1TC). MethodsThe SPARCS database was queried for all geriatric patients sustaining atraumatic femoral neck fractures within New York State between 2011 and 2017. Patients were then divided into two cohorts depending on the treating facility's trauma center designation: L1TC versus nL1TC. Patient samples were evaluated for trends and relationships using descriptive analysis, Student's t-tests, and Chi-squared. Multivariable linear-regressions were utilized to assess the effect of trauma center designation and potential confounders on patient mortality and inpatient healthcare expenses. ResultsIn total, 44,085 femoral neck fractures operatively managed at 161 medical centers throughout New York during a 7-year period. 4,974 fractures were managed at L1TC while 39,111 were treated at nL1TC. Following multivariate regression analysis, management at L1TC was the most significant cost driver, resulting in an average increased cost of $6,330.74 per fracture. ConclusionOur results suggest that femoral neck fractures treated at L1TC have more comorbidities, higher in-hospital mortality, longer LOS, and greater hospital costs.

Postoperative Outcomes of Femoral Neck Fracture Management in Dialysis-Dependent Patients

AbstractFemoral neck fractures are common in patients with chronic kidney disease (CKD) due to abnormalities of bone metabolism. In patients on dialysis, femoral neck fractures have been shown to occur at a younger age than in nondialysis patients. The purpose of this study was to compare the associated complication rates of femoral neck fractures among dialysis patients treated with total hip arthroplasty (THA) versus hemiarthroplasty (HA) as well as evaluate for any differences in outcomes compared to the nondialysis patient population. This was a retrospective cohort study performed using the National Surgical Quality Improvement Program database that included 54,328 patients with femoral neck fractures managed surgically from 2006 to 2016. One-thousand seventy patients were identified as dialysis-dependent. Demographics, medical comorbidities, perioperative complication rates, and mortality rates were collected. Data was first analyzed descriptively and with analysis of variance or chi-squared analyses as appropriate. Odds ratios were then calculated for perioperative outcomes and complications. Femoral neck fractures in patients on dialysis occurred at a significantly younger age (73.3 vs. 77.0, p &lt; 0.001) than nondialysis patients. In dialysis patients who underwent THA, complication rates, postoperative length of stay, readmission rates, and 1-year mortality were greater when compared to nondialysis patients. There were no significant differences in perioperative medical or surgical complication rates within the dialysis population when comparing THA to HA. Dialysis patients treated with THA for femoral neck fracture experience more complications compared to nondialysis patients. However, among dialysis patients treated with THA compared to HA, there were no significant differences in outcomes. THA is, therefore, a viable option for dialysis-dependent patients with femoral neck fractures who are otherwise medically stable.

Management of pediatric femoral neck fractures: A prospective study

Introduction: Pediatric femoral neck fracture is an uncommon injury with a high complication rate, regardless of the appropriate diagnosis and management. The bony anatomy and blood supply of the proximal femur in a skeletally immature patient differs from those in adult patients. Pediatric femoral neck fractures are categorized using the Delbert classification system. This classification guides management and aids clinicians in determining the risk of avascular osteonecrosis. Aim and Objective: Aim of this study was to develop a guideline for the management of femoral neck fracture in children rapidly and accurately with fewer complications based on the best available scientific evidence. Materials and Methods: Thirteen children with fractures of femoral neck were included in this study. The enrolled patients presented in the emergency department of Bone and Joint Hospital, an associated hospital of Govt. Medical College Srinagar from June 2019- May 2020. Results: Using the clinical and radiological assessment by the Ratliff system, 9 (69.23%) patients had a good clinical outcome and 4 (30.77%) had fair outcomes. We did not encounter any patients with a poor outcome in our series. Of the 4 patients with fair outcomes, 3 had AVN and coxa Vara and 1 had a deep-seated infection of the hip leading to arthritic changes of the hip. Conclusion: In the management of pediatric femoral neck fractures, the early closed reduction and fixation may be effective to improve results and prevent long-term complications.

The use of the femoral neck system (FNS) leads to better outcomes in the surgical management of femoral neck fractures in adults compared to fixation with cannulated screws: A systematic review and meta-analysis.

Intracapsular femoral neck fractures are challenging to treat, with outcomes depending on the quality of reduction, and the stability of fixation. Cannulated cancellous screws (CCS) are the most commonly used implants to fix these fractures, but failure rates are significant. The recently introduced femoral neck system (FNS) may be a better option than CCS fixation and this review attempts to compare the results. Four electronic databases were searched for eligible articles that had comparative data on the outcomes of fixation of adult femoral neck fractures with FNS and CCS. Data on various outcome parameters were collected. Meta-analysis was conducted using a random-effects model with 95% confidence intervals. Eight studies with 509 cases having a mean age of 50.8years were included for final analysis. FNS was found to be associated with significantly reduced complication rates (p < 0.001), decreased incidence of postoperative femoral neck shortening (p < 0.001), quicker time to fracture union (p = 0.002), and better functional outcome scores (p < 0.001) compared to cannulated screws. FNS was also associated with a shorter operating time (mean difference 6.65min) although not statistically significant (p = 0.24). CCS group had significantly reduced mean blood loss (p < 0.001). The available literature supports FNS as a better option for adult femoral neck fractures, with a lower complication rate, quicker union, and better clinical outcomes. Level 3.

Biplane double supported screw fixation for femoral neck fracture in young adults: A prospective cohort study

IntroductionAchieving accurate anatomic reduction and stable internal fixation is mandatory in the management of femoral neck fractures (FNF) in adults. The spatial configuration and direction of the screws have been reported to provide stability to the fracture. The study's goal is to analyse the clinico-radiological outcome of the newer biplane double-supported screw fixation (BDSF) technique in the Indian cohort. Materials and methodsPatients with isolated FNFs underwent osteo-synthesis by BDSF technique. Radiological outcome was evaluated by time to union and fracture healing on plain radiographs. Clinical outcome was measured using the Harris hip score (HHS) at 1, 3, 6, and 12 months after surgery. The pain reduction was measured using the VAS score. ResultsTwenty-seven patients with a mean age of 37.33 ± 9.84 years (24–55 years) were followed up for at least 12 months (12–31 months). The mean HHS at 12 months was 94.81 ± 8.18 (range: 68–100). Twenty-five patients were able to achieve radiological union within a mean time of 14.60 ± 4.69 weeks (range: 8–28). The overall complication rate was found to be 18.51% (5 out of 27 patients). Individual complications were non-union (2 patients; 7.4%), AVN (3 patients; 11.11%), and screw back out with femoral neck shortening (4 patients; 14.81%). ConclusionScrew configuration using the BDSF technique provides a good union rate with minimum complications. The majority of patients resulted in a good (HHS >80) to excellent functional outcome. Based on the clinico-radiological outcome obtained, we conclude that this technique is effective in the fixation of FNF in adults. Level of studyLevel II.

Incidence and Risk Factors for Surgical Site Infection after Femoral Neck Fracture Surgery: An Observational Cohort Study of 2218 Patients.

Background Surgical site infection (SSI) was a formidable challenge for surgical management of femoral neck fractures; however, there was a lack of studies with comprehensive variables. We conducted this study to investigate the incidence and risk factors of SSI in elderly patients with femoral neck fractures. Methods This was a retrospective study of patients who presented with femoral neck fractures and underwent surgery in our institution between January 2016 and April 2020. All data were collected from a previously validated database. Patients were divided into SSI and non-SSI groups. Univariate and multivariate logistic regression analyses were conducted to identify the risk factors for SSI. Results A total of 2218 patients with femoral neck fractures were enrolled in the study, of whom 22 (1%) developed SSI, including 15 (0.7%) superficial and 7 (0.3%) deep SSIs. After multivariable adjustment for confounding factors, patients with and without SSI significantly differ in terms of gender, prolonged time to surgery, CHE < 5 U/L, and injury mechanism. Conclusions Our results were helpful for stratification of SSI risk and improved management of hip fracture. Clinicians should be alert to patients with these factors and improve modifiable factors such as preoperative waiting time.

Revisiting Pauwels' classification of femoral neck fractures.

Pauwels’ femoral neck fracture classification is based on the biomechanical principle that shear stress and varus force increase along more vertically oriented fractures, resulting in higher risk of fracture displacement and ultimately nonunion. This principle continues to guide construct selection for femoral neck fracture internal fixation and is the foundation for treating non-union with valgus osteotomy. However, with poor inter- and intra-rater reliability, dated treatment recommendations, and unreliable prognostic value, the Pauwels classification cannot be directly applied in its entirety to the management of femoral neck fractures in modern practice.

Comparative study of total hip arthroplasties with dual mobility cups versus hemiarthroplasties in management of femoral neck fractures: Survival and dislocation rate at 5 years of follow-up?

BackgroundInstability after hip arthroplasty, whether it is a total (THA) or intermediate (HA), poses a major risk, however arthroplasty is the standard treatment for displaced intracapsular fractures of the femoral neck of the elderly. Three types of arthroplasties can be proposed: total prostheses with or without a dual mobility cup (DM THA) reducing the risk of dislocation, and hemiarthroplasties. In the absence of clear recommendations regarding the type of implant to be used and the scarcity of studies comparing HA and DM THA, we conducted a monocentric comparative retrospective study using the propensity score method to compare DM THA versus HA on recently displaced femoral neck fractures: (1) survival and risk of dislocation, (2) functional results, (3) mortality. HypothesisThe rate of dislocation of THA fitted with a DM cup is lower than that of HA. Patients and methodsWe retrospectively identified 112 patients in the HA group and 153 patients in the DM THA group who underwent an emergency arthroplasty for a displaced cervical fracture between 2010 and 2013. The minimum follow-up was 5 years (range, 5–9 years). The mean age at surgery was 81 years (range, 55–101 years). Elective surgery patients (n=2), hardware fractures (n=10), pathological fractures of the femoral neck (n=6), associated fractures (n=3), and revision surgeries (n=5) were excluded. The primary outcome measure was instability. Clinical follow-up was performed by the WOMAC score and the risk of mortality was determined after adjusting for confounding factors using the propensity score method. ResultsAfter adjustment by the propensity score, the dislocation rate at 2-years was 2.2% (n=3/153) in the dual mobility THA group and 6.3% (n=7/112) in the HA group (OR=0.34 [95% CI: 0.06–1.96] (p=0.23)). After adjustment by the propensity score, the mean WOMAC score was 8.20 (±6.56) in the THA group, compared to 10.78±3.92 on average in the HA group (p=0.031). After adjustment by the propensity score, we did not find any significant difference in the reoperation rate without changing implants and revisions, and postoperative complications. After adjustment by the propensity score, mortality was significantly higher in the HA group 45.5% (n=69/152) versus 91.5% (n=102/112) in the HA group (OR=0.50 [95% CI: 0.25–0.98] (p=0.042)). DiscussionFew studies have compared these two types of implant in the context of trauma. Although the results of our study are not significant regarding the risk of dislocation, the use of a dual mobility cup seems to be a very satisfactory solution in this trauma context. Level of evidenceIII; comparative retrospective cohort.

The ‘Unsolved’ Fracture Neck of Femur– A Comprehensive Review

Introduction: Fractures involving the neck of the femur constitute a small proportion of total fractures in the body. Though these fractures mainly occur in the elderly population, their occurrence in youngsters due to high-velocity trauma is not uncommon. These fractures are commonly termed the ‘unsolved fractures’ as the outcome of these fractures are highly variable. The peculiar anatomy and precarious blood supply to the proximal femur and intracapsular location create an unfavourable biological environment for fracture union. The lack of prospective clinical trials which have evaluated the ideal surgical timing, technique and construct of the implant further adds to the confusion. Discussion: The aim of this review was to go through the recent relevant literature on the management of femoral neck fractures to find out the answers to the debated questions and to summarize the current diagnostic and management approaches to a patient with a suspected fracture neck of the femur. Conclusion: Knowing the patient and fracture related factors which influence the outcome are extremely important to achieve the goal of early uncomplicated fracture healing. This would help the surgeon in the thoughtful selection of the operative intervention for each patient on an individual basis and facilitate a thorough discussion between the surgeon and the patient which is vital in decision making. Keywords: Closed reduction, Hemiarthroplasty, Hip fractures, Intracapsular, Neck of Femur, Pauwel

Management of femoral neck fractures with the ALMIS approach in elderly patients: Outcomes compared to posterior approach

IntroductionOver the last 2 decades, several minimally invasive surgical techniques and approaches have been introduced for hip arthroplasty, including anterolateral minimally invasive surgery (ALMIS) introduced by Röttinger in 2004. As described, this muscle sparing approach promises faster recovery and lower dislocation rates. Although there has been a peaked recent interest in minimally invasive surgery (MIS) hip arthroplasty, few studies support the superiority of ALMIS compared to the more traditional posterior approach. The present study examines the safety and early complications of elderly patients undergoing ALMIS compared to a posterior approach for hemiarthroplasty of displaced femoral neck fractures. MethodsIn a retrograde level III case-control study, 100 consecutive elderly patients with primary hip arthroplasty were divided into two groups. The first group consisted of 50 consecutive cases operated with the ALMIS approach and the second group of 50 consecutive cases operated through a posterior approach. Operative time, postoperative complication rates, length of hospitalization, blood loss, and leg-length discrepancy, were reviewed retrospectively. ResultsNo differences were observed in post-operative complications. Overall, the operative time was significantly greater in the ALMIS group compared to the posterior approach group (75 ± 12 vs 67.5 ± 16 min, respectively; p ≤ 0.01). However, the operating time of the second half of the ALMIS cohort (N = 25), did not differ from the posterior approach group (72.7 ± 10.5 vs 67.5 ± 16, respectively; p = 0.19). Leg length discrepancy was significantly less in the ALMIS group compared to the posterior exposure group (1.5 ± 3.2 vs 3.2 ± 3.3, respectively; P≤0.1). ConclusionsThe results of the retrograde analysis, although limited in sample size, shows no major differences in ALMIS compared to a more traditional posterior approach in terms of immediate post-operative complications. Although the overall operating time was longer in the patients treated with ALMIS, the second cohort of patients treated with this method had an operating time that was similar to that observed with posterior approach. Leg-length discrepancies were significantly less in patients treated with ALMIS.

Dual-Mobility Articulations in Femoral Neck Fractures: A Systematic Review of the Literature and Meta-analysis of the Outcomes.

Femoral neck fractures have been traditionally managed with hemiarthroplasty (HA) or conventional total hip arthroplasty (CTHA). There has been recent interest in using dual-mobility components (DMC) in total hip arthroplasty for patients with femoral neck fractures to provide increased stability and decrease the need for future revision. We conducted a systematic review of the literature reporting on the use of DMC in the management of femoral neck fractures in geriatric patients. We included studies in which DMC were used alone and studies that included a comparison to total hip arthroplasty or HA. The outcomes of interest were postoperative dislocation, revision, and revision surgery rates. Two separate subgroup analyses were conducted. For the comparative studies, we analyzed the differences in outcomes using a random-effects model of relative risks. For the noncomparative studies, we estimated the cumulative incidence of the different outcomes. Eighteen studies met the inclusion criteria and were included in our analysis. Eleven noncomparative studies showed a cumulative incidence of dislocation to be 1.2% (95% confidence interval = 0.3% to 2.7%) when DMC were used alone. Subgroup analyses of the seven comparative studies yielded a relative risk of dislocation using DMC was 59% less than HA and 83% less than CTHA. DMC also compared favorably in terms of revision surgery and revision rates to HA. There was insufficient quality evidence to comment on revision surgery and revision rates when compared with CTHA in comparative studies, but among the noncomparative studies, there was a low rate of revision and revision surgery. Our study revealed overall lower risk of dislocation using DMC compared with both CTHA and HA. There were also lower revision and revision surgery rates when DMC were used compared with HA. Further studies are required to elucidate cost-effectiveness and long-term outcomes of DMC in these scenarios. Level III-meta-analysis.