Finding the optimal treatment model: a systematic review and meta- analysis of manipulative interventions following failed initial treatment of radial head subluxation in children

The hyperpronation (HP) maneuver, known for its high success rate in reducing radial head subluxation after initial treatment failure, has gained significant favor among surgeons over the traditional supination-flexion (SF) maneuver. Despite its perceived advantages, the optimal treatment approach remains a topic of debate in the medical community due to uncertainties surrounding repeat and crossover reduction outcomes. Further research and clinical assessments are needed to establish a definitive treatment protocol ensuring optimal patient outcomes. This systematic review and meta-analysis aim to compare the efficacy of HP and SF maneuvers following unsuccessful initial treatments for radial head subluxation. A thorough search of PubMed, Embase, and Cochrane Library databases up to May 13, 2024 was conducted. The Cochrane risk-of-bias tool evaluated study quality, and RevMan 5.3 facilitated systematic review calculations. Subgroup analyses explored reasons for heterogeneity by considering second reduction attempts with crossover and repeat maneuvers. Sensitivity analyses using fixed and random effects models were performed for ambiguous decisions. Nine studies with 170 patients were analyzed. The success rate for the second reduction was significantly higher with HP (OR = 2.48, 95% CI 1.18 to 5.20, P = 0.02) compared to SF. Repeat maneuver success rate for the second reduction also favored HP (OR = 3.79, 95% CI 1.57 to 9.16, P