Surgical Versus Nonsurgical Treatment for Midshaft Clavicle Fractures in Patients Aged 16 Years and Older: A Systematic Review,Meta-analysis,and Comparison of Randomized Controlled Trials and Observational Studies
Restricted accessResearch articleFirst published online July, 2017
Surgical Versus Nonsurgical Treatment for Midshaft Clavicle Fractures in Patients Aged 16 Years and Older: A Systematic Review,Meta-analysis,and Comparison of Randomized Controlled Trials and Observational Studies
There is no consensus on the choice of treatment of midshaft clavicle fractures (MCFs).
Purpose:
The aims of this systematic review and meta-analysis were (1) to compare fracture healing disorders and functional outcomes of surgical versus nonsurgical treatment of MCFs and (2) to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies.
Study Design:
Systematic review and meta-analysis.
Methods:
The PubMed/MEDLINE, Embase, CENTRAL, and CINAHL databases were searched for both RCTs and observational studies. Using the MINORS instrument, all included studies were assessed on their methodological quality. The primary outcome was a nonunion. Effects of surgical versus nonsurgical treatment were estimated using random-effects meta-analysis models.
Results:
A total of 20 studies were included, of which 8 were RCTs and 12 were observational studies including 1760 patients. Results were similar across the different study designs. A meta-analysis of 19 studies revealed that nonunions were significantly less common after surgical treatment than after nonsurgical treatment (odds ratio [OR], 0.18 [95% CI, 0.10-0.33]). The risk of malunions did not differ between surgical and nonsurgical treatment (OR, 0.38 [95% CI, 0.12-1.19]). Both the long-term Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley scores favored surgical treatment (DASH: mean difference [MD], −2.04 [95% CI, −3.56 to −0.52]; Constant-Murley: MD, 3.23 [95% CI, 1.52 to 4.95]). No differences were observed regarding revision surgery (OR, 0.85 [95% CI, 0.42-1.73]). Including only high-quality studies, both the number of malunions and days to return to work show significant differences in favor of surgical treatment (malunions: OR, 0.26 [95% CI, 0.07 to 0.92]; return to work: MD, −8.64 [95% CI, −16.22 to −1.05]).
Conclusion:
This meta-analysis of high-quality studies showed that surgical treatment of MCFs results in fewer nonunions, fewer malunions, and an accelerated return to work compared with nonsurgical treatment. A meta-analysis of surgical treatments need not be restricted to randomized trials, provided that the included observational studies are of high quality.
AbrahamNSByrneCJYoungJMSolomonMJ.Meta-analysis of well-designed nonrandomized comparative studies of surgical procedures is as good as randomized controlled trials. J Clin Epidemiol. 2010;63(3):238-245.
2.
AlthausenPLShannonSLuMO’MaraTJBrayTJ.Clinical and financial comparison of operative and nonoperative treatment of displaced clavicle fractures. J Shoulder Elbow Surg. 2013;22(5):608-611.
3.
AnglemyerAHorvathHTBeroL.Healthcare outcomes assessed with observational study designs compared with those assessed in randomized trials. Cochrane Database Syst Rev. 2014;4:MR000034.
4.
BanIBrannerUHolckKKrasheninnikoffMTroelsenA.Clavicle fractures may be conservatively treated with acceptable results: a systematic review. Dan Med J. 2012;59(7):A4457.
5.
BohmeJBonkABacherGOWilharmAHoffmannRJostenC.[Current treatment concepts for mid-shaft fractures of the clavicle: results of a prospective multicentre study]. Z Orthop Unfall. 2011;149(1):68-76.
6.
BradburnMJDeeksJJBerlinJARussellLA.Much ado about nothing: a comparison of the performance of meta-analytical methods with rare events. Stat Med. 2007;26(1):53-77.
7.
BravmanJTVidalAF.Midshaft clavicle fractures: are surgical indications changing?Orthopedics. 2009;32(12):909-913.
8.
BrinYSPalmanovichEDolevENyskaMKishBJ.Displaced mid-shaft clavicular fractures: is conservative treatment still preferred?Isr Med Assoc J. 2014;16(12):748-752.
9.
Canadian Orthopaedic Trauma Society. Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures: a multicenter, randomized clinical trial. J Bone Joint Surg Am. 2007;89(1):1-10.
10.
ChenQYKouDQChengXJ. Intramedullary nailing of clavicular midshaft fractures in adults using titanium elastic nail. Chin J Traumatol. 2011;14(5):269-276.
11.
ConstantCRMurleyAH.A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214:160-164.
12.
DaniilidisKRaschkeMJVogtB. Comparison between conservative and surgical treatment of midshaft clavicle fractures: outcome of 151 cases. Technol Health Care. 2013;21(2):143-147.
13.
DuanXZhongGCenSHuangFXiangZ.Plating versus intramedullary pin or conservative treatment for midshaft fracture of clavicle: a meta-analysis of randomized controlled trials. J Shoulder Elbow Surg. 2011;20(6):1008-1015.
14.
EggerMDaveySGSchneiderMMinderC.Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629-634.
15.
EvaniewNSimunovicNMcKeeMDSchemitschE.Cochrane in CORR(R): surgical versus conservative interventions for treating fractures of the middle third of the clavicle. Clin Orthop Relat Res. 2014;472(9):2579-2585.
16.
GeorgeDMMcKayBPJaarsmaRL.The long-term outcome of displaced mid-third clavicle fractures on scapular and shoulder function: variations between immediate surgery, delayed surgery, and nonsurgical management. J Shoulder Elbow Surg. 2015;24(5):669-676.
17.
GrassiFATajanaMSD’AngeloF.Management of midclavicular fractures: comparison between nonoperative treatment and open intramedullary fixation in 80 patients. J Trauma. 2001;50(6):1096-1100.
18.
GummessonCAtroshiIEkdahlC.The Disabilities of the Arm, Shoulder and Hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery. BMC Musculoskelet Disord. 2003;4:11.
19.
HillCE.Is intramedullary nailing more effective than non-operative treatment in adults with displaced middle-third clavicle fractures?J Orthop Traumatol. 2014;15(3):155-164.
20.
HouwertRMSmeeingDPAhmed AliUHietbrinkFKruytMCVan der MeijdenOA.Plate fixation or intramedullary fixation for midshaft clavicle fractures: a systematic review and meta-analysis of randomized controlled trials and observational studies. J Shoulder Elbow Surg. 2016;25(7):1195-1203.
21.
HozoSPDjulbegovicBHozoI.Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005;5:13.
22.
HudakPLAmadioPCBombardierC.Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder and Hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996;29(6):602-608.
23.
HughesPJBolton-MaggsB.Fractures of the clavicle in adults. Curr Orthop. 2002;16(2):133-138.
24.
JonesLDGrammatopoulosGKambouroglouG.Titanium elastic nails, open reduction internal fixation and non-operative management for middle third clavicle fractures: a comparative study. Eur J Orthop Surg Traumatol. 2014;24(3):323-329.
25.
JubelAAndermahrJFaymonvilleCBinneboselMProkopARehmKE.[Reconstruction of shoulder-girdle symmetry after midclavicular fractures: stable, elastic intramedullary pinning versus rucksack bandage]. Chirurg. 2002;73(10):978-981.
26.
JuddDBPallisMPSmithEBottoniCR.Acute operative stabilization versus nonoperative management of clavicle fractures. Am J Orthop (Belle Mead NJ). 2009;38(7):341-345.
27.
KhoramiMFakourMMokarramiHArtiHRNasabAMShahrivarF.The comparison of results of treatment of midshaft clavicle fracture between operative treatment with plate and non-operative treatment. Arch Bone Joint Surg. 2014;2(3):210-214.
28.
KongLZhangYShenY.Operative versus nonoperative treatment for displaced midshaft clavicular fractures: a meta-analysis of randomized clinical trials. Arch Orthop Trauma Surg. 2014;134(11):1493-1500.
29.
KulshresthaVRoyTAudigeL.Operative versus nonoperative management of displaced midshaft clavicle fractures: a prospective cohort study. J Orthop Trauma. 2011;25(1):31-38.
30.
LenzaMBuchbinderRJohnstonRVBellotiJCFaloppaF.Surgical versus conservative interventions for treating fractures of the middle third of the clavicle. Cochrane Database Syst Rev. 2013;6:CD009363.
31.
LiuGQZhaoLLiLWangLMZhangJH.A meta-analysis of comparison between operative and nonoperative treatment on the midshaft clavicle fractures. Life Sci J. 2014;11(8):810-816.
32.
McKeeMD.Clavicle fractures in 2010: sling/swathe or open reduction and internal fixation?Orthop Clin North Am. 2010;41(2):225-231.
33.
MeleanPAZunigaAMarsalliM. Surgical treatment of displaced middle-third clavicular fractures: a prospective, randomized trial in a working compensation population. J Shoulder Elbow Surg. 2015;24(4):587-592.
34.
MirzatolooeiF.Comparison between operative and nonoperative treatment methods in the management of comminuted fractures of the clavicle. Acta Orthop Traumatol Turc. 2011;45(1):34-40.
35.
MoherDCookDJEastwoodSOlkinIRennieDStroupDF.Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet. 1999;354(9193):1896-1900.
36.
MoherDLiberatiATetzlaffJAltmanDG.Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.
37.
NordqvistAPeterssonC.The incidence of fractures of the clavicle. Clin Orthop Relat Res. 1994;300:127-132.
PearsonAMTostesonANKovalKJ. Is surgery for displaced, midshaft clavicle fractures in adults cost-effective? Results based on a multicenter randomized, controlled trial. J Orthop Trauma. 2010;24(7):426-433.
40.
PeinemannFTushabeDAKleijnenJ.Using multiple types of studies in systematic reviews of health care interventions: a systematic review. PLoS One. 2013;8(12):e85035.
41.
PostacchiniFGuminaSDeSPAlboF.Epidemiology of clavicle fractures. J Shoulder Elbow Surg. 2002;11(5):452-456.
42.
RehnCHKirkegaardMVibergBLarsenMS.Operative versus nonoperative treatment of displaced midshaft clavicle fractures in adults: a systematic review. Eur J Orthop Surg Traumatol. 2014;24(7):1047-1053.
43.
Review Manager (RevMan) [computer program]. Version 5.3.Copenhagen: The Nordic Cochrane Centre, Cochrane Collaboration; 2014.
44.
RobinsonCM.Fractures of the clavicle in the adult: epidemiology and classification. J Bone Joint Surg Br. 1998;80(3):476-484.
45.
RobinsonCMGoudieEBMurrayIR. Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial. J Bone Joint Surg Am. 2013;95(17):1576-1584.
46.
SlimKNiniEForestierDKwiatkowskiFPanisYChipponiJ.Methodological Index for Non-Randomized Studies (MINORS): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712-716.
47.
SmekalVIrenbergerAAttalREOberladstaetterJKrappingerDKralingerF.Elastic stable intramedullary nailing is best for mid-shaft clavicular fractures without comminution: results in 60 patients. Injury. 2011;42(4):324-329.
48.
SmekalVIrenbergerAStruvePWambacherMKrappingerDKralingerFS.Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures: a randomized, controlled, clinical trial. J Orthop Trauma. 2009;23(2):106-112.
49.
StegemanSAde JongMSierCF. Displaced midshaft fractures of the clavicle: non-operative treatment versus plate fixation (Sleutel-TRIAL). A multicentre randomised controlled trial. BMC Musculoskelet Disord. 2011;12:196.
50.
StegemanSAFernandesNCKrijnenPSchipperIB.Online radiographic survey of midshaft clavicular fractures: no consensus on treatment for displaced fractures. Acta Orthop Belg. 2014;80(1):82-87.
51.
StegemanSARoeloffsCWvan den BremerJKrijnenPSchipperIB.The relationship between trauma mechanism, fracture type, and treatment of midshaft clavicular fractures. Eur J Emerg Med. 2013;20(4):268-272.
52.
ThyagarajanSDayMDentCWilliamsREvansR.Treatment of mid-shaft clavicle fractures: a comparative study. Int J Shoulder Surg. 2009;3(2):23-27.
53.
van der VenDJCTimmersTKFlikweertPEVan IjseldijkALvan OldenGD.Plate fixation versus conservative treatment of displaced midshaft clavicle fractures: functional outcome and patients’ satisfaction during a mean follow-up of 5 years. Injury. 2015;46(11):2223-2229.
54.
Vander HaveKLPerdueAMCairdMSFarleyFA.Operative versus nonoperative treatment of midshaft clavicle fractures in adolescents. J Pediatr Orthop. 2010;30(4):307-312.
55.
VirtanenKJRemesVPajarinenJSavolainenVBjorkenheimJMPaavolaM.Sling compared with plate osteosynthesis for treatment of displaced midshaft clavicular fractures: a randomized clinical trial. J Bone Joint Surg Am. 2012;94(17):1546-1553.
56.
WaltonBMeijerKMelanconK.A cost analysis of internal fixation versus nonoperative treatment in adult midshaft clavicle fractures using multiple randomized controlled trials. J Orthop Trauma. 2015;29(4):173-180.
57.
WitzelK.[Intramedullary osteosynthesis in fractures of the mid-third of the clavicle in sports traumatology]. Z Orthop Unfall. 2007; 145(5):639-642.
58.
XuJXuLXuWGuYXuJ.Operative versus nonoperative treatment in the management of midshaft clavicular fractures: a meta-analysis of randomized controlled trials. J Shoulder Elbow Surg. 2014;23(2):173-181.
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