Operative treatment of displaced midshaft clavicle fractures: has randomised control trial evidence changed practice patterns?

Abstract

ObjectivesTo determine if level 1 evidence from a landmark trial changed practice patterns for treatment of patients with displaced midshaft clavicle fractures.DesignRetrospective cohort study.SettingTwo level 1 trauma centres.ParticipantsDisplaced midshaft clavicle fractures.Results686 patients met inclusion criteria. The pretrial cohort (n=108) was 68.5% male, with a mean age of 37.7 (±13.9) years. The post-trial cohort (n=578) was 76.1% male, with a mean age of 41.9 (±12.7) years. There was nearly a 10-fold increase in the patients treated with openreduction and internal fixation (ORIF) in the post-trial cohort (34.1%) compared with the pretrial cohort (3.7%) (p<0.001). Patients in the post-trial cohort were more likely to undergo ORIF if they were <40 years (OR=2.2; 95% CI 1.53 to 3.10), if their Injury Severity Score was >9 (OR=1.6; 95% CI 0.89 to 2.99) or if they were treated at a centre that participated in theCanadian Orthopaedic Trauma Society (COTS)trial (OR=5.2; 95% CI 3.31 to 8.21).ConclusionsThis study demonstrated a significant shift towards more frequentORIFfor displaced midshaft clavicle fractures following the COTS trial. Quantifying changes in practice pattern following publication of level 1 evidence is important to further our understanding of the impact largerandomisedclinical trailsare having on clinical practice.

Management of Displaced Midshaft Clavicle Fractures with Figure-of-Eight Bandage: The Impact of Residual Shortening on Shoulder Function

“…Nevertheless, current studies, including recent randomized controlled trials and meta-analyses, are still conflicting and fail to demonstrate the absolute superiority of surgical versus conservative management [ 6 , 14 , 17 , 18 , 19 , 20 ]. Several studies report better outcomes of surgery along with lower risk of nonunion compared to nonoperative management [ 18 , 21 ]. Conversely, other studies do not show differences in functional outcomes between conservative treatment and plate fixation of acute displaced MCFs, not only at one year of follow-up [ 10 , 13 , 14 , 22 , 23 , 24 , 25 , 26 ], but also after 24 weeks as well as after five years of follow-up [ 27 ].…”

Closed midshaft clavicle fractures

“…The management of mid-shaft clavicle fractures (MSCFs) has evolved over the last three decades. 3 , 4 The publication of a prospective multicentre randomized control trial in 2007, by the Canadian Orthopaedic Trauma Society (COTS), 4 led to a shift in practice in certain centres. 3 The absolute indications for surgery remain unchanged: open fractures, clavicle fractures associated with a floating shoulder, and those associated with neurovascular compromise, requiring immediate exploration.…”

Are two plates better than one? A systematic review of dual plating for acute midshaft clavicle fractures

“…In fact, the rate of operative fixation has exponentially increased following the publication of a landmark randomized controlled trial by the Canadian Orthopaedic Trauma Society which was the first of many level I studies to demonstrate higher union rates, decreased rates of symptomatic malunion, earlier return to function, and improved patient-reported outcomes with plate fixation of displaced midshaft clavicle fractures. 6 , 9 – 11 …”

“…In fact, the rate of operative fixation has exponentially increased following the publication of a landmark randomized controlled trial by the Canadian Orthopaedic Trauma Society which was the first of many level I studies to demonstrate higher union rates, decreased rates of symptomatic malunion, earlier return to function, and improved patient-reported outcomes with plate fixation of displaced midshaft clavicle fractures. 6,[9][10][11] Traditional plating techniques for open reduction and internal fixation of clavicle fractures involve the use of a single 3.5-mm plate placed superiorly or anteriorly. 12 However, these plates are often very prominent under the skin causing irritation, and in many cases result in reoperation for hardware removal.…”