Surgical treatment of displaced middle-third clavicular fractures: a prospective, randomized trial in a working compensation population

Operative treatment of displaced midshaft clavicular fractures is not cost-effective

“…23 The probabilities of the following outcomes were estimated based on a meta-analysis of data from existing RCTs (Table I): nonunion, accepting an operation after development of a nonunion, plate removal, and deep infection. 4,12,13,25,33,35 The RCTs were identified through a systematic literature search performed during spring 2017 (a similar protocol was described by Woltz et al 34 ). Because all patients are instructed to visit a shoulder and/or elbow ambulatory care provider and general practitioner after operative treatment, the probabilities of these outcomes were set to 1.…”

“…6,16,26 However, recent investigations have examined the best treatment method for uncomplicated displaced midshaft clavicular fractures. 4,12,13,25,33,35 Current literature comparing nonoperative treatment and plate fixation of displaced midshaft clavicular fractures has found that operative treatment reduces the number of nonunions. 4,12,25,33,35 However, a recent meta-analysis, including 6 randomized controlled trials (RCTs), concluded that surgery is not associated with a clinically relevant improvement in functional capacity compared with nonoperative treatment.…”

“…34 Some studies, however, have reported a faster return to work for patients receiving surgery. 2,12 As a great number of persons experiencing clavicular fractures are within the working age, 24 an earlier return to work would represent a reduced loss of productivity for society. Currently, only 1 Canadian cost-utility analysis using a health-sector perspective has investigated the economic impact of plate fixation compared with nonoperative treatment.…”

What’s New in Shoulder and Elbow Surgery?

“…Clavicular fracture management has been critically examined in recent Level-I studies. Melean et al performed a prospective randomized trial comparing conservative and surgical management of displaced midshaft clavicular fractures in the Workers' Compensation population 28 . Seventy-six patients were randomized to conservative treatment versus open reduction and internal fixation.…”

Who should be treated surgically for a displaced clavicle fracture?

“…Also the most recent RCT on a working population (Melean et al. 2015) found no clinical relevant differences in Constant score between plate fixation and nonsurgically treated patients but a shorter time to return to work. A similar reoperation frequency was found in both groups, 9% in the nonsurgical group because of nonunion at 4 month and 11% in the surgical group for plate removal because of local symptoms…”