Functional outcomes and adverse effects following three interventions for displaced midshaft clavicular fractures: A Bayesian network meta-analysis of randomized controlled trials.

INTRODUCTION: The efficacy of the most commonly used interventions for clavicle fractures remains controversial. These interventions are: open reduction and plate fixation (ORPF), non-surgical intervention (NSI), and use of an intramedullary nail (IMN). In adult patients with clavicle fractures, choosing which intervention might be best is challenging. MATERIALS AND METHODS: PubMed, Journals@Ovid Full Text, Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, and Embase were performed to search English-language studies from the inception to February 2020. Randomized controlled trials (RCTs) comparing any of these three interventions were included. Patient and baseline characteristics, nonunion, major complications, Constant-Murley score (CMS), and Disabilities of the Arm, Shoulder and Hand score (DASH) were extracted. Then, we evaluated the functional outcomes and adverse effects after use of these three interventions for the management of displaced midshaft clavicle fractures in a Bayesian network meta-analysis. RESULTS: A Bayesian random-effects model was conducted, and nonunion and major complications were evaluated with: risk ratio (RR) and 95% confidential interval (CI); while CMS and DASH were evaluated with mean differences (MD) and the corresponding 95% confidential interval CI. The rank probability of each endpoint was assessed on the basis of the surface area under the cumulative ranking curve (SUCRA). DISCUSSION: ORPF is most likely to be successful in achieving objective functional outcomes as captured by the CMS, and IMN demonstrates significant efficacy for subjective functional outcomes, as captured by DASH scores. Compared with the other interventions examined, IMN was associated with decreased risk for adverse effects. LEVELS OF EVIDENCE: I; meta-analysis.

Is Minimally Invasive Plating Osteosynthesis Better Than Conventional Open Plating for Humeral Shaft Fractures? A Systematic Review and Meta-Analysis of Comparative Studies.

INTRODUCTION: The aim of systematic review and meta-analysis was to find out whether minimally invasive plate osteosynthesis (MIPO) is better than open reduction and internal plate fixation (ORIF) in terms of functional outcome, achieving union (union time and incidence of non-union), intraoperative parameters (surgical duration, blood loss, and radiation exposure), and complications (iatrogenic radial nerve palsy and infection) for humeral shaft fractures. MATERIALS AND METHODS: We searched online databases (Pubmed, Embase, Scopus, and The Cochrane Library) from inception till 3rd September 2020 for articles comparing MIPO with ORIF for humeral shaft fractures. The methodological quality of randomized controlled trials (RCTs) was done by Cochrane Risk of Bias assessment tool 2 (RoB2) and of non-randomized studies (case-control and cohort studies) by Methodological Index for non-randomized studies (MINORS). Meta-analysis was performed using Review Manager 5.4 software. RESULTS: 11 studies (5 RCTs and 6 non-randomized comparative studies) involving a total of 582 patients (MIPO-290, ORIF-292) meeting our inclusion criteria were included in the study. There was no statistically significant difference in pooled analysis of functional outcome scores between MIPO and ORIF. Union time was significantly lesser (mean difference = 3.12 weeks) and incidence of non-union lower (odd's ratio = 0.27) in MIPO group. Surgical duration and intraoperative blood loss were significantly lesser in MIPO group. Iatrogenic radial nerve palsy and infection were higher in ORIF group. CONCLUSIONS: This study showed that MIPO gives similar functional outcomes as compared to ORIF but causes significantly lesser blood loss, requires lesser operative duration and has a lesser incidence of major complications. TRIAL REGISTRATION: International prospective register of systematic reviews (PROSPERO)-CRD42020208346, Date of registration 09/10/2020. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00413-6.

Mechanical failure of plate breakage after open reduction and plate fixation of displaced midshaft clavicle fracture - a possible new risk factor: a case report.

BACKGROUND: Plate breakage is one form of construct failure after a clavicle fracture treated with an open reduction and plate fixation. A recent study evaluated construct failure after an open reduction and plate fixation and reported a construct failure rate of 6.9% of which 1.9% were related to broken plates. Plate breakage is rare, thus, there are insufficient data regarding risk factors, pathogenesis, or how to avoid it. CASE PRESENTATION: This case report presents an unusual case of a 35-year-old Caucasian man, 7 weeks after open reduction and internal plate fixation of a fracture in the middle third of his clavicle, who developed breakage of the implant. Surgery was advised, the implant was retrieved, the fracture was reduced, and a new bridging locking plate was implanted. CONCLUSIONS: In the current case it seems that the use of a bridging plate, the fundamental anatomical structure of the clavicle and the forces that are applied on it, the lack of discipline in complying with the postoperative functional restrictions, and an unclear "patient expectation" process were the main reasons for the failure. These aspects should be carefully considered and addressed in clavicle fractures.