Sling Compared with Plate Osteosynthesis for Treatment of Displaced Midshaft Clavicular Fractures

Virtanen, Kari; Remes, Ville; Pajarinen, Jukka; Savolainen, Vesa; Björkenheim, Jan-Magnus; Paavola, Mika

doi:10.2106/jbjs.j.01999

Cited by 173 publications

(126 citation statements)

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“…Collation of literature on clavicle fractures suggests that the expected nonunion rate is 8.6%. This percentage was derived from the reported healing rate in 12 separate publications [59][60][61][62][63][64][65][66][67][68][69][70] spanning the period from 2004 to 2013 and including 3168 patients treated with a range of conservative and operative methods. Both samples are large, and the nonunion rate in our database again differs by less than a percentage point from the literature values.…”

Section: Discussionmentioning

confidence: 99%

Epidemiology of Fracture Nonunion in 18 Human Bones

et al. 2016

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IMPORTANCE Failure of bone fracture healing occurs in 5% to 10% of all patients. Nonunion risk is associated with the severity of injury and with the surgical treatment technique, yet progression to nonunion is not fully explained by these risk factors.OBJECTIVE To test a hypothesis that fracture characteristics and patient-related risk factors assessable by the clinician at patient presentation can indicate the probability of fracture nonunion.DESIGN, SETTING, AND PARTICIPANTS An inception cohort study in a large payer database of patients with fracture in the United States was conducted using patient-level health claims for medical and drug expenses compiled for approximately 90.1 million patients in calendar year 2011. The final database collated demographic descriptors, treatment procedures as per Current Procedural Terminology codes; comorbidities as per International Classification of Diseases, Ninth Revision codes; and drug prescriptions as per National Drug Code Directory codes. Logistic regression was used to calculate odds ratios (ORs) for variables associated with nonunion. Data analysis was performed from January 1, 2011, to December 31, 2012, EXPOSURES Continuous enrollment in the database was required for 12 months after fracture to allow sufficient time to capture a nonunion diagnosis. RESULTSThe final analysis of 309 330 fractures in 18 bones included 178 952 women (57.9%); mean (SD) age was 44.48 (13.68) years. The nonunion rate was 4.9%. Elevated nonunion risk was associated with severe fracture (eg, open fracture, multiple fractures), high body mass index, smoking, and alcoholism. Women experienced more fractures, but men were more prone to nonunion. The nonunion rate also varied with fracture location: scaphoid, tibia plus fibula, and femur were most likely to be nonunion. The ORs for nonunion fractures were significantly increased for risk factors, including number of fractures (OR, 2.65; 95% CI, 2.34-2.99), use of nonsteroidal anti-inflammatory drugs plus opioids (OR, 1.84; 95% CI, 1.73-1.95), operative treatment (OR, 1.78; 95% CI, 1.69-1.86), open fracture (OR, 1.66; 95% CI, 1.55-1.77), anticoagulant use (OR, 1.58; 95% CI, 1.51-1.66), osteoarthritis with rheumatoid arthritis (OR, 1.58; 95% CI, 1.38-1.82), anticonvulsant use with benzodiazepines (OR, 1.49; 95% CI, 1.36-1.62), opioid use (OR, 1.43; 95% CI, 1.34-1.52), diabetes (OR, 1.40; 95% CI, 1.21-1.61), high-energy injury (OR, 1.38; 95% CI, 1.27-1.49), anticonvulsant use (OR, 1.37; 95% CI, 1.31-1.43), osteoporosis (OR, 1.24; 95% CI, 1.14-1.34), male gender (OR, 1.21; 95% CI, 1.16-1.25), insulin use (OR, 1.21; 95% CI, 1.10-1.31), smoking (OR, 1.20; 95% CI, 1.14-1.26), benzodiazepine use (OR, 1.20; 95% CI, 1.10-1.31), obesity (OR, 1.19; 95% CI, 1.12-1.25), antibiotic use (OR, 1.17; 95% CI, 1.13-1.21), osteoporosis medication use (OR, 1.17; 95% CI, 1.08-1.26), vitamin D deficiency (OR, 1.14; 95% CI, 1.05-1.22), diuretic use (OR, 1.13; 95% CI, 1.07-1.18), and renal insufficiency (OR, 1.11; 95% CI, 1.04-1.17) (multivariate P < .001 for all).C...

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Section: Discussionmentioning

confidence: 99%

Epidemiology of Fracture Nonunion in 18 Human Bones

et al. 2016

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“…38 Reporting bias was deemed high in 7 studies, 10,30,34,35,37,38,41 while 6 were unclear [31][32][33]39,40,42 and 2 were considered as low. 5,36 Agreement between reviewers in the assessment of methodologic quality was excellent (weighted κ value = 0.85). The funnel plot did not suggest publication bias (Figure 3).…”

Section: Study Characteristicsmentioning

confidence: 99%

“…Fifteen of these studies proved eligible for inclusion ( Figure 1). 5,10,[30][31][32][33][34][35][36][37][38][39][40][41][42] The overall agreement between the 2 reviewers for final eligibility was excellent (κ value = 0.94, 95% confidence interval [CI] 0.84-1). All 15 studies were published between 2007 and 2013; their characteristics are summarized in Table 1.…”

Section: Study Characteristicsmentioning

confidence: 99%

“…5,10,[30][31][32][33][34][35][36][37]39,40 Eight studies were considered to be at low risk for attrition bias, 5,30,33,[35][36][37]40,42 6 were classified as high risk, 10,31,32,34,39,41 and 1 was judged as unclear. 38 Reporting bias was deemed high in 7 studies, 10,30,34,35,37,38,41 while 6 were unclear [31][32][33]39,40,42 and 2 were considered as low.…”

Section: Study Characteristicsmentioning

confidence: 99%

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Operative versus nonoperative interventions for common fractures of the clavicle: a meta-analysis of randomized controlled trials

et al. 2015

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C lavicle fractures are common injuries, affecting about 22 000 Canadians each year and numbering 1.75 million fractures worldwide. [1][2][3][4][5][6] The majority of these fractures are located in the midshaft, accounting for about 80% of all clavicle fractures.1,2 Closed midshaft fractures were traditionally treated nonoperatively, a practice largely based on previous studies by Neer and Rowe. 7,8 In the last decade, evidence challenged the standard of nonoperative treatment, reporting high rates of nonunion (15%-20%), poor early function, and residual sequelae at 6 months following nonoperative management in up to 42% of patients.9 Small clinical trials that followed have fuelled a growing popularity to treat these fractures surgically with plates and screws or intramedullary devices; however, these procedures carry inherent surgical risks for infection, implant failure and hardware irritation requiring subsequent removal. 10,11 Whether surgery or a conservative approach is the optimal method of management for midshaft clavicle fractures is still an issue of debate. Several trials have compared operative and nonoperative approaches to treatment. In the last 5 years, a number of trials have also investigated various surgical techniques and the use of different implants. Previous reviews focused only on the operative versus nonoperative debate. 1,9,11,12 Our review adds to this body of literature by providing data from the largest and most recent trial. It also provides a summary of the evidence on surgical techniques for these injuries, as well as nonsurgical options.We performed a meta-analysis to determine the effect of operative and nonoperative interventions for treating acute displaced midshaft clavicle fractures on the risk of secondary operation and all complications and on long-term function. Background: The popularity of surgery for acute displaced midshaft clavicle fractures has been fuelled by early randomized controlled trials (RCTs) showing improved rates of radiographic union and perceived functional benefits compared with nonoperative approaches. We performed a meta-analysis to determine the effect of operative and nonoperative interventions on the risk of secondary operation and complications and on long-term function. Operative versus nonoperative interventions for common

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“…This traditional treatment is not without complications, including shortening, nonunion, deformity and unsatisfactory patient outcomes [7][8][9][10][11][12][13][14]. More recently, modern operative treatment has demonstrated superior results [15][16][17][18][19][20][21][22][23][24][25][26].…”

Section: Introductionmentioning

confidence: 99%