Locking versus nonlocking superior plate fixations for displaced midshaft clavicle fractures: A prospective randomized trial comparing clinical and radiografic results

Functional outcomes and complications of plate fixation for midshaft clavicle fractures by type and location: a systematic review and meta-analysis

Background

Various plate types are used in the surgical treatment of displaced midshaft clavicle fractures. These plates can be positioned in different locations on the clavicle, although no studies to date have elucidated optimal plate type and location of fixation. This systematic review compares the functional outcomes and complications in the management of displaced midshaft clavicle fractures using plate fixation by stratifying by both plate type and location.

Methods

A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted to identify all papers reporting functional outcomes, union rates, and/or complications using plates for the management of midshaft clavicle fractures. Multiple databases and trial registries were searched from inception until March 2022. A meta-analysis was conducted for functional outcomes and type of complication, stratified by plate type (locking, compression, or reconstruction) and location (superior or anteroinferior). Pooled estimates of functional outcome scores and incidence of complications were calculated using a random effects model. Risk of bias and quality were assessed using the risk of bias version 2 and ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tools. The confidence in estimates were rated and described according to the recommendations of the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) working group.

Results

Forty-five studies were included in the systematic review and 43 were included in the meta-analysis. Depending on plate type and location, pooled Constant-Murley Scores ranged from 89.23 to 93.48 at 12 months. Nonunion rates were 3% (95% confidence interval [CI] 1-6) for superior locking plates (GRADE Low). Rates of any complication (nonunion, hardware failure, hardware irritation, wound dehiscence, keloid, superficial infection, deep infection, delayed union, malunion, and/or persistent pain) by plate type and location ranged from 3% to 17% (GRADE Very Low to Moderate). Superior compression plates had the highest incidence of any complications (17% [95% CI 5-44], GRADE Very Low), while anterior inferior compression plates had the lowest incidence of any complication (3% [95% CI 0-15], GRADE Very Low). Hardware irritation was the most reported individual complication for superior locking plates and superior compression plates, 11% (95% CI 7-17, GRADE Low) and 11% (95% CI 3-33, GRADE Very Low), respectively.

Conclusion

Although most studies were of low quality, studies reporting functional outcomes generally showed good functional results and similar incidence of any complication regardless of plate type and location. There is no evidence of a plate and location combination to optimize patient functional outcomes or complications. We were unable to reliably evaluate union rates or individual complications for most plate types stratified by location.

Lateral clavicle fracture-plating options and considerations

Clavicle fractures are among the most prevalent types of fractures with numerous treatment strategies that have evolved over time. In the realm of lateral-third clavicle fracture management, several surgical methods are available, with plate and screw constructs being one of the most frequently employed options. Within this construct, numerous choices exist for fixing the fracture. This editorial provides an overview of the common plate options utilized in the management of distal third clavicle fractures underscoring the critical considerations and approaches that guide clinicians in selecting the most appropriate fixation techniques, considering the complex landscape of clavicle fractures and their challenging management.

Clavicle Nonunion and Malunion: Surgical Interventions for Functional Improvement

Clavicle nonunion and malunion are relatively uncommon but, when symptomatic, can result in pain and dysfunction that requires surgical intervention. Various reconstructive and grafting techniques are available to achieve stable fixation and union. In the setting of persistent nonunion, vascularized bone grafting may be necessary. A thorough understanding of the patient's type of nonunion and potential for healing is crucial for achieving satisfactory results because is thoughtful preoperative planning and surgical fixation.

Current concepts in the treatment of midshaft clavicle fractures in adults

Midshaft clavicle fractures are the most common fracture of the clavicle accounting for 80% of all clavicle fractures. Traditionally, midshaft clavicle fractures are treated with conservative treatment even when prominent displacement is observed; however, recent studies revealed that nonunion or malunion rate may be higher with conservative treatment. Moreover, recent studies have shown better functional results and patient satisfaction with surgical treatment. This review article provides a review of clavicle anatomy, describes the current clavicle fracture classification system, and outlines various treatment options including current surgical options for clavicle fracture in adults.