Yet another clavicle fracture review

Systematic reviews and meta-analyses on clavicle fractures are never ending sources of publications. We did our share by investigating the potential of sources of heterogeneity among RCTs investigating operative and nonoperative treatment in midshaft claviclar fractures.

Our study titled Factors explaining heterogeneity in studies comparing surgical and nonsurgical treatment of midshaft clavicle fractures: a meta-regression analysis of randomized controlled trials and high-quality observational studies was recently published in the Journal of Shoulder and Elbow Surgery (JSES). The bottom line in our study was as follows:

It is evident, therefore, that objective superiority between surgical and nonsurgical treatment relies on the values of both surgeons and patients.

Reito et al. (2020)

Another systematic review and meta-analysis on very same topic was published also recently in the JSES International which is a sister journal of the JSES. This was study by Vannabouathong et al. and titled: An evaluation of treatment options for medial, midshaft, and distal clavicle fractures: a systematic review and meta-analysis.

They write in the Results section in the abstract:

For midshaft fractures, we found statistically significant improvements in function and time to radiographic union with plating, an elastic stable intramedullary nail (ESIN), and the Sonoma CRx intramedullary nail over nonoperative treatments.

Vannabouathong et al. (2020)

They continue in the Conclusion section:

The current evidence suggests that plating, an ESIN, and a CRx intramedullary nail are all good options for midshaft fractures

Vannabouathong et al. (2020)

Being an advocate of shared decision making, I´m little pessimistic about these statements. Improvement is not a binary outcome: it is a continuum from negligible to considerable benefit. Here are the results regarding function from the by Vannabouathong et al.:

From: Vannabouathong et al. (2020)

Sure there are improvements in the shoulder function. Only problem here is that the scale used is not mentioned, but I assume it is a combined version of both DASH and Constant score in which 8-10 points can be considered clinically relevant. Hence all improvements reported here cannot be considered clinically relevant. This is no different to our study and numerous earlier reviews and meta-analyses on this topic. So in that sense their study provides nothing new.

Both nonoperative and operative are good options for midshaft fractures. It´s up to our patients and their values, which option is the right choice.

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