Managements of Acute Midshaft Clavicular Fracture - Evidence-Based Medicine. 骨科部外傷骨科游宜勳 December 29th 2009

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1 Managements of Acute Midshaft Clavicular Fracture - Evidence-Based Medicine 骨科部外傷骨科游宜勳 December 29th 2009

2 Acute midshaft clavicular fracture Early opinion (before and around 1990) Favor conservative treatment Current opinion Favor surgical intervention

3 Evidence Based Medicine Question Search Critical Appraisal Practice Audit

4 Question Acute midshaft clavicular fracture Surgery or Non-surgery? Which conservative treatment is better? Which surgical treatment is better?

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6 Treatment of acute midshaft clavicle fracture: systemic review of 2144 fractures Zlowodzki M. et al J Ortho Trauma 2005 Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fracture: a multicenter, randomized clinical trail Canadian Orthopaedic Trauma Society JBJS-A 2007 Conservative interventions for treating middle third clavicle fractures in adolescents and adults (Review) Lenza M. et al The Cochrane Collaboration 2009 Surgical intervention for treating acute fractures or nonunion of the middle third of the clavicle (Review) Lenza M. et al The Cochrane Collaboration 2009

7 Treatment of acute midshaft clavicle fracture: systemic review of 2144 fractures Zlowodzki M. et al J Ortho Trauma 2005 EBM-level I: 2 EBM-level II: 3 EBM-level III: 3 EBM-level IV: 14

8 Overall results for all fractures Overall results for displaced fractures only

9 Nonoperative treatment Nonunion rate: 5.9% (all fractures) 15.1% (displaced fractures) Factors of nonunion: Dsiplacement (RR=2.3); Comminution (RR=1.4); Female (RR=1.4); Aging Factors of long-term sequelae Displacement (OR: ); Comminution (OR = 2); Fragments (OR = 1.4); Aging Sling versus figure-of-eight bandage Dissatisfied rate: 1.3% versus 26%

10 Operative versus nonoperative Plating versus nonoperative 1. Pooled data Nonunion rate: Overall: 2.5% versus 5.9% Displaced fractures: 2.2% versus 15.1% 2. One RCT Nonunion rate: 0% versus 24% Neurologic complaints: 6% versus 30% Cosmetic complaints: 44% in nonop Removal of hardware: 30% in OP

11 IM pin versus nonoperative Pooled data Nonunion rate: 1.6% versus 5.9% Displaced fractures: 2% versus 15.1%

12 Surgical technique Plate position anterior-inferior versus superior All union VAS: better in anterior-inferior IM pin versus plating: controversial

13 Nonoperative treatment of acute midshaft clavicle fractures: Grade C Nonunion: OP versus nonop = 5.9% versus 15.1% Factors of nonunion in nonop: Displacement, comminution, female, aging Factors of long-term sequelae after nonop: Displacement, comminution, fragments, aging Sling versus figure-of-eight bandage: Grade B Satisfied in sling Anterior-inferior versus superior plating: Grade C Anterior-inferior: lower symptoms

14 Nonoperative treatment compared with plate fixation of displaced midshaft clavicular fracture: a multicenter, randomized clinical trail Multicenter, prospective, randomized clinical trial involving 8 centers. (Apr ~ Dec. 2004) Inclusion criteria: complete displaced; midshaft; age between 16 and 60 years; safe for general anesthesia; complete informed consent Exclusion criteria: 11 items Randomization: Canadian Orthopaedic Trauma Society JBJS-A 2007 Doctor visiting research nurse explanation take consent home non-op or OP

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18 Conclusion The data support primary fixation of completely displaced midshaft clavicular fractures in active adults

19 Conservative interventions for treating middle third clavicle fractures in adolescents and adults (Review) Lenza M. et al The Cochrane Collaboration 2009 Objective: to evaluate the relative effects of different methods of conservative treatment for midshaft clavicle fractures in adolescents and adults Search methods / Data collection and analysis Electronic searches; selection of studies; data extraction and management; assess of risk of bias; measure the treatment effect; dealing with missing data; assessment of heterogenicity; data synthesis; subgroup analysis; sensitivity analysis;

20 Treatment of clavicular fractures: Figure-ofeight bandage versus a simple sling Anderson 1987 Closed treatment of clavicular fractures: A prospective randomized trial Hoofwijk 1988 Low-intensity pulsed ultrasound in fresh clavicular fractures: A multicenter double blinded randomized controlled trial Lubbert 2008

21 Figure-8 bandage versus Arm sling Bandage wear higher pain greater discomfort No significant difference in functional outcome ** Both trials are underpowered and compromised by poor methodology

22 Low-intensity pulsed ultrasound versus Placebo LIPUS versus placebo No significant difference of fracture healing or in any other reported outcomes ** The trial is underpowered but had a low risk of bias

23 Author s conclusion Insufficient evidence Further study is warranted

24 Surgical interventions for treating acute fractures or nonunion of the middle third clavicle (Review) Lenza M. et al The Cochrane Collaboration 2009 Objective: to evaluate effectiveness of different methods of surgical treatment for acute fracture or nonunion of the middle third of the clavicle Search methods / Data collection and analysis Electronic searches; selection of studies; data extraction and management; assess of risk of bias; measure the treatment effect; dealing with missing data; assessment of heterogenicity; data synthesis; subgroup analysis; sensitivity analysis;

25 Treatment of midlavicular nonunion: comparison of dynamic compression plating and low-contact dynamic compression plating techniques Kobak 2004 Operative treatment of midclavicular fractures In 62 elderly patients: Knowles pin versus plate Lee 2007 A three-dimensional reconstruction plate for displaced midshaft fracture of the clavicle Shen 2008

26 LCDCP versus DCP for treating nonunion LCDCP has superior outcomes in better upper-limb function early union and return to work reduced hardware-induced symptoms

27 Knowels pin versus DCP for treating nonunion Knowels pin has superior outcomes in lower failure (re-op, nonunion, implant failure) lower pain short hospital stay

28 3D plate versus superior plate for treating acute fracture 3D plate has superior outcomes in lower failure (re-op and delay union) pain improvement radiographic outcome Superior plate has superior outcomes in length of surgery length of hospital stay

29 Author s conclusion Limited evidence

30 Public information - Wikipedia In older practice, a figure-8 brace was used More recent clinical studies have shown that the outcomes of this method were not measurably different from simple sling this method has mostly lapsed. Current practice is generally to provide a sling, and pain relief, and to allow the bone to heal itself, monitoring progress with X-rays every week or few weeks

31 Public information - YouTube A angry male Just discharge from a hospital The orthopedic doctor said: 綁八字肩帶就會好了啦, 不用開 From YouTube Website

32 Textbooks opinions OKU 8 & 9: Surgery if indicated Rockhood author s prefer method my treatment protocol is based more on patient comfort and need to return to activities than it is on rates of healing.

33 CGMH Orthopaedic Traumatologists opinions Conservation more than surgery Conservation: figure-8 bandage Surgery: plating

34 My conclusion Principle of surgery Patient s demand Thanks for attention & Happy 2010!