Nourian Alex, Dhaliwal Satvinder, Vangala Sitaram, Vezeridis Peter S
*Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles; Departments of †Medicine Statistics Core, and ‡Orthopaedic Surgery, University of California, Los Angeles, CA.
J Orthop Trauma. 2017 Sep;31(9):461-467. doi: 10.1097/BOT.0000000000000936.
To compare the outcomes of clavicle fracture fixation using anteroinferior versus superior plate placement.
We performed a meta-analysis of studies that have reported on outcomes after superior or anteroinferior plate fixation for acute midshaft clavicle fractures (Orthopaedic Trauma Association 15-B). A computerized literature search in the Pubmed, Scopus, and Cochrane Library databases was used to identify relevant articles. Only full text articles without language restrictions were evaluated. The inclusion criteria consisted of: (1) fracture of the midshaft clavicle; (2) surgery for acute fractures (within 1 month of the fracture); (3) adult patients (16 years of age and older); and (4) open reduction and internal fixation with plate application in either the anteroinferior or superior position. Studies were excluded if they did not specify plate location, evaluated multitrauma patients, investigated minimally invasive procedures, or studied operations for revision, nonunion, malunion, or infection. The primary measured outcomes were symptomatic hardware (implant prominence or irritation) and surgery for implant removal. The secondary outcomes were time to union, fracture union, nonunion, malunion, Disabilies of the Arm, Shoulder and Hand score, Constant score, and implant failure. Frequencies and proportions of cases were recorded for binary outcomes, whereas mean and standard deviations were recorded for continuous outcomes. Other summary statistics provided were used to impute mean and standard deviations under the assumption of normality when these were not reported. Continuous outcomes were compared between groups using linear mixed effects models, whereas binary outcomes were compared using mixed effects logistic regression models, including fixed group effects and random study effects. P-values less than 0.05 were considered statistically significant. All analyses were performed using SAS v. 9.4 (SAS Institute Inc, Cary, NC).
A total of 1428 articles were identified among the 3 databases, of which 897 remained after removing duplicates. From that pool, 57 relevant studies were evaluated. Articles were excluded because of an inability to specify plate location (6), a subject pool not exclusively consisting of acute fractures (4) or midshaft fractures (2), a minimally invasive surgical approach (6), use of nonstandard plates (1), poor reporting of functional outcomes (2), and a duplicate group of patients (2). This left 34 articles to be used in the meta-analysis. Of these, 8 studies reported on patients with anteroinferior plating (N = 390) and 27 studies reported on patients with superior plating (N = 1104). No significant differences were found with respect to the functional shoulder scores (Disabilies of the Arm, Shoulder and Hand and Constant) between the 2 groups. There was no significant difference between each group for the probability of having a union (P = 0.41), malunion (P = 0.28), nonunion (0.29), or implant failure (P = 0.39). Patients in the superior plating group had a significantly higher probability of suffering from symptomatic hardware (0.17) as compared to patients in the anteroinferior plating group (0.08), (P = 0.005). In addition, the superior plating group had a significantly higher rate of surgery for implant removal (0.11 vs. 0.05), (P = 0.008).
The findings of this investigation demonstrate that plating along the superior and anteroinferior aspects of the clavicle lead to similar operative outcomes with respect to union, nonunion, malunion, and implant failure, as well as similar functional outcomes scores. Plates applied to the superior aspect of the clavicle are associated with higher rates of symptomatic hardware and more frequent implant removal.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
比较锁骨骨折采用下前方钢板置入与上方钢板置入的治疗效果。
我们对已报道的关于急性锁骨中段骨折（骨科创伤协会15 - B型）采用上方或下前方钢板固定后治疗效果的研究进行了荟萃分析。通过在PubMed、Scopus和Cochrane图书馆数据库中进行计算机文献检索来识别相关文章。仅对无语言限制的全文文章进行评估。纳入标准包括：（1）锁骨中段骨折；（2）急性骨折手术（骨折后1个月内）；（3）成年患者（16岁及以上）；（4）采用下前方或上方位置的钢板进行切开复位内固定。如果研究未明确钢板位置、评估多发伤患者、研究微创手术或研究翻修、骨不连、畸形愈合或感染的手术，则将其排除。主要测量结果为有症状的内固定物（植入物突出或刺激）及取出植入物的手术。次要结果为骨愈合时间、骨折愈合、骨不连、畸形愈合、上肢、肩部和手部功能障碍评分、Constant评分及植入物失败。对于二元结果记录病例的频率和比例，而对于连续结果记录均值和标准差。当未报告这些数据时，在正态性假设下使用提供的其他汇总统计量来估算均值和标准差。使用线性混合效应模型比较组间连续结果，而使用混合效应逻辑回归模型比较二元结果，包括固定组效应和随机研究效应。P值小于0.05被认为具有统计学意义。所有分析均使用SAS v. 9.4（SAS Institute Inc，北卡罗来纳州卡里）进行。
在3个数据库中共识别出1428篇文章，去除重复后剩余897篇。从该集合中，评估了57项相关研究。因无法明确钢板位置（6项）、研究对象并非仅为急性骨折（4项）或中段骨折（2项）、采用微创手术方法（6项）、使用非标准钢板（1项）、功能结果报告不佳（2项）以及患者组重复（2项）而排除文章。这使得34篇文章可用于荟萃分析。其中，8项研究报告了下前方钢板置入患者（N = 390），27项研究报告了上方钢板置入患者（N = 1104）。两组之间在肩部功能评分（上肢、肩部和手部功能障碍评分及Constant评分）方面未发现显著差异。两组在骨折愈合概率（P = 0.41）、畸形愈合概率（P = 0.28）、骨不连概率（0.29）或植入物失败概率（P = 0.39）方面均无显著差异。与下前方钢板置入组患者（0.08）相比，上方钢板置入组患者出现有症状内固定物的概率显著更高（0.17），（P = 0.005）。此外，上方钢板置入组取出植入物的手术率显著更高（0.11对0.05），（P = 0.008）。
本研究结果表明，沿锁骨上方和下前方置入钢板在骨折愈合、骨不连、畸形愈合和植入物失败方面以及功能结果评分方面导致相似手术效果。应用于锁骨上方的钢板与有症状内固定物的发生率较高及更频繁的植入物取出相关。
治疗性III级。有关证据水平的完整描述，请参阅作者指南。
