Istituto Ortopedico Rizzoli, IRCCS, Bologna, Italy.
Orthopaedic and Traumatology Unit, Ospedale Regionale di Lugano, EOC, Lugano, Switzerland.
Am J Sports Med. 2019 Dec;47(14):3541-3551. doi: 10.1177/0363546519826961. Epub 2019 Mar 5.
There is no agreement on the best treatment for displaced midshaft clavicle fractures (MCFs), which are currently addressed by nonoperative or surgical approaches.
To compare fracture healing and functional outcome after surgical versus nonsurgical treatment of MCFs, to help specialists in deciding between these different strategies by providing a synthesis of the best literature evidence.
Meta-analysis.
A systematic research of the literature was performed in different online databases: PubMed, Web of Science, Cochrane library, and grey literature. PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines were used. The risk of bias was evaluated with the Cochrane Collaboration's "risk of bias" tool, and the quality of evidence was graded according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Randomized controlled trials investigating differences between surgery and nonoperative treatment for displaced MCFs were included. The primary outcome was the nonunion rate. Other outcomes analyzed were time to union and to return to activities, Constant score, and Disabilities of the Arm, Shoulder and Hand (DASH) index. Patients' satisfaction, secondary operations, and complications were also recorded.
Out of 832 records found, 14 randomized controlled trials with 1546 patients were included. A significantly lower risk ratio was found for nonunion (10%; 95% CI, 6%-18%, < .001) favoring surgery. Time to union was 5.1 weeks shorter with surgery ( = .007). The complication rate (including the number of reinterventions) was higher in the surgical group (31.3% vs 20.5%, < .001). Shoulder function at short-term follow-up was significantly better in the surgical group (DASH index mean difference = 4.0 points), while no statistical difference was found in the Constant score and in the DASH index at midterm follow-up ( = .41 and .80, respectively). At long-term follow-up, both shoulder functional scores were significantly better in the surgery group: the overall Constant score mean difference was 5.3 points (95% CI, 2.3-8.4 points; < .001), and the DASH index mean difference was 4.3 points (95% CI, 0.2-8.4 points; = .04).
Surgical treatment of MCFs significantly reduces the nonunion rate and shortens the time to union as compared with the nonoperative approach and, despite a slightly higher incidence of complications, leads to better shoulder functional scores at short- and long-term follow-up. Further studies should address the clinical significance of the documented improvement.
对于移位的锁骨中段骨折（MCF），目前存在非手术和手术治疗方法，尚无最佳治疗方法的共识。
通过综合最佳文献证据，比较手术与非手术治疗 MCF 的骨折愈合和功能结果，帮助专家在这些不同策略之间做出决策。
荟萃分析。
在不同的在线数据库中进行了文献的系统研究：PubMed、Web of Science、Cochrane 图书馆和灰色文献。使用 PRISMA（系统评价和荟萃分析的首选报告项目）指南。使用 Cochrane 协作的“偏倚风险”工具评估偏倚风险，并根据推荐评估、制定与评估（GRADE）指南对证据质量进行分级。纳入比较手术与非手术治疗移位 MCF 的差异的随机对照试验。主要结局是非愈合率。分析的其他结局包括愈合时间和恢复活动时间、Constant 评分和上肢残疾问卷（DASH）指数。还记录了患者满意度、二次手术和并发症。
在 832 条记录中，纳入了 14 项随机对照试验，共 1546 名患者。手术组的非愈合风险比显著降低（10%；95%CI，6%-18%，<0.001），有利于手术。手术组的愈合时间缩短了 5.1 周（=0.007）。手术组的并发症发生率（包括再次手术的数量）更高（31.3%比 20.5%，<0.001）。短期随访时，手术组的肩部功能明显更好（DASH 指数平均差值=4.0 分），而中期随访时 Constant 评分和 DASH 指数无统计学差异（=0.41 和 0.80）。长期随访时，手术组的肩部功能评分均明显更好：总体 Constant 评分平均差值为 5.3 分（95%CI，2.3-8.4 分；<0.001），DASH 指数平均差值为 4.3 分（95%CI，0.2-8.4 分；=0.04）。
与非手术治疗相比，手术治疗 MCF 可显著降低非愈合率并缩短愈合时间，尽管并发症发生率略高，但在短期和长期随访时可获得更好的肩部功能评分。进一步的研究应解决记录的改善的临床意义。
