Advertisement

Intramedullary nailing versus plating fixation for the treatment of midshaft clavicular fractures: A meta-analysis of randomized controlled trials

  • Author Footnotes
    # The authors have contributed equally to this work.
    Jing-Xin Zhao
    Footnotes
    # The authors have contributed equally to this work.
    Affiliations
    Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China

    China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
    Search for articles by this author
  • Author Footnotes
    # The authors have contributed equally to this work.
    Yan-Peng Zhao
    Footnotes
    # The authors have contributed equally to this work.
    Affiliations
    Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China

    China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
    Search for articles by this author
  • Zhi Mao
    Affiliations
    Department of Critical Care Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing, China
    Search for articles by this author
  • Peng-Bin Yin
    Affiliations
    Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China

    China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
    Search for articles by this author
  • Ming Hao
    Affiliations
    Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China

    China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
    Search for articles by this author
  • Hou-Chen Lyu
    Affiliations
    Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China

    China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
    Search for articles by this author
  • Xiang Cui
    Affiliations
    Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China

    China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
    Search for articles by this author
  • Li-Cheng Zhang
    Correspondence
    Corresponding author.
    Affiliations
    Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China

    China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
    Search for articles by this author
  • Pei-Fu Tang
    Affiliations
    Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China

    China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
    Search for articles by this author
  • Author Footnotes
    # The authors have contributed equally to this work.
Published:February 09, 2022DOI:https://doi.org/10.1016/j.injury.2022.02.026

      Highlights

      • IM nailing could increase the shoulder function score after one year post-operatively when comparing with plating fixation.
      • The functional advantage of IM nailing mainly came from the subgroup of locked IM nailing.
      • The rates of the infection, overall major complications and revision surgery were significantly higher after plating fixation than IM nailing.
      • The operative time, blood loss and wound length were significantly less in the IM nailing group than the plating group.

      Abstract

      Purpose

      This study was to test the hypothesis that intramedullary (IM) nailing fixation of midshaft clavicle fractures could result in better clinical outcomes and lower complications rates than plating fixation.

      Methods

      PubMed, Embase, and the Cochrane Library database were used to search all English language published randomized controlled trials (RCTs) of midshaft clavicle fractures using plating versus IM nailing. The characteristics of the study participants were collected. Outcomes of postoperative shoulder functional measurements, operative data and complications rates were meta-analyzed.

      Results

      Eight hundred and ninety-five patients in ten RCTs and three quasi-RCTs were involved in the meta-analysis. The results of meta-analysis of these studies showed that the functional outcome evaluated by the Constant Shoulder and Disabilities of the Arm, Shoulder and Hand (DASH) scores after accepting IM nailing was significantly better than that of plating fixation at one year post-operatively (P < 0.01), with the heterogeneity of 43% and 91%, respectively. Sensitivity analyses of the pooled results of Constant and DASH scores displayed that the functional advantage of IM nailing fixation comes from the subgroup of locked IM nailing. Further, regarding the operative statistics, operative time, blood loss and wound length were significantly less in the IM nailing group than the plating group (P < 0.001). The rates of infection, major complications and complications-related revision surgery were significantly higher in the plating group than the IM nailing group; however, there were no significantly statistical differences in other complications, e.g., nonunion, refracture after hardware removal, implant failure, symptomatic hardware, etc. (P > 0.05).

      Conclusion

      The observations in this review suggested that IM nailing, especially locked IM nailing, could provide better shoulder functional outcome at one-year follow-up. Moreover, IM nailing fixation could effectively reduce operative time, blood loss, rates of infection, major complications, and revision surgery than plating. Further high-quality clinical trials with large samples and consistent designs are still needed to verify the long-term functional advantage of locked and unlocked IM nailing for midshaft clavicle fractures.

      Level of evidence

      Level II.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kleweno C.P.
        • Jawa A.
        • Wells J.H.
        • O'Brien T.G.
        • Higgins L.D.
        • Harris M.B.
        • et al.
        Midshaft clavicular fractures: comparison of intramedullary pin and plate fixation.
        J Shoulder Elbow Surg. 2011; 20: 1114-1117
        • Jones L.D.
        • Grammatopoulos G.
        • Kambouroglou G.
        Titanium elastic nails, open reduction internal fixation and non-operative management for middle third clavicle fractures: a comparative study.
        Eur J Orthopaed Surg Traumatol Orthopedie Traumatologie. 2014; 24: 323-329
        • Wijdicks F.J.
        • Houwert M.
        • Dijkgraaf M.
        • de Lange D.
        • Oosterhuis K.
        • Clevers G.
        • et al.
        Complications after plate fixation and elastic stable intramedullary nailing of dislocated midshaft clavicle fractures: a retrospective comparison.
        Int Orthop. 2012; 36: 2139-2145
        • Neer 2nd, C.S.
        Fractures of the distal third of the clavicle.
        Clin Orthop Relat Res. 1968; 58: 43-50
        • Xu J.
        • Xu L.
        • Xu W.
        • Gu Y.
        • Xu J.
        Operative versus nonoperative treatment in the management of midshaft clavicular fractures: a meta-analysis of randomized controlled trials.
        J Shoulder Elbow Surg. 2014; 23: 173-181
        • Houwert R.M.
        • Wijdicks F.J.
        • Steins Bisschop C.
        • Verleisdonk E.J.
        • Kruyt M
        Plate fixation versus intramedullary fixation for displaced mid-shaft clavicle fractures: a systematic review.
        Int Orthop. 2012; 36: 579-585
        • Assobhi J.E.
        Reconstruction plate versus minimal invasive retrograde titanium elastic nail fixation for displaced midclavicular fractures.
        J Orthopaed Traumatol. 2011; 12: 185-192
        • Lee Y.S.
        • Huang H.L.
        • Lo T.Y.
        • Hsieh Y.F.
        • Huang C.R.
        Surgical treatment of midclavicular fractures: a prospective comparison of Knowles pinning and plate fixation.
        Int Orthop. 2008; 32: 541-545
        • van der Meijden O.A.
        • Houwert R.M.
        • Hulsmans M.
        • Wijdicks F.J.
        • Dijkgraaf M.G.
        • Meylaerts S.A.
        • et al.
        Operative treatment of dislocated midshaft clavicular fractures: plate or intramedullary nail fixation? A randomized controlled trial.
        J Bone Joint Surg Am. 2015; 97: 613-619
        • Andrade-Silva F.B.
        • Kojima K.E.
        • Joeris A.
        • Santos Silva J.
        • Mattar Jr., R.
        Single, superiorly placed reconstruction plate compared with flexible intramedullary nailing for midshaft clavicular fractures: a prospective, randomized controlled trial.
        J Bone Joint Surg Am. 2015; 97: 620-626
        • Saha P.
        • Datta P.
        • Ayan S.
        • Garg A.K.
        • Bandyopadhyay U.
        • Kundu S.
        Plate versus titanium elastic nail in treatment of displaced midshaft clavicle fractures: a comparative study.
        Indian J Orthop. 2014; 48: 587-593
        • Tabatabaei S.
        • Shalamzari S.
        Treatment of displaced midshaft clavicular fractures: a comparison between smooth pin and LCDCP and reconstruction plate fixation.
        Pak J Med Sci. 2011; 27: 1129-1134
        • Ferran N.A.
        • Hodgson P.
        • Vannet N.
        • Williams R.
        • Evans R.O.
        Locked intramedullary fixation vs plating for displaced and shortened mid-shaft clavicle fractures: a randomized clinical trial.
        J Shoulder Elbow Surg. 2010; 19: 783-789
        • Zhu Y.
        • Tian Y.
        • Dong T.
        • Chen W.
        • Zhang F.
        • Zhang Y.
        Management of the mid-shaft clavicle fractures using plate fixation versus intramedullary fixation: an updated meta-analysis.
        Int Orthop. 2015; 39: 319-328
        • Xu B.
        • Lin Y.
        • Wang Z.
        • Cao J.
        • Yang Y.
        • Xia H.
        • et al.
        Is intramedullary fixation of displaced midshaft clavicle fracture superior to plate fixation? Evidence from a systematic review of discordant meta-analyses.
        Int J Surg. 2017; 43: 155-162
        • Xie L.
        • Zhao Z.
        • Zhang S.
        • Hu Y.
        Intramedullary fixation versus plate fixation for displaced mid-shaft clavicle fractures: a systematic review of overlapping meta-analyses.
        Medicine (Baltimore). 2018; 97: e9752
        • Wang X.H.
        • Cheng L.
        • Guo W.J.
        • Li A.B.
        • Cheng G.J.
        • Lei T.
        • et al.
        Plate Versus Intramedullary Fixation Care of Displaced Midshaft Clavicular Fractures: a Meta-Analysis of Prospective Randomized Controlled Trials.
        Medicine (Baltimore). 2015; 94: e1792
        • Hussain N.
        • Sermer C.
        • Prusick P.J.
        • Banfield L.
        • Atrey A.
        • Bhandari M.
        Intramedullary Nailing Versus Plate Fixation for the Treatment Displaced Midshaft Clavicular Fractures: a Systematic Review and Meta-Analysis.
        Sci Rep. 2016; 6: 34912
        • Duan X.
        • Zhong G.
        • Cen S.
        • Huang F.
        • Xiang Z.
        Plating versus intramedullary pin or conservative treatment for midshaft fracture of clavicle: a meta-analysis of randomized controlled trials.
        J Shoulder Elbow Surg. 2011; 20: 1008-1015
        • Zhang B.
        • Zhu Y.
        • Zhang F.
        • Chen W.
        • Tian Y.
        • Zhang Y.
        Meta-analysis of plate fixation versus intramedullary fixation for the treatment of mid-shaft clavicle fractures.
        Scand J Trauma Resusc Emerg Med. 2015; 23: 27
        • Xiao H.
        • Gao H.
        • Zheng T.
        • Zhao J.
        • Tian Y.
        Plate fixation versus intramedullary fixation for midshaft clavicle fractures: meta-analysis of complications and functional outcomes.
        J Int Med Res. 2016; 44: 201-215
        • Houwert R.M.
        • Smeeing D.P.
        • Ahmed Ali U.
        • Hietbrink F.
        • Kruyt M.C.
        • van der Meijden O.A
        Plate fixation or intramedullary fixation for midshaft clavicle fractures: a systematic review and meta-analysis of randomized controlled trials and observational studies.
        J Shoulder Elbow Surg. 2016; 25: 1195-1203
        • Gao Y.
        • Chen W.
        • Liu Y.J.
        • Li X.
        • Wang H.L.
        • Chen Z.Y.
        Plating versus intramedullary fixation for mid-shaft clavicle fractures: a systemic review and meta-analysis.
        PeerJ. 2016; 4: e1540
        • Barlow T.
        • Beazley J.
        • Barlow D.
        A systematic review of plate versus intramedullary fixation in the treatment of midshaft clavicle fractures.
        Scott Med J. 2013; 58: 163-167
        • King P.R.
        • Ikram A.
        • Eken M.M.
        • Lamberts R.P.
        The Effectiveness of a Flexible Locked Intramedullary Nail and an Anatomically Contoured Locked Plate to Treat Clavicular Shaft Fractures: a 1-Year Randomized Control Trial.
        J Bone Joint Surg Am. 2019; 101: 628-634
        • Fuglesang H.F.S.
        • Flugsrud G.B.
        • Randsborg P.H.
        • Oord P.
        • Benth J.S.
        • Utvag S.E.
        Plate fixation versus intramedullary nailing of completely displaced midshaft fractures of the clavicle: a prospective randomised controlled trial.
        Bone Joint J. 2017; 99-b: 1095-1101
        • Calbiyik M.
        • Ipek D.
        • Taskoparan M.
        Prospective randomized study comparing results of fixation for clavicular shaft fractures with intramedullary nail or locking compression plate.
        Int Orthop. 2017; 41: 173-179
      1. Higgins J.P., Green S. Cochrane Handbook for Systematic Reviews of Interventions 5.1.0[Updated March 2011]. The Cochrane Collaboration. 2011. Available from www.cochrane-handbook.org.

        • Egger M.
        • Davey Smith G.
        • Schneider M.
        • Minder C
        Bias in meta-analysis detected by a simple, graphical test.
        BMJ. 1997; 315: 629-634
        • Zehir S.
        • Zehir R.
        • Sahin E.
        • Calbiyik M.
        Comparison of novel intramedullary nailing with mini-invasive plating in surgical fixation of displaced midshaft clavicle fractures.
        Arch Orthop Trauma Surg. 2015; 135: 339-344
        • Narsaria N.
        • Singh A.K.
        • Arun G.R.
        • Seth R.R.
        Surgical fixation of displaced midshaft clavicle fractures: elastic intramedullary nailing versus precontoured plating.
        J Orthopaed Traumatol. 2014; 15: 165-171
        • Lee Y.S.
        • Lin C.C.
        • Huang C.R.
        • Chen C.N.
        • Liao W.Y.
        Operative treatment of midclavicular fractures in 62 elderly patients: knowles pin versus plate.
        Orthopedics. 2007; 30: 959-964
        • Fuglesang H.F.S.
        • Flugsrud G.B.
        • Randsborg P.H.
        • Hammer O.L.
        • Utvåg S.E.
        Five-Year Follow-up Results of a Randomized Controlled Study Comparing Intramedullary Nailing with Plate Fixation of Completely Displaced Midshaft Fractures of the Clavicle in Adults.
        JB & JS Open Access. 2018; 3: e0009
        • Axelrod D.E.
        • Ekhtiari S.
        • Bozzo A.
        • Bhandari M.
        • Johal H.
        What Is the Best Evidence for Management of Displaced Midshaft Clavicle Fractures? A Systematic Review and Network Meta-analysis of 22 Randomized Controlled Trials.
        Clin Orthop Relat Res. 2020; 478: 392-402
        • Smith S.D.
        • Wijdicks C.A.
        • Jansson K.S.
        • Boykin R.E.
        • Martetschlaeger F.
        • de Meijer P.P.
        • et al.
        Stability of mid-shaft clavicle fractures after plate fixation versus intramedullary repair and after hardware removal.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 448-455
        • Millett P.J.
        • Hurst J.M.
        • Horan M.P.
        • Hawkins R.J.
        Complications of clavicle fractures treated with intramedullary fixation.
        J Shoulder Elbow Surg. 2011; 20: 86-91
        • Lenza M.
        • Buchbinder R.
        • Johnston R.V.
        • Belloti J.C.
        • Faloppa F.
        Surgical versus conservative interventions for treating fractures of the middle third of the clavicle.
        Cochrane Datab Syst Rev. 2013; 6CD009363
        • Fridberg M.
        • Ban I.
        • Issa Z.
        • Krasheninnikoff M.
        • Troelsen A.
        Locking plate osteosynthesis of clavicle fractures: complication and reoperation rates in one hundred and five consecutive cases.
        Int Orthop. 2013; 37: 689-692

      Linked Article