Interventions for Treating Displaced Midshaft Clavicular Fractures A Bayesian Network Meta-Analysis of Randomized Controlled Trials Jia Wang, MD, PhD, Xiao-Hui Meng, MD, Zhi-Ming Guo, MD, Ying-Hua Wu, MD, and Jia-Guo Zhao, MD
Abstract: Displaced midshaft clavicle fractures are frequent injuries. There are 3 treatment methods including conservative treatment, plate fixation, and intramedullary pin fixation. However, which is the best treatment remains a topic of debate. To establish the optimum treatment for displaced midshaft clavicular fractures, we did a network meta-analysis to compare 3 treatments in terms of postoperative nonunion and infection. We searched PubMed, the Cochrane Library, and Embase for relevant randomized controlled trials (RCTs) until the end of October 2014. Two investigators independently reviewed the abstract and full text of eligible studies and extracted information. We used WinBUGS 1.4 (Imperial College School of Medicine at St Mary’s, London) to perform our Bayesian network meta-analysis. We used the graphical tools in STATA12 (StataCorp, Texas) to present the results of statistical analyses of WinBUGS14. Nonunion and infection were presented as odd ratios (ORs) with 95% confidence intervals (CIs). We also presented the results using surface under the cumulative ranking curve (SUCRA). A higher SUCRA value suggests better results for respective treatment method. Thirteen RCTs were included in our network meta-analysis, with a total of 894 patients randomized to receive 1 of 3 treatments. Nonunion rates were 0.9%, 2.4%, and 11.4% for intramedullary pin fixation, plate fixation, and conservative method, respectively. Nonunion occurred more commonly in patients treated with conservative method than in patients treated with either plate fixation (OR, 0.18; 95% CI, 0.05–0.46) or intramedullary pin fixation (OR, 0.12; 95% CI, 0.01–0.50). There was no significant difference between plate and intramedullary pin fixation in nonunion (OR, 3.64; 95% CI, 0.31–17.27). Furthermore, SUCRA probabilities were 87.8%, 62.0%, and 0.2% for intramedullary pin fixation, plate fixation, and conservative method, respectively. Infection rates were 3.6% and 3.9% for intramedullary pin fixation and plate fixation, respectively. There was no significant difference Editor: Johannes Mayr. Received: January 6, 2015; revised: February 3, 2015; accepted: February 5, 2015. From the Department of Orthopaedic Surgery (JW, Z-MG, Y-HW), Tianjin Hospital; Graduate School (X-HM), Tianjin University of Traditional Chinese Medicine; and Department of Orthopaedic Surgery (J-GZ), Clinical College of Orthopaedic Surgery, Tianjin Medical University, Tianjin, China. Correspondence: Dr Jia-Guo Zhao, Department of Orthopaedic Surgery, Tianjin Hospital, No. 406 Jiefang South Road, Hexi District, Tianjin 300211, China (e-mail:
[email protected]). JW, X-HM, Z-MG, and J-GZ contributed equally to this study as first authors. The authors have no funding and conflicts of interest to disclose. Copyright # 2015 Wolters Kluwer Health, Inc. All rights reserved. This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. ISSN: 0025-7974 DOI: 10.1097/MD.0000000000000595
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between plate and intramedullary pin fixation in infection (OR, 3.64; 95% CI, 0.31–17.27). SUCRA probabilities were 46.5% and 8.5% for intramedullary pin and plate fixation, respectively. Our network meta-analysis suggested that intramedullary pin fixation is the optimum treatment method for displaced midshaft clavicle fracture because of the low probabilities of nonunion and infection. (Medicine 94(11):e595) Abbreviations: CI = confidence interval, OR = odd ratio, SUCRA = surface under the cumulative ranking curve.
INTRODUCTION
C
lavicle fractures are frequent injuries, accounting for 2.6% to 4% of all fracture in adults.1 The most common type of clavicle fracture is the midshaft fracture. It frequently results in short-term disability and pain, eventually causing longer-term deformity and disability.2,3 Conservative interventions are widely used and are recommended for treating midshaft clavicle fractures. Traditionally, displaced clavicle fractures are treated conservatively with a figure-of-eight bandage or a sling.4,5 Recently, surgery treatment methods have been increasingly used for displaced midshaft fracture of the clavicle, mainly involving plate or intramedullary pin fixation. Some randomized controlled trials (RCTs)6– 8 have been published regarding surgical treatment versus conservative treatment and comparison of different operation methods. Individual RCTs may be underpowered to show subtle clinical differences because of the smaller patient number. Several meta-analyses or systematic reviews comparing surgical versus conservative interventions for the treatment of midshaft clavicular fracture have also been published.9 –11 In addition, 2 systematic reviews also compared the difference between plate and intramedullary pin fixation.12,13 However, traditional metaanalysis methods only directly compare 2 different methods. When comparing 3 treatments, it is impossible. Bayesian network meta-analysis is known as mixed treatment comparison and it could combine direct and indirect comparisons to resolve this problem. To establish the optimum treatment for displaced midshaft clavicular fractures, we did a network meta-analysis to compare 3 treatments including conservative treatment, plate fixation, and intramedullary pin fixation in terms of postoperative nonunion and infection.
METHOD We did our systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.14 Ethical approval and informed patient consent was not required as this study was a literature review and had no direct patient contact or influence on patient care. www.md-journal.com |
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Search Strategy
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We searched PubMed, the Cochrane Library, and Embase for relevant RCTs until the end of October 2014. The following keywords were used: ‘‘clavicle’’ or ‘‘clavicular,’’ ‘‘fracture,’’ and ‘‘random’’. No language or publication restrictions were applied. Articles in languages other than English were translated with the help of medically knowledgeable speakers.
been used previously to determine the methodological quality of published orthopedic RCTs and has shown good consistency and reliability. A quality score of >75% (16 scores) was considered to indicate high quality, scores >50% and 18 y, isolated acute, closed, displaced midshaft fracture Incl: athletes with an isolated fracture of middle third of the clavicle Incl: ages between 17 and 40, isolated acute, displaced, closed fractures of the middle third of the clavicle Excl: open fractures, neurologic compromise Incl: isolated midshaft clavicle fracture with displacement Excl: polytrauma, concurrent upper limb injuries, medical contraindications to surgery Incl: ages between 16 and 60 y, displaced midshaft clavicle fracture Excl: ipsilateral injuries, pathological fractures, open fractures Incl: comminuted, displaced midshaft fractures of the clavicle, age in the range of 18–65 y Excl: any fracture in an upper extremity distal to the shoulder, an old fracture (>3 weeks prior to accident) Incl: isolated, unilateral, displaced midshaft clavicle fracture, age between 18 and 65 y Excl: pathological or open fractures, an associated neurovascular injury Incl: displaced middle-third clavicle fracture, age between 18 and 70 y Excl: multiply injured patient, associated neurovascular injury, pathological fracture, open fracture, concomitant upper-extremity fracture
Incl: isolated displaced midshaft fracture, age between 16 and 60 y
Included/Excluded Criteria
36
37
35
31
29
26
35
30
58
34
Mean Age, y
8 (15%)
14 (13%)
9 (18%)
5 (13%)
5 (16%)
5 (9%)
23 (34%)
9 (22%)
36 (58%)
24 (21%)
Female Patients (%)
12
24
12
12
12
12
19
12
30
12
Follow-Up, mo
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Virtanen et al7 (2012)
40
Single RCT
Figueiredo et al25 (2008) Koch et al26 (2008)
62
Single RCT
Lee et al23 (2007)
111
Number of Patients
Multicenter RCT
Design
COTS6,24 (2007)
Study (Year)
TABLE 1. Characteristics of the 13 Included Studies
Medicine Interventions for Treating Displaced Midshaft Clavicular Fractures
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24 15 (23%) 39
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DCP VS elastic intramedullary nail 65 Single RCT Narsaria et al34 (2014)
COTS ¼ Canadian Orthopaedic Trauma Society, DCP ¼ dynamic compression plate, Excl ¼ excluded criteria, Incl ¼ included criteria, LCDCP ¼ limited contact dynamic compression plate, RCT ¼ randomized controlled trial, RTEN ¼ a single titanium elastic nail fixation in a retrograde mode. Plate type was not available.
12 12 NA 25 (13%) NA 32
Incl: age >15 y, midshaft clavicle fracture Incl: age between 16 and 60 y, isolated displaced midshaft clavicle fracture, no pathological fracture, no open fracture, no neurovascular injury Incl: age >16 and
