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Cirovic AV, Cirovic AV, Vujacic MD, Djonic DD, Djuric MP, Milovanovic PD. Ex vivo analysis of cortical microarchitecture of the distal clavicle: implications for surgical management of fractures. Arch Orthop Trauma Surg 2024; 144:2583-2590. [PMID: 38691146 DOI: 10.1007/s00402-024-05345-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 04/15/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Cortical thickness and porosity are two main determinants of cortical bone strength. Thus, mapping variations in these parameters across the full width of the distal end of the clavicle may be helpful for better understanding the basis of distal clavicle fractures and for selecting optimal surgical treatment. METHODS Distal ends of 11 clavicles (6 men, 5 women; age: 81.9 ± 15.1 years) were scanned by micro-computed tomography at 10-µm resolution. We first analyzed cortical thickness and porosity of each 500-μm-wide area across the superior surface of distal clavicle at the level of conoid tubercle in an antero-posterior direction. This level was chosen for detailed evaluation because previous studies have demonstrated its superior microarchitecture relative to the rest of the distal clavicle. Subsequently, we divided the full width of distal clavicle to three subregions (anterior, middle, and posterior) and analyzed cortical porosity, pore diameter, pore separation, and cortical thickness. RESULTS We found the largest number of low-thickness and high-porosity areas in the anterior subregion. Cortical porosity, pore diameter, pore separation, and cortical thickness varied significantly among the three subregions (p < 0.001 p = 0.016, p = 0.001, p < 0.001, respectively). Cortex of the anterior subregion was more porous than that of the middle subregion (p < 0.001) and more porous and thinner than that of the posterior subregion (p < 0.001, p = 0.030, respectively). Interaction of site and sex revealed higher porosity of the anterior subregion in women (p < 0.001). The anterior subregion had larger pores than the middle subregion (p = 0.019), whereas the middle subregion had greater pore separation compared with the anterior (p = 0.002) and posterior subregions (p = 0.006). In general, compared with men, women had thinner (p < 0.001) and more porous cortex (p = 0.03) with larger cortical pores (p < 0.001). CONCLUSIONS Due to high cortical porosity and low thickness, the anterior conoid subregion exhibits poor bone microarchitecture, particularly in women, which may be considered in clinical practice. LEVELS OF EVIDENCE Level IV.
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Affiliation(s)
- Aleksandar V Cirovic
- Center of Bone Biology, Institute of Anatomy, University of Belgrade-Faculty of Medicine, Dr Subotica 4/2, 11000, Belgrade, Serbia
| | - Ana V Cirovic
- Institute of Anatomy, University of Belgrade-Faculty of Medicine, Dr Subotica 4/2, 11000, Belgrade, Serbia
| | - Marko D Vujacic
- Institute for Orthopedic Surgery "Banjica", Mihaila Avramovića 28, Belgrade, Serbia
| | - Danijela D Djonic
- Center of Bone Biology, Institute of Anatomy, University of Belgrade-Faculty of Medicine, Dr Subotica 4/2, 11000, Belgrade, Serbia
| | - Marija P Djuric
- Center of Bone Biology, Institute of Anatomy, University of Belgrade-Faculty of Medicine, Dr Subotica 4/2, 11000, Belgrade, Serbia
| | - Petar D Milovanovic
- Center of Bone Biology, Institute of Anatomy, University of Belgrade-Faculty of Medicine, Dr Subotica 4/2, 11000, Belgrade, Serbia.
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Yurteri A, Mercan N, Gem K, Bilgiç A, Kiliç M, Doğar F. Single-plate versus double-plate comparison in the surgical treatment of comminuted clavicle fractures: Is the secondary plate reliable? Medicine (Baltimore) 2023; 102:e36711. [PMID: 38134057 PMCID: PMC10735136 DOI: 10.1097/md.0000000000036711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/27/2023] [Indexed: 12/24/2023] Open
Abstract
The objective of this study is to retrospectively assess the use of single-plate (SP) and double-plate (DP) fixation in the open reduction and internal fixation of comminuted clavicle fractures, focusing on fracture union and complications. We retrospectively evaluated comminuted diaphyseal clavicle fractures (Arbeitsgemeinschaft für Osteosynthesefragen type 15.B1-3) treated with open reduction and internal fixation and having a minimum 1-year follow-up. Two patient cohorts were identified: DP (utilizing a superiorly located clavicle-specific plate and an anteriorly located tubular plate) and SP (utilizing a superiorly located clavicle-specific plate). These groups were compared in terms of union time, peri-incisional numbness, implant irritation, return to work time, union rates, re-operation rates, Disabilities of Arm, Shoulder and Hand (DASH), and American Shoulder and Elbow Surgeons (ASES) scores. The study included 27 SP and 23 DP patients meeting the inclusion criteria. There was no significant difference between the 2 cohorts in terms of union time, peri-incisional numbness, implant irritation, return to work time, union rates, re-operation rates, DASH, and ASES scores at the end of the first year (P = .889, P = 1.00, P = .122, P = 1.00, P = 1.00, P = .493, P = .736, P = .762, P = .937 respectively). However, it was observed that the DP group showed a significantly earlier return to work time and better DASH scores at 3rd and 6th months, whereas the SP group exhibited significantly better ASES scores at 3rd and 6th months (P = .034, P = .016, P = .032, P = .036, P = .021, respectively). No significant difference was observed in terms of union and complications in acute clavicle fractures treated with SP and DP fixation. The DP group demonstrated an earlier return to work and superior early functional scores compared to the SP group. Our findings suggest that a secondary plate can be reliably used, particularly in situations where clavicle fracture fixation is insufficient or in cases of comminuted clavicle fractures.
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Affiliation(s)
- Ahmet Yurteri
- Department of Orthopaedic and Traumatology, Konya City Hospital, Konya, Turkey
| | - Numan Mercan
- Department of Orthopaedic and Traumatology, Necip Fazil City Hospital, Kahramanmaras, Turkey
| | - Kadir Gem
- Department of Orthopaedic and Traumatology, Manisa Alaşehir State Hospital, Manisa, Turkey
| | - Abdulkadir Bilgiç
- Department of Orthopaedic and Traumatology, Manisa City Hospital, Manisa, Turkey
| | - Mehmet Kiliç
- Department of Orthopaedic and Traumatology, Konya City Hospital, Konya, Turkey
| | - Fatih Doğar
- Department of Orthopaedic and Traumatology, Faculty of Medicine, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey
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Charles SJC, Kumar P, Reddy RP, Cong T, Chen S, Mittwede P, Moloney G, Siska P, Lin A. Dual Versus Single Plate Fixation of Displaced Midshaft Clavicle Fractures: A Cost-Effectiveness Analysis. J Bone Joint Surg Am 2023; 105:1886-1896. [PMID: 37967070 DOI: 10.2106/jbjs.23.00338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
BACKGROUND Prior studies have highlighted lower rates of reoperation if fixation of a displaced midshaft clavicle fracture is performed with dual plating (DP) compared with single plating (SP). Despite higher initial costs associated with the DP construct, the observed reduction in secondary surgeries compared with the SP construct may make it a more cost-effective treatment option. The objective of this study was to assess the cost-effectiveness of DP compared with SP in patients with operatively indicated displaced midshaft clavicle fractures. METHODS We developed a decision tree to model the occurrence of postoperative complications (acute hardware complications, wound healing issues, deep infection, nonunion, and symptomatic hardware) associated with secondary surgeries. Complication-specific risk estimates were pooled for both plating techniques using the available literature. The time horizon was 2 years, and the analysis was conducted from the health-care payer's perspective. The costs were estimated using direct medical costs, and the benefits were measured in quality-adjusted life-years (QALYs). We assumed that DP would be $300 more expensive than SP initially. We conducted probabilistic and 1-way sensitivity analyses. RESULTS The model predicted reoperation in 6% of patients in the DP arm compared with 14% of patients in the SP arm. In the base case analysis, DP increased QALYs by 0.005 and costs by $71 per patient, yielding an incremental cost-effectiveness ratio (ICER) of $13,242 per QALY gained. The sensitivity analysis demonstrated that the cost-effectiveness of DP was driven by the cost of the index surgery, risk of symptomatic hardware, and nonunion complications with SP and DP. At a willingness-to-pay threshold of $100,000 per QALY gained, 95% of simulations suggested that DP was cost-effective compared with SP. CONCLUSIONS When indicated, operative management of displaced midshaft clavicle fractures using DP was found to be cost-effective compared with SP. Despite its higher initial hardware costs, DP fixation appears to offset its added costs with greater health utility via lower rates of reoperation and improved patient quality of life. LEVEL OF EVIDENCE Economic and Decision Analysis Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Shaquille J-C Charles
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Praveen Kumar
- Public Health Dynamics Laboratory, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rajiv P Reddy
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ting Cong
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephen Chen
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Peter Mittwede
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gele Moloney
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Peter Siska
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Albert Lin
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Del Papa J, Hobson J, Mann S. Utility of routine postoperative chest radiography in patients undergoing clavicle fixation: a retrospective chart review. Can J Surg 2023; 66:E467-E471. [PMID: 37673439 PMCID: PMC10495164 DOI: 10.1503/cjs.013421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Although uncommon, pneumothorax is a potentially serious complication following open reduction and internal fixation (ORIF) of clavicle fractures. In many centres it is routine practice to obtain postoperative chest radiographs following ORIF of clavicle fractures to assess for iatrogenic pneumothorax. Given the need to contain health care costs, the low sensitivity for detecting small pneumothorax and a desire to decrease patient radiation exposure, the practice of ordering chest radiographs following ORIF of clavicle fractures may be unnecessary. METHODS All patients undergoing ORIF of clavicle fractures with plate and screw fixation at Kingston Health Sciences Centre between April 2009 and June 2020 were identified from the Discharge Abstract Database (inpatient) and National Ambulatory Care Reporting System (outpatient) using relevant Canadian Classification of Health Intervention procedure codes. Charts were manually reviewed to confirm diagnosis and procedure, and patients with preoperative pneumothorax were excluded. The frequency of postoperative chest radiograph and pneumothorax detection were calculated. RESULTS Among the 292 patients who underwent ORIF of clavicle fractures during the study period, 17 were excluded for having a pneumothorax on preoperative chest radiograph. Of the remaining 275 patients, 101 (36.7%) had postoperative chest radiographs, of whom none were found to have postoperative iatrogenic pneumothorax. CONCLUSION Since 2009, the rate of routine postoperative chest radiography following ORIF of clavicle fractures is 36.7% at our centre. During this time period, none of the 101 patients who had postoperative chest radiographs had a postoperative iatrogenic pneumothorax. To our knowledge, this is the largest series of patients available, and our findings confirm those of several smaller studies. Owing to the low rate of postoperative iatrogenic pneumothorax, we conclude that postoperative chest radiography is unnecessary following ORIF of clavicle fractures.
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Affiliation(s)
- Joshua Del Papa
- School of Medicine, Queen's University, Kingston, Ont. (Del Papa); Department of Surgery, Queen's University, Kingston, Ont. (Hobson, Mann)
| | - Josh Hobson
- School of Medicine, Queen's University, Kingston, Ont. (Del Papa); Department of Surgery, Queen's University, Kingston, Ont. (Hobson, Mann)
| | - Steve Mann
- School of Medicine, Queen's University, Kingston, Ont. (Del Papa); Department of Surgery, Queen's University, Kingston, Ont. (Hobson, Mann)
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Tandron M, Cohen L, Cohen J, Allegra P, Munoz J, Kaplan L, Baraga M. The fifty most-cited articles regarding midshaft clavicle fractures. J Orthop 2023; 39:50-58. [PMID: 37125014 PMCID: PMC10130696 DOI: 10.1016/j.jor.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/17/2023] [Accepted: 03/30/2023] [Indexed: 05/02/2023] Open
Abstract
Introduction The clavicle is the most frequently fractured bone in the human body, and up to 80% of clavicle fractures occur in the middle third diaphyseal region of the clavicle (midshaft). We conducted a bibliometric analysis to identify and evaluate the 50 most-cited publications pertaining to midshaft clavicle fractures (MCF). Materials and methods Two independent reviewers conducted separate queries on Web of Science in December 2021 for "midshaft clavicle fractures". The publications yielded were organized from highest to lowest number of citations. We included articles, review articles, and editorial materials and excluded other document types. Both reviewers independently reviewed all abstracts until 50 studies pertaining to MCF were included. Theory We hypothesized that most articles would be published between 2000 and 2019, pertain to outcomes, and those with a greater (lower numeric) level of evidence would correlate with number of citations. Results The most prolific decade was from 2010 to 2019, with 50% (25/50) of articles published. Average citation density was 6.3 ± 5.5 (range, 1.3-33.1), defined as the average number of citations per year since publication. The median level of evidence (LOE) was 3.5 (IQR: 3). One-way ANOVA tests were used to compare the effects of LOE on total citations and citation density. There were statistically significant differences in total citations (F value = 12.07, p = 0.001) and citation density (F value = 21.14, p < 0.001) between LOE groups. The median number of total citations, grouped by LOE of 1 through 5, were as follows: 110, 66, 66, 51, 52. Conclusions This review provides an overview of the 50 most cited papers regarding MCF. This should be used as a reference for physicians and other providers who treat patients with MCF for treatment guidance and for those in teaching roles as a student and resident/fellow educational resource.
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Affiliation(s)
- Marissa Tandron
- University of Miami, Department of Orthopaedic Surgery, Miami, FL, 33136, USA
| | - Lara Cohen
- Harvard Combined Orthopaedic Residency Program, Boston, MA, 02114, USA
| | - Jacob Cohen
- University of Miami, Department of Orthopaedic Surgery, Miami, FL, 33136, USA
| | - Paul Allegra
- Lenox Hill Hospital, Department of Orthopaedic Surgery, New York, NY, 10075, USA
| | - Julianne Munoz
- University of Miami, Department of Orthopaedic Surgery, Miami, FL, 33136, USA
| | - Lee Kaplan
- University of Miami, Department of Orthopaedic Surgery, Miami, FL, 33136, USA
| | - Michael Baraga
- University of Miami, Department of Orthopaedic Surgery, Miami, FL, 33136, USA
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Gulbrandsen MT, Filler RJ, Rice RC, Chung JH, Gulbrandsen TR, Phipatanakul WP, Liu JN. Spin in the Abstracts of Meta-analyses and Systematic Reviews: Midshaft Clavicle Fracture. J Orthop Trauma 2022; 37:e128-e134. [PMID: 36191349 DOI: 10.1097/bot.0000000000002497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Spin is a reporting bias that presents the beneficial effect of an experimental treatment as greater than what is found in the results of the study. This bias can result in patient care recommendations that are more subjective than objective. The purpose of this study is to identify the prevalence of spin in meta-analysis and systematic review abstracts regarding treatment of midshaft clavicle fractures. METHODS Electronic libraries (MEDLINE, Embase, Web of Science, Google Scholar) were systematically searched. Meta-analyses and systematic reviews regarding treatment of midshaft clavicular fractures were analyzed. The nine most severe types of spin commonly found in abstracts were used as an evaluation tool to assess the articles. Other variables analyzed include year of publication, journal impact factor, number of citations, and methodologic quality according to A Measurement Tool to Assess Systematic Reviews (AMSTAR-2). RESULTS The database search resulted in 401 articles, of which 53 met inclusion criteria. After review, it was found that 52.8% (28/53) of the included articles contained spin within the abstract. Of the nine most severe types of spin found in abstracts, type 3 spin ("selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention") was found to be the most prevalent 28.3% (15/53). CONCLUSION This study demonstrated the presence of spin in the majority of meta-analyses and systematic review abstracts pertaining to midshaft clavicular fractures. Orthopedic surgeons should be aware and recognize spin as they review articles when deciding the treatment course for such injuries. LEVEL OF EVIDENCE Level 3. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Matthew T Gulbrandsen
- Department of Orthopaedic Surgery, Loma Linda University School of Medicine, Loma Linda, CA
| | - Ryan J Filler
- Department of Orthopaedic Surgery, Loma Linda University School of Medicine, Loma Linda, CA
| | - Richard Casey Rice
- Department of Orthopaedic Surgery, Loma Linda University School of Medicine, Loma Linda, CA
| | - Jun Ho Chung
- Department of Orthopaedic Surgery, Loma Linda University School of Medicine, Loma Linda, CA
| | - Trevor R Gulbrandsen
- Department of Orthopaedic Surgery, University of Iowa Hospital, Iowa City, IA; and
| | - Wesley P Phipatanakul
- Department of Orthopaedic Surgery, Loma Linda University School of Medicine, Loma Linda, CA
| | - Joseph N Liu
- Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA
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Wall KC, Reddy GB, Corrigan KL, Toth AP, Garrigues GE. Operative Versus Nonoperative Management of Displaced Midshaft Clavicle Fractures: A Cost-effectiveness Analysis. Orthopedics 2022; 45:e243-e251. [PMID: 35700404 DOI: 10.3928/01477447-20220608-08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
To date, the optimal management of displaced midshaft clavicle fractures remains unknown. Operatively, plate or nail fixation may be used. Nonoperatively, the options are sling or harness. Given the equivocal effectiveness between approaches, the costs to the health care system and the patient become critical considerations. A decision tree model was constructed to study plate and sling management of displaced midshaft clavicle fractures. Primary analysis used 6 randomized controlled trials that directly compared open reduction and internal fixation with a plate to sling. Secondary analysis included 18 studies that studied either plate, sling, or both. Incremental cost-effectiveness ratios (ICERs) were calculated using quality-adjusted life-years (QALYs). Second-order Monte Carlo probabilistic sensitivity analysis (PSA) was subsequently conducted. In primary analysis, at a willingness-to-pay (WTP) threshold of $100,000, operative management was found to be less cost-effective relative to nonoperative management, with an ICER of $606,957/QALY (0.03 additional QALYs gained for an additional $16,120). In PSA, sling management was cost-effective across all WTP ranges. In secondary analysis, the ICER decreased to $75,230/QALY. Primary analysis shows that plate management is not a cost-effective option. In secondary analysis, the incremental effectiveness of plate management increased enough that the calculated ICER is below the WTP threshold of $100,000; however, the strength of evidence in secondary analysis is lower than in primary analysis. Thus, because neither option is dominant in this model, both plate and sling remain viable approaches, although the cost-conscious decision will be to treat these fractures with a sling until future data suggest otherwise. [Orthopedics. 2022;45(5):e243-e251.].
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Fox HM, Hsue LJ, Thompson AR, Ramsey DC, Hadden RW, Mirarchi AJ, Nazir OF. Humeral shaft fractures: a cost-effectiveness analysis of operative versus nonoperative management. J Shoulder Elbow Surg 2022; 31:1969-1981. [PMID: 35398163 DOI: 10.1016/j.jse.2022.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/12/2022] [Accepted: 02/24/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Humeral shaft fractures can be managed operatively or nonoperatively with functional bracing in the absence of neurovascular injury, open fracture, or polytrauma. A consensus on optimal management has not been reached, nor has the cost-effectiveness perspective been investigated. METHODS A decision tree was constructed describing the management of humeral shaft fractures with open reduction-internal fixation (ORIF), intramedullary nailing (IMN), and functional bracing in a non-elderly population. Probabilities were defined using weighted averages determined from systematic review of the literature. Cost-effectiveness was evaluated with incremental cost-effectiveness ratios, measured in cost per quality-adjusted life-year (QALY). Willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were evaluated. RESULTS Eighty-six studies were included. Using bracing as the referent in the health care model, we observed that bracing was the preferred strategy at both incremental cost-effectiveness ratio thresholds. ORIF and IMN had higher overall effectiveness (0.917 QALYs and 0.913 QALYs, respectively) compared with bracing (0.877 QALYs). The cost-effectiveness of bracing was driven by a substantially lower overall cost. In the societal model-accounting for both health care and societal costs-the cost difference narrowed between bracing, ORIF, and IMN. Bracing remained the preferred strategy at the $50,000/QALY threshold; ORIF was preferred at the $100,000/QALY threshold. ORIF and IMN were comparable strategies across a range of probability values in sensitivity analyses. CONCLUSIONS Functional bracing, with its low cost and satisfactory clinical outcomes, is often the most cost-effective strategy for humeral shaft fracture management. ORIF becomes preferable at the higher willingness-to-pay threshold when societal burden is considered. QALY values for ORIF and IMN were comparable.
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Affiliation(s)
- Henry M Fox
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Lauren J Hsue
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Austin R Thompson
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Duncan C Ramsey
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Ryan W Hadden
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Adam J Mirarchi
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Omar F Nazir
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA.
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Ahearn BM, Shanley E, Thigpen CA, Pill SG, Kissenberth MJ. Factors influencing time to return to sport following clavicular fractures in adolescent athletes. J Shoulder Elbow Surg 2021; 30:S140-S144. [PMID: 33895299 DOI: 10.1016/j.jse.2021.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is a trend toward increased surgical treatment of displaced clavicle fractures in the adolescent population presumably because of extrapolation of adult-derived best practice guidelines. The purpose of this study was to compare return to sport between nonoperative and operative treatment of clavicle fractures in high school athletes. METHODS A retrospective review of clavicle fractures sustained in scholastic athletes participating in school-sponsored athletics in the upstate South Carolina was performed from 2015 to 2019. Injury circumstances, demographics, radiographs, treatment, and return to sport data were documented for all patients. Radiographs were evaluated for fracture location, comminution, displacement, shortening, and angulation. Patients were followed until complete return to sport, and results were compared based on sport participation, injury mechanism, fracture morphology, treatment type, and time to return to sport. RESULTS Forty-seven patients (44 were male; average age 15.6 years) were included who all returned to sport within the original or subsequent season. Thirty-six patients (73%) were managed conservatively (30 middle third fractures, 4 medial third fractures, 2 distal third fractures), whereas 11 were managed surgically (11 middle third fractures). Eighty-one percent of fractures occured in collision athletes (55% in football). There was no difference in time loss based on participating in collision vs. noncontact sports (P = .4). Conservatively managed fractures returned to sport faster (61 ± 38 days vs. 100 ± 49 days; P = .008) compared with surgically managed patients. Fracture displacement ≥100% (100 ± 51 days vs. 54 ± 27 days; P = .001), greater comminution (128 ± 50 days vs. 59 ± 31 days; P = .001), and angulation (86 ± 52 days vs. 54 ± 22 days; P = .001) all were statistically significant for slower return to sport. Athletes presenting with clavicular shortening <2 cm returned to sport within a similar time frame as athletes with ≥2 cm (P = 0.1). CONCLUSION Our results show that adolescent athletes with clavicular fractures predictably return to athletics, including collision sports. Athletes conservatively managed returned 40% faster than those with surgery. However, this appears to be associated with the severity and complexity of fractures treated surgically. This study provides evidence to counsel adolescent athletes following clavicular fractures on return to sport expectations.
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Affiliation(s)
- Briggs M Ahearn
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | - Ellen Shanley
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA; ATI Physical Therapy, Greenville, SC, USA
| | - Charles A Thigpen
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA; ATI Physical Therapy, Greenville, SC, USA
| | - Stephan G Pill
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA
| | - Michael J Kissenberth
- Steadman Hawkins Clinic of the Carolinas, Prisma Health-Upstate, Greenville, SC, USA.
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Franovic S, Pietroski A, Kuhlmann N, Bazzi T, Zhou Y, Muh S. Rockwood Grade-III Acromioclavicular Joint Separation: A Cost-Effectiveness Analysis of Treatment Options. JB JS Open Access 2021; 6:JBJSOA-D-20-00171. [PMID: 34056509 PMCID: PMC8154465 DOI: 10.2106/jbjs.oa.20.00171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: The treatment of Rockwood Grade-III acromioclavicular (AC) joint separation has been widely disputed since the introduction of the classification system. The present literature does not reach consensus on whether operative or nonoperative management is more advantageous, nor does it effectively distinguish between operative measures. We hypothesized that nonoperative treatment of Rockwood Grade-III AC joint separation would be more cost-effective when compared with surgical options. Methods: We created a decision-tree model outlining the treatment of Rockwood Grade-III separations using nonoperative management or hook-plate, suture-button, or allograft fixation. After nonoperative intervention, the possible outcomes predicted by the model were uneventful healing, delayed operative management, a second round of sling use and physical therapy, or no reduction and no action; and after operative intervention, the possible outcomes were uneventful healing, loss of reduction and revision, and depending on the implant, loss of reduction and no action, or removal of the implant. A systematic review was conducted, and probabilities of each model state were averaged. A cost-effectiveness analysis was conducted both through rollback analysis yielding net monetary benefit and through incremental cost-effectiveness ratios (ICERs). Thresholds of $50,000/quality-adjusted life-year (QALY) and $100,000/QALY were used for ICER analysis. Furthermore, a sensitivity analysis was utilized to determine whether differential probabilities could impact the model. Results: Forty-five papers were selected from a potential 768 papers identified through our literature review. Nonoperative treatment was used as our reference case and showed dominance over all 3 of the operative measures at both the $50,000 and $100,000 ICER thresholds. Nonoperative treatment also showed the greatest net monetary benefit. Nonoperative management yielded the lowest total cost ($6,060) and greatest utility (0.95 QALY). Sensitivity analysis showed that allograft fixation became the favored technique at a willingness-to-pay threshold of $50,000 if the rate of failure of nonoperative treatment rose to 14.6%. Similarly, at the $100,000 threshold, allograft became dominant if the probability of failure of nonoperative treatment rose to 22.8%. Conclusions: The cost-effectiveness of nonoperative treatment is fueled by its notably lower costs and overall high rates of success in Grade-III separations. It is important to note that, in our analysis, the societal cost (measured in lost productivity) of nonoperative treatment neared that of surgical treatment, but the cost from the health-care system perspective was minimal. Physicians should bear in mind the sensitivity of these conclusions and should consider cost-effectiveness analyses in their decision-making guidelines. Level of Evidence: Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sreten Franovic
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Alex Pietroski
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Noah Kuhlmann
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Talal Bazzi
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Yang Zhou
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan
| | - Stephanie Muh
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan
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Dual Mini-Fragment Plating Is Comparable With Precontoured Small Fragment Plating for Operative Diaphyseal Clavicle Fractures: A Retrospective Cohort Study. J Orthop Trauma 2020; 34:e229-e232. [PMID: 31868765 DOI: 10.1097/bot.0000000000001727] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare precontoured (Pc) small fragment plating to dual mini-fragment plating (DmF) for open reduction and internal fixation of diaphyseal clavicle fractures. DESIGN Retrospective cohort. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS A total of 133 patients with displaced fractures of the diaphyseal clavicle (OTA/AO 15-B1, -2, and -3) treated with open reduction and internal fixation with a minimum of 1 year follow-up or until radiographic and clinical union. INTERVENTION Two patient cohorts were identified: (1) patients treated with orthogonal DmF plate constructs and (2) patients treated with Pc clavicle-specific plates. OUTCOME MEASUREMENTS Union rate and implant removal were assessed using standard descriptive statistics. Odds ratios, 95% confidence intervals, and P values (P) were calculated. RESULTS There were 60 DmF and 74 Pc patients. There were no significant differences between groups with respect to age, sex, surgeon, body mass index, or mode of fixation. There was no significant difference in union (98.3% DmF; 100% Pc, P = 0.45) or maintenance of reduction (98.3% DmF; 100% Pc, P = 0.45). A total of 8% of DmF patients had symptomatic implant removal compared with 20% of Pc patients (odds ratio 0.36, confidence interval 0.12-1.05, P = 0.061). CONCLUSIONS This retrospective comparative study found no difference in union or maintenance of reduction for diaphyseal clavicle fractures fixed with DmF compared with Pc plating. Patients treated with DmF plates may have lower rates of symptomatic implant removal. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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12
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Cunningham BP, Bosch L, Swanson D, McLemore R, Rhorer AS, Parikh HR, Albersheim M, Ortega G. The floating flail chest: Acute management of an injury combination of the floating shoulder and flail chest. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2020. [DOI: 10.1177/2210491719899076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background/purpose: The combination of ipsilateral floating shoulder and flail chest is a unique injury pattern that has not been previously described in the literature. We termed the injury pattern floating flail chest (FFC). The purpose of this study was to evaluate the effect of operative treatment of the shoulder girdle component to overall hospital length of stay (LOS). Methods: Forty-one patients were enrolled between two level I trauma centers identifying with a combination ipsilateral floating shoulder and flail chest injury, 23 treated with operative stabilization and 18 treated non-operatively. This retrospective cohort study evaluated the overall LOS and intensive care unit (ICU) days. Results: The operative group had decreased overall LOS (10.1 vs. 19.8 days, p = 0.02) and decreased ICU days (3.4 vs. 10.3, p = 0.04). Conclusion: This study describes a unique injury pattern that combines the floating shoulder and flail chest, FFC. Our study suggests that operative treatment of the shoulder girdle may decrease both overall LOS and ICU days in patients with FFC.
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Affiliation(s)
- Brian P Cunningham
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
- Department of Orthopaedic Surgery, Regions Hospital, St Paul, MN, USA
| | - Liam Bosch
- Stanford Medicine Orthopaedic Residency, Stanford, CA, USA
| | - David Swanson
- Sonoran Orthopaedic Trauma Surgeons, Scottsdale, AZ, USA
| | - Ryan McLemore
- Clinical Outcomes and Data Engineering (CODE) Technology, Phoenix, AZ, USA
| | | | - Harsh R Parikh
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
- Department of Orthopaedic Surgery, Regions Hospital, St Paul, MN, USA
| | - Melissa Albersheim
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN, USA
- Department of Orthopaedic Surgery, Regions Hospital, St Paul, MN, USA
| | - Gilbert Ortega
- Sonoran Orthopaedic Trauma Surgeons, Scottsdale, AZ, USA
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Cost-Effectiveness of Operative Versus Non-Operative Treatment for Clavicle Fracture: a Systematic Literature Review. Curr Rev Musculoskelet Med 2020; 13:391-399. [PMID: 32383036 PMCID: PMC7340703 DOI: 10.1007/s12178-020-09640-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Operative and non-operative treatment of midshaft clavicle fractures seems to yield comparative functional results. Furthermore, it has been suggested that surgery is more expensive compared with non-operative treatment of clavicle fracture. Cost-effectiveness seems to be more important in trends of treatment decisions. The purpose of this study is to investigate the cost-effectiveness of clavicle fracture treatment. RECENT FINDINGS Seven publications were selected, and 5 studies showed that operative treatment is more expensive than non-operative treatment. The mean overall cost per person in discounted prices was 10,230 USD for operative and 7923 USD for non-operative treatment. The mean absence from work ranged 8-193 and 24-69 days for operative and non-operative treatment, respectively. Studies varied in methods of assessing the cost-effectiveness of treatment modalities. Based on this literature review, routine operative treatment seems to be more expensive. In some cases, operative treatment might be more cost-effective. In all studies, direct and indirect costs of health care were calculated, but a great heterogeneity exists in the sources of cost data between countries. The cost-effectiveness of the treatment of clavicle fracture depends strongly on the cost of operative treatment and length of absence from work. Cost-effectiveness analysis could be a routine in RCT studies in the future.
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Tischer T, Lenz R, Breinlinger-O’Reilly J, Lutter C. Cost Analysis in Shoulder Surgery: A Systematic Review. Orthop J Sports Med 2020; 8:2325967120917121. [PMID: 32435659 PMCID: PMC7223215 DOI: 10.1177/2325967120917121] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Cost analysis studies in medicine were uncommon in the past, but with the rising importance of financial considerations, it has become increasingly important to use available resources most efficiently. PURPOSE To analyze the current state of cost-effectiveness analyses in shoulder surgery. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS A systematic review of the current literature was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All full economic analyses published since January 1, 2010 and including the terms "cost analysis" and "shoulder" were checked for usability. The methodological quality of the studies was assessed using the Oxford Centre for Evidence-Based Medicine levels of evidence and established health economic criteria (Quality of Health Economic Studies [QHES] instrument). RESULTS A total of 34 studies fulfilled the inclusion criteria. Compared with older studies, recent studies were of better quality: one level 1 study and eight level 2 studies were included. The mean QHES score was 87 of 100. The thematic focus of most studies (n = 13) was rotator cuff tears, with the main findings as follows: (1) magnetic resonance imaging is a cost-effective imaging strategy, (2) primary (arthroscopic) rotator cuff repair (RCR) with conversion to reverse total shoulder arthroplasty in case of failure is the most cost-effective strategy, (3) the platelet-rich plasma augmentation of RCR seems not to be cost-effective, and (4) the cost-effectiveness of double-row RCR remains unclear. Other studies included shoulder instability (n = 3), glenohumeral osteoarthritis (n = 3), proximal humeral fractures (n = 4), subacromial impingement (n = 4), and other shoulder conditions (n = 7). CONCLUSION Compared with prior studies, the quality of recently available studies has improved significantly. Current studies could help decision makers to appropriately and adequately allocate resources. The optimal use of financial resources will be of increasing importance to improve medical care for patients. However, further studies are still necessary.
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Affiliation(s)
- Thomas Tischer
- Department of Orthopaedic Surgery, University Medicine Rostock, Rostock, Germany
| | - Robert Lenz
- Department of Orthopaedic Surgery, University Medicine Rostock, Rostock, Germany
| | | | - Christoph Lutter
- Department of Orthopaedic Surgery, University Medicine Rostock, Rostock, Germany
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15
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Fox HM, Ramsey DC, Thompson AR, Hoekstra CJ, Mirarchi AJ, Nazir OF. Neer Type-II Distal Clavicle Fractures: A Cost-Effectiveness Analysis of Fixation Techniques. J Bone Joint Surg Am 2020; 102:254-261. [PMID: 31809393 DOI: 10.2106/jbjs.19.00590] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Neer type-II distal clavicle fractures are unstable and are generally appropriately managed with operative fixation. Fixation options include locking plates, hook plates, and suture button devices. No consensus on optimal technique exists. METHODS A decision tree model was created describing fixation of Neer type-II fractures using hook plates, locking plates, or suture buttons. Outcomes included uneventful healing, symptomatic implant removal, deep infection requiring debridement, and nonunion requiring revision. Weighted averages derived from a systematic review were used for probabilities. Cost-effectiveness was evaluated by calculating incremental cost-effectiveness ratios (ICERs). The ICER is defined as the ratio of the difference in cost and difference in effectiveness of each strategy, and is measured in cost per quality-adjusted life year (QALY). The model was evaluated using thresholds of $50,000/QALY and $100,000/QALY. Sensitivity analysis was performed on all outcome probabilities for each fixation strategy to assess cost-effectiveness across a range of values. RESULTS Forty-three papers met final inclusion criteria. Using suture buttons as the reference case in the health-care cost model, suture button repair was dominant (both less expensive and clinically superior). Hook plates cost substantially more ($5,360.52) compared with suture buttons and locking plates ($3,713.50 and $4,007.44, respectively). Suture buttons and locking plates yielded similar clinical outcomes (0.92 and 0.91 QALY, respectively). Suture button dominance persisted in the societal perspective model. Sensitivity analysis on outcome probabilities showed that locking plates became the most cost-effective strategy if the revision rate after their use was lowered to 2.2%, from the overall average in the sources of >19%. No other changes in outcome probabilities for any of the 3 techniques allowed suture buttons to be surpassed as the most cost-effective. CONCLUSIONS The cost-effectiveness of suture buttons is driven by low revision rates and high uneventful healing rates. Similar QALY values for locking plate and suture button fixation were observed, which is consistent with existing literature that has failed to identify either as the clinically superior technique. Cost-effectiveness should fit prominently into the decision-making rubric for these injuries. LEVEL OF EVIDENCE Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Henry M Fox
- Departments of Orthopaedics and Rehabilitation (H.M.F., D.C.R., A.R.T., A.J.M., and O.F.N.) and Medical Informatics and Clinical Epidemiology (C.J.H.), Oregon Health & Science University, Portland, Oregon
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CORR Insights®: 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; 478:403-405. [PMID: 32022765 PMCID: PMC7438136 DOI: 10.1097/corr.0000000000001092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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17
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Moverley R, Little N, Gulihar A, Singh B. Current concepts in the management of clavicle fractures. J Clin Orthop Trauma 2020; 11:S25-S30. [PMID: 31992912 PMCID: PMC6978197 DOI: 10.1016/j.jcot.2019.07.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/23/2019] [Accepted: 07/24/2019] [Indexed: 10/26/2022] Open
Abstract
Clavicle fractures comprise approximately 3% of all adult fractures and there is evidence that the incidence is increasing. Fractures of the lateral and middle third of the clavicle present distinct challenges in both surgical fixation techniques and clinical outcome, as such they should be recognised as separate clinical entities. Despite conflicting evidence, most studies indicate that superior clinical results are found in patients with united clavicle fractures rather than those that go onto non-union. Furthermore there is level-1 evidence that operative treatment of clavicle fractures leads to significantly increased rates of union. Despite these findings, significant controversy still exists on which patients would benefit from primary fixation and those who could successfully be managed non-operatively. We present an evidence-based review of clavicle fracture management including surgical indications, techniques, and results.
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Affiliation(s)
| | - Nick Little
- Epsom & St Helier Hospitals NHS Trust, London, UK
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18
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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. [PMID: 31574019 PMCID: PMC7438117 DOI: 10.1097/corr.0000000000000986] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Displaced mid-third clavicle fractures are common, and their management remains unclear. Although several meta-analyses have compared specific operative techniques with nonoperative management, it is not possible to compare different operative constructs with one another using a standard meta-analysis. Conversely, a network meta-analysis allows comparisons among more than two treatment arms, using both direct and indirect comparisons between interventions across many trials. To our knowledge, no network meta-analysis has been performed to compare the multiple treatment options for displaced clavicle fractures. QUESTIONS/PURPOSES We performed a network meta-analysis of randomized, controlled trials (RCTs) to determine from among the approaches used to treat displaced midshaft clavicle fractures: (1) the intervention with the highest chance of union at 1 year, (2) the intervention with the lowest risk of revision surgery, and (3) the intervention with the highest functional outcome scores. Secondarily, we also (4) compared the surgical subtypes in the available RCTs on the same above endpoints. METHODS MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were reviewed for relevant randomized controlled trials published up to July 25, 2018. Two hundred and eighty four papers were reviewed, with 22 meeting inclusion criteria of RCTs with appropriate randomization techniques, adult population, minimum of 1 year follow-up and including at least one operative treatment arm. In total, 1002 patients were treated with a plate construct, 378 with an intramedullary device, and 585 patients were managed nonoperatively. Treatment subtypes included locked intramedullary devices (56), unlocked intramedullary devices (322), anterior plating (89), anterosuperior plating (150), superior plating (449) or plating not otherwise specified (314). We performed a network meta-analysis to compare and rank the treatments for displaced clavicle fractures. We considered the following outcomes: union achievement, revision surgery risk and functional outcomes (DASH and Constant Scores). The minimal clinically important difference (MCID) was considered for both Constant and DASH scores to be at 8 points, representing the average of MCID scores reported for both DASH and Constant in the evidence, respectively. RESULTS Union achievement was lower in patients treated nonoperatively (88.9%), and higher in patients treated operatively (96.7%, relative risk [RR] 1.128 [95% CI 1.1 to 1.17]; p < 0.001), Number needed to treat (NNT) = 10). Union achievement increased with any plate construct (97.8%, RR 1.13 [95% CI 1.1 to 1.7]; p < 0.0001, NNT = 9) and with anterior or anterosuperior plates (99.3%, RR 1.14 [95% CI 1.1 to 1.8]; p < 0.0001, NNT = 8). Risk of reoperation, when considering planned removal of hardware, was similar across all treatment arms. Lastly, operative treatment outperformed nonoperative treatment with minor improvements in DASH and Constant scores, though not approaching the MCID. At the subtype level, anterosuperior plating ranked highest in DASH and Constant functional scores with mean differences reaching 10-point improvement for Constant scores (95% CI 4.4 to 2.5) and 7.6 point improvement for DASH (95% CI 5.2 to 20). CONCLUSIONS We found that surgical treatment led to a greater likelihood of union at 1 year of follow-up among adult patients with displaced mid-third clavicle fractures. In aggregate, surgical treatment did not increase functional scores by amounts that patients were likely to consider clinically important. Use of specific subtypes of plating (anterior, anterosuperior) resulted in improvements in the Constant score that were slightly above the MCID but did not reach the MCID for the DASH score, suggesting that any outcomes-score benefits favoring surgery were likely to be imperceptible or small. In light of these findings, we believe patients can be informed that surgery for this injury can increase the likelihood of union incrementally (about 10 patients would need to undergo surgery to avoid one nonunion), but they should not expect better function than they would achieve without surgery; most patients can avoid surgery altogether with little absolute risk of nonunion. Patients who opt for surgery must be told that the decision should be weighed against complications and the possibility of undergoing a second procedure for hardware removal. Patients opting not to have surgery for acute midshaft clavicle fractures can be told that nonunion occurs in slightly more than 10% of patients, and that these can be more difficult to manage than acute fractures. LEVEL OF EVIDENCE Level I, therapeutic study.
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Herteleer M, De Jaegere A, Winckelmans T, Casteur H, Nijs S, Hoekstra H. Healthcare utilization and related cost of midshaft clavicle fracture treatment in Belgium. Eur J Trauma Emerg Surg 2020; 47:1281-1287. [PMID: 31989209 DOI: 10.1007/s00068-020-01307-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 01/16/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The debate regarding the economic impact and cost effectiveness of surgical midshaft clavicle fracture treatment is ongoing. Variations exist between healthcare systems in terms of financing, provider payment mechanism and the role of the government in all of this. Therefore, the primary aim of our study was to describe the in-hospital-related healthcare costs associated with midshaft clavicle fracture treatment in Belgium. The secondary aim was to define those clinical variables that drive the costs related to surgically treated clavicle fractures and define strategies that could reduce these costs. PATIENTS AND METHODS A total of 345 patients with a midshaft clavicle fracture were included in the study. We selected 17 clinical variables and 5 cost categories were defined. Three multivariate linear models were built to determine which parameters drive the costs. RESULTS The median total healthcare cost for non-operatively treated patients was €367 and the median total cost for operatively treated patients was €3296. The length-of-stay was the most important variable that predicted the total cost. The clinical variables Number of fracture fragments, Delayed Stage Surgery, Revision Surgery and Infection most influenced the length-of-stay. DISCUSSION In conclusion, the initial healthcare utilization cost of operatively treated midshaft clavicle fractures is larger than that of non-operatively treated fractures. The length-of-stay is the most important parameter that drives the cost and is predominantly influenced by patients' age, fracture complexity and complications requiring a surgical re-intervention. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Michiel Herteleer
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium. .,KU Leuven, University of Leuven, Organ Systems, 3000, Louvain, Belgium.
| | - Anaïs De Jaegere
- KU Leuven, University of Leuven, Faculty of Medicine, 3000, Louvain, Belgium
| | - Thomas Winckelmans
- KU Leuven, University of Leuven, Faculty of Medicine, 3000, Louvain, Belgium
| | - Hans Casteur
- Imelda Ziekenhuis, Orthopedie, 2820, Bonheiden, Belgium
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, 3000, Louvain, Belgium
| | - Harm Hoekstra
- Department of Trauma Surgery, University Hospitals Leuven, Herestraat 49, 3000, Louvain, Belgium.,Department of Development and Regeneration, KU Leuven, University of Leuven, 3000, Louvain, Belgium
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Sørensen AKR, Hammeken LH, Qvist AH, Jensen SL, Ehlers LH. Operative treatment of displaced midshaft clavicular fractures is not cost-effective. J Shoulder Elbow Surg 2020; 29:27-35. [PMID: 31563507 DOI: 10.1016/j.jse.2019.07.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 07/04/2019] [Accepted: 07/08/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Conventional treatment of displaced midshaft clavicular fractures is nonoperative. Recent studies have implied that operative treatment might result in a faster return to work, resulting in a decreased productivity loss for society. The cost utility of plate fixation vs. nonoperative treatment of displaced midshaft clavicular fractures has not previously been investigated using a societal perspective. METHODS Decision analytical modeling of incremental costs and quality-adjusted life-years (QALYs) was performed. Data on utility, hospitalization, and productivity costs were retrieved from a Danish randomized controlled trial. Supplementary data were taken from randomized controlled trials identified in the literature. A 1-year time horizon was applied, and all prices were reported with respect to a 2016 level. RESULTS Operative treatment was associated with a larger QALY gain in patients and a higher cost compared with nonoperative treatment. The incremental cost-effectiveness ratio (ICER) was estimated in Danish currency (Danish krone [kr]) at kr1,360,000 (€182,306) per QALY from a health-sector perspective and kr1,388,738 (€186,158) per QALY from a societal perspective. Considering a subgroup analysis of patients with a high-load shoulder profession, operative treatment was dominated by nonoperative treatment from a health-sector perspective. Considering a societal perspective, the ICER was estimated at -kr889,091 (-€119,181) per reduction of 1 QALY. One-way and probabilistic sensitivity analyses showed that the results were subject to uncertainty. CONCLUSION Operative treatment is not cost-effective when considering a threshold of €34,000/QALY. However, for a subgroup of patients with a high-load shoulder profession, operative treatment might be cost-effective compared with nonoperative treatment.
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Affiliation(s)
- Anne-Kathrine R Sørensen
- Department of Business and Management, Danish Center for Healthcare Improvements, Aalborg University, Aalborg, Denmark.
| | - Lianna H Hammeken
- Department of Business and Management, Danish Center for Healthcare Improvements, Aalborg University, Aalborg, Denmark
| | - Andreas H Qvist
- Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Steen L Jensen
- Department of Orthopaedic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Lars H Ehlers
- Department of Business and Management, Danish Center for Healthcare Improvements, Aalborg University, Aalborg, Denmark
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Affiliation(s)
- Sally Kerr
- Department of Trauma and Orthopaedics, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - David Warwick
- Department of Orthopaedics, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Fares S Haddad
- The Bone & Joint Journal, University College London Hospitals, The Princess Grace Hospital, and The NIHR Biomedical Research Centre at UCLH, London, UK
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Schneider P, Bransford R, Harvey E, Agel J. Operative treatment of displaced midshaft clavicle fractures: has randomised control trial evidence changed practice patterns? BMJ Open 2019; 9:e031118. [PMID: 31488493 PMCID: PMC6731861 DOI: 10.1136/bmjopen-2019-031118] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To determine if level 1 evidence from a landmark trial changed practice patterns for treatment of patients with displaced midshaft clavicle fractures. DESIGN Retrospective cohort study. SETTING Two level 1 trauma centres. PARTICIPANTS Displaced midshaft clavicle fractures. RESULTS 686 patients met inclusion criteria. The pretrial cohort (n=108) was 68.5% male, with a mean age of 37.7 (±13.9) years. The post-trial cohort (n=578) was 76.1% male, with a mean age of 41.9 (±12.7) years. There was nearly a 10-fold increase in the patients treated with openreduction and internal fixation (ORIF) in the post-trial cohort (34.1%) compared with the pretrial cohort (3.7%) (p<0.001). Patients in the post-trial cohort were more likely to undergo ORIF if they were <40 years (OR=2.2; 95% CI 1.53 to 3.10), if their Injury Severity Score was >9 (OR=1.6; 95% CI 0.89 to 2.99) or if they were treated at a centre that participated in the Canadian Orthopaedic Trauma Society (COTS) trial (OR=5.2; 95% CI 3.31 to 8.21). CONCLUSIONS This study demonstrated a significant shift towards more frequent ORIF for displaced midshaft clavicle fractures following the COTS trial. Quantifying changes in practice pattern following publication of level 1 evidence is important to further our understanding of the impact large randomisedclinical trails are having on clinical practice.
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Affiliation(s)
- Prism Schneider
- Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | | | - Edward Harvey
- Orthopaedics, Montreal General Hospital, Montreal, Quebec, Canada
| | - Julie Agel
- Orthopaedics, Harborview Medical Center, Seattle, Washington, USA
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Marsalli M, Rojas JT, Barahona M. Acute Surgery vs. Non-union Surgery of Displaced Midshaft Clavicle Fractures: A Case-control Study. Cureus 2019; 11:e5480. [PMID: 31754593 PMCID: PMC6855902 DOI: 10.7759/cureus.5480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction There is a lack of information about the results of surgical treatment and complications in midshaft clavicle fracture non-unions. Our hypothesis was that there is no difference in functional outcomes between the surgical treatment of an acute displaced middle-third clavicle fracture and the surgical treatment of a chronic symptomatic non-union of a displaced middle-third clavicle fracture. Methods This was a case-control study. Fourteen cases were considered with a displaced midshaft clavicle fracture, initially treated non-surgically, but which developed symptomatic non-union and required surgical treatment. The control group was a cohort of 18 patients with a displaced midshaft clavicle fracture, who had surgical treatment in an acute setting (<3 weeks). Our cases had a median follow-up of 77 months and were retrospectively analyzed. All those in the control group had a 12-month prospective follow-up evaluation. The variables measured were Constant score, time to discharge to work, and bone union rate. Results The median Constant score at final follow-up for surgically treated non-unions was 87.5 (control group 84.5, p > 0.05). The median time to complete return to work was 3.2 months in the control group and 9.7 months in the case group (p=0.001). Hundred percent of those patients who were initially treated with surgery had bone union without other treatment. Two out of 14 cases required a second surgery with a plate and bone graft to achieve bone union. Conclusion Symptoms from displaced midshaft clavicular fracture non-unions are due to related pain and dysfunctional deficits that result from displacement and shortening. According to our study, patients with a displaced midshaft clavicle fracture non-union who needed surgery achieved similar functional results as compared to patients treated in an acute setting for a displaced midshaft clavicle fracture. The median time to discharge and return to work was more than doubled in the non-union surgery group.
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Affiliation(s)
- Michael Marsalli
- Orthopaedic Department, Clínica Universidad De Los Andes, Santiago, CHL
| | - José T Rojas
- Orthopaedic Department, Hospital San José, Santiago, CHL
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Nicholson JA, Clement N, Goudie EB, Robinson CM. Routine fixation of displaced midshaft clavicle fractures is not cost-effective: a cost analysis from a randomized controlled trial. Bone Joint J 2019; 101-B:995-1001. [PMID: 31362556 DOI: 10.1302/0301-620x.101b8.bjj-2018-1253.r2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIMS The primary aim of this study was to establish the cost-effectiveness of the early fixation of displaced midshaft clavicle fractures. PATIENTS AND METHODS A cost analysis was conducted within a randomized controlled trial comparing conservative management (n = 92) versus early plate fixation (n = 86) of displaced midshaft clavicular fractures. The incremental cost-effectiveness ratio (ICER) was used to express the cost per quality-adjusted life-year (QALY). The Six-Dimension Short-Form Health Survey (SF-6D) score was used as the preference-based health index to calculate the cost per QALY at 12 months after the injury. RESULTS The mean 12-month SF-6D was 0.9522 (95% confidence interval (CI) 0.9355 to 0.9689) following conservative management and 0.9607 (95% CI 0.9447 to 0.9767) following fixation, giving an advantage for fixation of 0.0085, which was not statistically significant (p = 0.46). The mean cost per patient was £1322.69 for conservative management and £5405.32 for early fixation. This gave an ICER of £480 309.41 per QALY. For a threshold of £20 000 per QALY, the benefit of fixation would need to be present for 24 years to be cost-effective compared with conservative treatment. Linear regression analysis identified nonunion as the only factor to adversely influence the SF-6D at 12 months (p < 0.001). CONCLUSION Routine plate fixation of displaced midshaft clavicular fractures is not cost-effective. Nonunion following conservative management has an increased morbidity with comparable expense to early fixation. This may suggest that a targeted approach of fixation in patients who are at higher risk of nonunion would be more cost-effective than the routine fixation of all displaced fractures. Cite this article: Bone Joint J 2019;101-B:995-1001.
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Affiliation(s)
- J A Nicholson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - N Clement
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - E B Goudie
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
| | - C M Robinson
- Department of Orthopaedic Surgery, University of Edinburgh, Edinburgh, UK
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Abstract
PURPOSE OF REVIEW Over the past ten years, there has been a change in the management of adolescent clavicle fractures. Utilizing data from the adult population, clinicians have become more aggressive in terms of surgical fixation. The purpose of this paper is to critically analyze the recent literature in regard to adolescent clavicle fractures, and to determine the role of open reduction and internal fixation. RECENT FINDINGS Although there have been many case series that demonstrate that open reduction and internal fixation can be done safely and with predictable healing, studies which compare operative versus non-operative intervention suggest there may not be functional outcome differences between the two treatment options. Further study is necessary to determine the specific indications for fixation of clavicle fractures in the adolescent population. Shared decision-making between patient, family, and clinicians is essential to determine the specific fracture patterns and patients who might benefit from fixation to improve functional outcome.
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Lenza M, Buchbinder R, Johnston RV, Ferrari BAS, Faloppa F. Surgical versus conservative interventions for treating fractures of the middle third of the clavicle. Cochrane Database Syst Rev 2019; 1:CD009363. [PMID: 30666620 PMCID: PMC6373576 DOI: 10.1002/14651858.cd009363.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Clavicle fractures are common, accounting for 2.6% to 4% of all fractures. Eighty per cent of clavicle fractures are located in the middle third of the clavicle. Although treatment of these fractures is usually non-surgical, displaced clavicle fractures may be considered for surgical treatment because of their greater risk of non-union. This is an update of a Cochrane Review first published in 2013. OBJECTIVES To assess the effects (benefits and harms) of surgical versus conservative interventions for treating middle third clavicle fractures. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Specialised Register, CENTRAL, MEDLINE, Embase, LILACS, trials registries and reference lists updated to December 2017. We did not apply any language or publication restrictions. SELECTION CRITERIA We considered randomised and quasi-randomised controlled trials evaluating surgical versus conservative interventions for treating fractures in the middle third of the clavicle. The primary outcomes were shoulder function or disability, pain and treatment failure, defined as the number of participants who had been given a non-routine secondary surgical intervention (excluding hardware removal), for symptomatic non-union, malunion or other complications. DATA COLLECTION AND ANALYSIS At least two review authors selected eligible studies, independently assessed risk of bias and cross-checked data. Where appropriate, we pooled results of comparable studies. MAIN RESULTS We included 14 studies involving 1469 participants with acute middle third clavicle fractures. All studies included adults, with the overall range from 17 to 70 years. Of the studies that reported gender, men were over-represented. Ten studies compared plate fixation with sling or figure-of-eight bandage, or both, and four studies compared intramedullary fixation with wearing either a sling or a figure-of-eight bandage. Almost all studies had design features that carry a high risk of bias, thus limiting the strength of their findings.Low-quality evidence from 10 studies (838 participants), showed that, compared with conservative treatment, surgical treatment of acute middle third clavicle fractures may not improve upper arm function at follow-up of one year or longer: standardised mean difference (SMD) 0.33, 95% confidence interval (CI) -0.02 to 0.67. We downgraded the quality of the evidence because of risk of bias and high statistical heterogeneity (I2 = 83%). This corresponds to a mean improvement of 2.3 points in favour of surgery (0.14 points worse to 4.69 points better), on the 100-point Constant score; this does not represent a clinically important difference. There may be no difference in pain measured using a visual analogue scale (0 to 100 mm; higher scores mean worse pain) between treatments (mean difference (MD) -0.60 mm, 95% CI -3.51 to 2.31; 277 participants, 3 studies; low-quality evidence reflecting risk of bias and imprecision). Surgery may reduce the risk of treatment failure, that is, number of participants who had non-routine secondary surgical intervention (excluding hardware removal), for symptomatic non-union, malunion or other complication (risk ratio (RR) 0.32, 95% CI 0.20 to 0.50; 1197 participants, 12 studies; low-quality evidence, downgraded for risk of bias and imprecision). The main source of treatment failure was mechanical failure (3.4%) in the surgery group and symptomatic non-union (11.6%) in the conservative-treatment group.We are uncertain whether surgery results in fewer people having one or more cosmetic problems, such as deformities, which were more common after conservative treatment, or hardware prominence or scarring, which only occurred in the surgery group (RR 0.55, 95% CI 0.31 to 0.98; 1130 participants, 11 studies; I2 = 63%; very low-quality evidence downgraded for risk of bias, imprecision and inconsistency). We are uncertain whether there is any difference between surgery and conservative treatment in the risk of incurring an adverse outcome that includes local infection, dehiscence, symptomatic malunion, discomfort leading to implant removal, skin and nerve problems: RR 1.34, 95% CI 0.68 to 2.64; 1317 participants, 14 studies; I2 = 72%; very low-quality evidence, downgraded for risk of bias, imprecision and inconsistency). Hardware removal for discomfort was a common adverse outcome in the surgery group (10.2%) while symptomatic malunion was more common in the conservative-treatment group (11.3% versus 1.2% in the surgery group). Infection occurred only in the surgery group (3.2%). There may be no between-group difference in quality of life at one year (SF-12 or SF-36 physical component scores: 0 to 100 scale, where 100 is the best score): MD 0.30 (95% CI -1.95 to 2.56, 321 participants, 2 studies; low-quality evidence downgraded for risk of bias and imprecision). AUTHORS' CONCLUSIONS There is low-quality evidence that surgical treatment has no additional benefits in terms of function, pain and quality of life compared with conservative treatment, but may result in fewer treatment failures overall. Very low-quality evidence means that we are very uncertain of the findings of a slightly better cosmetic result after surgery and of no difference between surgical and conservative treatment in the risk of adverse events. For both composite outcomes, there is a need to consider the balance of risks between the individual outcomes; for example, surgical adverse events, including wound infection or dehiscence and hardware irritation, against risk of adverse events that may be more commonly associated with conservative treatment such as symptomatic malunion and shoulder stiffness.Treatment options must be chosen on an individual patient basis, after careful consideration of the relative benefits and harms of each intervention and of patient preferences.
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Affiliation(s)
- Mário Lenza
- Faculdade Israelita de Ciencias da Saude Albert Einstein and Hospital Israelita Albert EinsteinOrthopaedic Department and School of MedicineAv. Albert Einstein, 627/701São PauloSão PauloBrazilCEP 05651‐901
| | - Rachelle Buchbinder
- Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical EpidemiologyMelbourneAustralia
| | - Renea V Johnston
- Cabrini Institute and Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash UniversityMonash Department of Clinical EpidemiologyMelbourneAustralia
| | - Bruno AS Ferrari
- Faculdade Israelita de Ciencias da Saude Albert Einstein and Hospital Israelita Albert EinsteinOrthopaedic Department and School of MedicineAv. Albert Einstein, 627/701São PauloSão PauloBrazilCEP 05651‐901
| | - Flávio Faloppa
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyRua Borges Lagoa, 783‐5th FloorSão PauloSão PauloBrazil04038‐032
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Liu J, Srivastava K, Washington T, Hoegler J, Guthrie ST, Hakeos W, Moutzouros V. Cost-Effectiveness of Operative Versus Nonoperative Treatment of Displaced Midshaft Clavicle Fractures: A Decision Analysis. J Bone Joint Surg Am 2019; 101:35-47. [PMID: 30601414 DOI: 10.2106/jbjs.17.00786] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND While previous studies have shown higher union rates and a quicker return to work with operative treatment of substantially displaced clavicle fractures, there is disagreement whether operative treatment results in improved clinical outcomes. Patients who undergo operative treatment sometimes require additional surgery for implant removal. Nonoperative treatment may fail so that delayed surgical intervention is ultimately required. The duration for which the clinical benefits of operative treatment remain superior to those of nonoperative treatment has not been well established in the literature. Considering these uncertainties, surgeons are faced with a difficult decision regarding whether operative treatment of a midshaft clavicle fracture will be cost-effective. The purpose of this study was to identify the most cost-effective strategy by considering these uncertain parameters with use of decision-analysis techniques. METHODS An expected-value decision tree was built to estimate the quality-adjusted life years (QALYs) and costs for operative and nonoperative treatment of substantially displaced midshaft clavicle fractures. Values for parameters in the decision model were derived from the literature. Medical costs were obtained from the Medicare database. A Markov model was used to calculate the QALYs for the duration of life expectancy. The decision model was used to analyze the duration for which the clinical results of operative treatment were superior to those of nonoperative treatment during the first 5 years after the operation and during a lifetime. Sensitivity analysis was performed to determine which parameters have the most influence on cost-effectiveness. RESULTS Operative treatment was more cost-effective than nonoperative treatment in 54% and 68% of the Monte Carlo trials in the 5-year and lifetime analyses, respectively. The cost per QALY with operative management was <$38,000 and <$8,000 in the 5-year and lifetime analyses, respectively. This is below the willingness-to-pay threshold of $50,000 per QALY. For operative treatment to remain cost-effective, its clinical benefits must persist for at least 3 years. CONCLUSIONS Operative treatment is more cost-effective than nonoperative treatment for substantially displaced midshaft clavicle fractures. The clinical benefits derived with operative treatment must persist for at least 3 years for operative treatment to remain cost-effective. This research should not be used to conclude that all clavicle fractures should be treated surgically. It is best that such a decision is made through a patient-surgeon shared decision-making process. LEVEL OF EVIDENCE Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jane Liu
- Department of Orthopedic Surgery, Henry Ford Health System, Detroit, Michigan
| | - Karan Srivastava
- Department of Orthopedic Surgery, Henry Ford Health System, Detroit, Michigan
| | - Travis Washington
- Department of Orthopedic Surgery, Henry Ford Health System, Detroit, Michigan
| | - Joseph Hoegler
- Department of Orthopedic Surgery, Henry Ford Health System, Detroit, Michigan
| | - S Trent Guthrie
- Department of Orthopedic Surgery, Henry Ford Health System, Detroit, Michigan
| | - William Hakeos
- Department of Orthopedic Surgery, Henry Ford Health System, Detroit, Michigan
| | - Vasilios Moutzouros
- Department of Orthopedic Surgery, Henry Ford Health System, Detroit, Michigan
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Rajan PV, Qudsi RA, Dyer GSM, Losina E. Cost-utility studies in upper limb orthopaedic surgery: a systematic review of published literature. Bone Joint J 2018; 100-B:1416-1423. [PMID: 30418054 PMCID: PMC6301026 DOI: 10.1302/0301-620x.100b11.bjj-2018-0246.r1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
AIMS The aim of this study was to assess the quality and scope of the current cost-effectiveness analysis (CEA) literature in the field of hand and upper limb orthopaedic surgery. MATERIALS AND METHODS We conducted a systematic review of MEDLINE and the CEA Registry to identify CEAs that were conducted on or after 1 January 1997, that studied a procedure pertaining to the field of hand and upper extremity surgery, that were clinical studies, and that reported outcomes in terms of quality-adjusted life-years. We identified a total of 33 studies that met our inclusion criteria. The quality of these studies was assessed using the Quality of Health Economic Analysis (QHES) scale. RESULTS The mean total QHES score was 82 (high-quality). Over time, a greater proportion of these studies have demonstrated poorer QHES quality (scores < 75). Lower-scoring studies demonstrated several deficits, including failures in identifying reference perspectives, incorporating comparators and sensitivity analyses, discounting costs and utilities, and disclosing funding. CONCLUSION It will be important to monitor the ongoing quality of CEA studies in orthopaedics and ensure standards of reporting and comparability in accordance with Second Panel recommendations. Cite this article: Bone Joint J 2018;100-B:1416-23.
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Affiliation(s)
- P V Rajan
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rameez A Qudsi
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - G S M Dyer
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - E Losina
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
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Napora JK, Grimberg DC, Childs BR, Vallier HA. Results and Outcomes After Midshaft Clavicle Fracture: Matched Pair Analysis of Operative Versus Nonoperative Management. Orthopedics 2018; 41:e689-e694. [PMID: 30052262 DOI: 10.3928/01477447-20180724-04] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 04/23/2018] [Indexed: 02/03/2023]
Abstract
This study evaluated patients with displaced clavicle fractures treated surgically vs nonoperatively. The authors hypothesized that functional outcomes would be no different. A retrospective comparative study was performed of 138 patients with closed midshaft clavicle fractures. Sixty-nine patients were treated operatively and matched for sex, age, and fracture pattern to 69 patients treated nonoperatively. Charts and radiographs were reviewed, and the American Shoulder and Elbow Surgeons survey was administered. A poor outcome was defined as a treatment complication or an American Shoulder and Elbow Surgeons score less than 60. There were 116 men and 22 women with a mean age of 37.7 years and fracture patterns of 15B-1 (n=78), 15B-2 (n=48), and 15B-3 (n=12). Thirty-seven percent were tobacco smokers, with 23 treated operatively and 28 nonoperatively. Ten (14.5%) initially nonoperative patients underwent plate fixation at a mean of 25.9 weeks (range, 7-48 weeks) because of persistent pain and motion at the fracture site. Fifteen (21.7%) of the 69 patients treated acutely with surgery had 16 complications, which resulted in secondary procedures in 11 patients (15.9%). Overall, poor outcomes occurred in 21 (30.4%) of 69 after fixation and in 19 (27.5%) of 69 in the nonoperative group. Unemployment (P=.05) and tobacco use (P=.03) were associated with poor outcome, irrespective of type of treatment. Initial nonoperative treatment presents a reasonable option for many patients. No differences in complications or poor outcomes were noted for surgical vs nonoperative treatment. Social factors proved to be greater predictors of outcome than other patient or injury features. Management of clavicle fractures should be individualized with assessment of patient expectations and activity level. Social factors should also be considered. [Orthopedics. 2018; 41(5):e689-e694.].
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Herteleer M, Hoekstra H, Nijs S. Diagnosis and treatment of clavicular fractures in Belgium between 2006 and 2015. J Shoulder Elbow Surg 2018. [PMID: 29519586 DOI: 10.1016/j.jse.2018.01.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Clavicular fractures are common fractures of the shoulder girdle. The debate about whether these fractures should be treated conservatively or surgically is ongoing. This study describes the incidence of clavicular fractures in Belgium between 2006 and 2015 and how the surgical treatment rates have evolved during this time span. METHODS The study included all patients who were diagnosed with a clavicular fracture or surgically treated in Belgium. The Belgian National Institute for Health and Disability Insurance provided the data, which included the patients' age, sex, location, and time of injury for the entire Belgian population. The fracture incidences and surgical treatment rates for different population groups were assessed. RESULTS The incidence of clavicular fractures in Belgium increased from 56.5/100,000 persons/year in 2006 to 70.6/100,000 persons/year in 2015. The age-related incidence was U-shaped, with high incidences seen in both men and women younger than 18 and older than 70. The rate of surgically treated clavicular fractures increased by 190% between 2006 and 2015. CONCLUSION The incidence of clavicular fractures in Belgium increased between 2006 and 2015. In the male population, the fracture incidence increased among all age groups, but in the female population, the increase was most noted in elderly patients. Although the preferred treatment strategy of clavicular fractures continues to be debated, there is a high and increasing rate of surgical treatment in Belgium, with an increasing percentage of patients that are surgically treated as outpatients.
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Affiliation(s)
- Michiel Herteleer
- Organ Systems, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Traumatology, Universitaire Ziekenhuizen Leuven, Leuven, Belgium.
| | - Harm Hoekstra
- Department of Traumatology, Universitaire Ziekenhuizen Leuven, Leuven, Belgium; Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Stefaan Nijs
- Department of Traumatology, Universitaire Ziekenhuizen Leuven, Leuven, Belgium; Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
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Abstract
Clavicle fractures are common fractures and the optimal treatment strategy remains debatable. The present paper reviews the available literature and current concepts in the management of displaced and/or shortened midshaft clavicle fractures. Operative treatment leads to improved short-term functional outcomes, increased patient satisfaction, an earlier return to sports and lower rates of non-union compared with conservative treatment. In terms of cost-effectiveness, operative treatment also seems to be advantageous. However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar. The optimal treatment strategy should be one tailor-made to the patient and his/her specific needs and expectations by utilizing a shared decision-making model.
Cite this article: EFORT Open Rev 2018;3:374-380. DOI: 10.1302/2058-5241.3.170033
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Affiliation(s)
- Paul Hoogervorst
- OLVG Amsterdam, Department of Orthopaedics and Traumatology, Amsterdam
| | - Peter van Schie
- OLVG Amsterdam, Department of Orthopaedics and Traumatology, Amsterdam
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Bhardwaj A, Sharma G, Patil A, Rahate V. Comparison of plate osteosynthesis versus non-operative management for mid-shaft clavicle fractures-A prospective study. Injury 2018; 49:1104-1107. [PMID: 29704955 DOI: 10.1016/j.injury.2018.04.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 04/07/2018] [Accepted: 04/15/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Treatment for mid-shaft clavicle fractures has recently seen a paradigm shift towards surgical management. The aim of the study was to compare clinical and functional outcome between plate osteosynthesis and conservative line of management in middle-third clavicle fractures. MATERIAL AND METHODS A prospective randomized study was conducted on 69 patients with closed displaced clavicle fractures between May 2014 and May 2016. Patients with medial or lateral third clavicle fractures, polytrauma and compound fractures were excluded from the study. Patients treated with plating were in group A (n = 36) while those treated with arm pouch were in group B (n = 33). RESULTS The mean age of the patient in group A was 32.4 ± 43 and group B was 31.7 ± 26 years. 48 (69.9%) females were involved in the study. History of fall was the most common mechanism of injury affecting 51 (73.9%) patients. All the patients were type 2 B as per the Robinson classification system. The average operative duration was 78.3 ± 12.4 min. Union was seen at 15.6 ± 0.8 in group A and 22.8 ± 0.4 in group B (p < 0.0001). Two (6%) of the patients in group B had non-union. One (2.7%) patient in group A had mal-union. Two (5.5%) patients had plate prominence. One (2.7%) patient had superficial infection. The Constant and Murley scoring at 24 months was 89.42 and 76.24 in group A and group B respectively. CONCLUSION Plating for displaced mid-shaft clavicle fractures is can lead to better functional and radiological outcomes with minimal complications as compared to the conservative modality of treatment.
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Affiliation(s)
| | - Gaurav Sharma
- Department of Orthopaedics, Prakash Institue of Medical Sciences, Islampu-Sangle Road, Tal- Walwa, Sangli, Uran, Islampur, 415409, Maharsahtra, India.
| | - Ashok Patil
- Department of Orthopaedics, Prakash Institue of Medical Sciences, Islampu-Sangle Road, Tal- Walwa, Sangli, Uran, Islampur, 415409, Maharsahtra, India
| | - Vaijnath Rahate
- Department of Orthopaedics, Prakash Institue of Medical Sciences, Islampu-Sangle Road, Tal- Walwa, Sangli, Uran, Islampur, 415409, Maharsahtra, India
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Coyle S, Kinsella S, Lenehan B, Queally JM. Cost-utility analysis in orthopaedic trauma; what pays? A systematic review. Injury 2018; 49:575-584. [PMID: 29428222 DOI: 10.1016/j.injury.2018.01.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 10/31/2017] [Accepted: 01/17/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND As healthcare systems come under ever-increasing pressure to provide more care with fewer resources, emphasis is being placed on value-based systems that maximise quality and minimize cost. The aim of this study was to determine which interventions in fracture care have been demonstrated to be cost effective. METHODS A systemic review of cost-utility studies on the management of fractures from 1976 to 2015 was carried out using a search of the Cost-Effectiveness Analysis Registry, National Health Service Economic Evaluation Database (NHS EED) and MEDLINE. RESULTS 20 studies were included with 15 (75%) studies assessing interventions in lower limb trauma and 8 (25%) studies assessing interventions in upper limb trauma. 50% of studies used a decision tree model and 50% used collected data alongside a randomised clinical trial. Interventions which were shown to be cost effective in lower limb trauma were total hip replacement in displaced femoral neck fractures, the SHS in stable (A1 and A2) fractures and IM nailing for unstable (A3) fractures, salvage treatment for grade IIIB and IIIC open tibial fractures and operative treatment of ankle and calcaneal fractures. For systems-based strategies, there is evidence demonstrating cost effectiveness to treating hip fractures in high volume centres and to having resources in place to facilitate fractures being treated within 48 h of injury. In upper limb trauma there was evidence showing operative treatment of displaced proximal humerus fractures to be neither clinically nor cost effective. There was evidence supporting the operative treatment of non-displaced scaphoid fractures. Overall the quality of the studies was poor with only 50% (10) of studies able to make a treatment recommendation. Reasons for this included poor quality primary source data and poor reporting methodological practices. CONCLUSION Certain aspects of fracture management have been shown to be cost effective. However, there is a paucity of evidence in this area and further research is required so that value-based interventions are chosen by healthcare providers engaged in orthopaedic trauma care.
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Affiliation(s)
- S Coyle
- Department of Orthopaedic Surgery, University Hospital Limerick, Limerick, Ireland
| | - S Kinsella
- Kemmy Business School, University of Limerick, Limerick, Ireland; School of Government, University of Melbourne, Australia
| | - B Lenehan
- Department of Orthopaedic Surgery, University Hospital Limerick, Limerick, Ireland
| | - J M Queally
- Department of Orthopaedic Surgey, Addenbrooke's Hospital, Cambridge, UK.
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Waldmann S, Benninger E, Meier C. Nonoperative Treatment of Midshaft Clavicle Fractures in Adults. Open Orthop J 2018; 12:1-6. [PMID: 29430265 PMCID: PMC5791205 DOI: 10.2174/1874325001812010001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 12/24/2017] [Accepted: 12/29/2017] [Indexed: 01/07/2023] Open
Abstract
Clavicle fractures are among the most common skeletal injuries accounting for 2-5% of all adult fractures. Historically, nonoperative treatment of midshaft clavicular fractures was considered the gold standard of care. Furthermore, nonoperative treatment has been challenged by an increasing popularity and rate of surgical fixations in recent years despite a lack of clear evidence in the current literature. Most fractures are suitable for conservative treatment. There is solid evidence in favour of nonoperative treatment for fractures with a displacement of less than 2cm and remaining contact of the bone fragments. Clear indications for conservative treatment versus surgical fixation of displaced midshaft fractures have not finally been established yet, leaving some questions and problems unanswered. Furthermore, there are no evidence-based recommendations concerning the kind and duration of shoulder immobilisation with no clear advantage for any treatment modality.
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Affiliation(s)
- Sören Waldmann
- Clinic for Orthopaedics and Traumatology, Department of Surgery, Kantonsspital Winterthur, Brauerstrasse 15, CH-8401, Winterthur, Basel, Switzerland
| | - Emanuel Benninger
- Clinic for Orthopaedics and Traumatology, Department of Surgery, Kantonsspital Winterthur, Brauerstrasse 15, CH-8401, Winterthur, Basel, Switzerland
| | - Christoph Meier
- Clinic for Orthopaedics and Traumatology, Department of Surgery, Kantonsspital Winterthur, Brauerstrasse 15, CH-8401, Winterthur, Basel, Switzerland
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Anterior-Inferior Plating Results in Fewer Secondary Interventions Compared to Superior Plating for Acute Displaced Midshaft Clavicle Fractures. J Orthop Trauma 2017; 31:468-471. [PMID: 28548997 DOI: 10.1097/bot.0000000000000856] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine whether a difference in plate position for fixation of acute, displaced, midshaft clavicle fractures would affect the rate of secondary intervention. DESIGN Retrospective Comparative Study. SETTING Two academic Level 1 Regional Trauma Centers. PATIENTS Five hundred ten patients treated surgically for an acutely displaced midshaft clavicle fracture between 2000 and 2013 were identified and reviewed retrospectively at a minimum of 24 months follow-up (F/U). Fractures were divided into 2 cohorts, according to plate position: Anterior-Inferior (AI) or Superior (S). Exclusion criteria included age <16 years, incomplete data records, and loss to F/U. Group analysis included demographics (age, sex, body mass index), fracture characteristics (mechanism of injury, open or closed), hand dominance, ipsilateral injuries, time between injury to surgery, time to radiographic union, length of F/U, and frequency of secondary procedures. INTERVENTION Patients were treated either with AI or S clavicle plating at the treating surgeon's discretion. MAIN OUTCOME MEASURES Rate and reason for secondary intervention. STATISTICAL ANALYSIS Fisher exact test, t test. and odds ratio were used for statistical analysis. RESULTS Final analysis included 252 fractures/251 patients. One hundred eighteen (47%) were in group AI; 134 (53%) were in group S. No differences in demographics, fracture characteristics, time to surgery, time to union, or length of F/U existed between groups. Seven patients/7 fractures (5.9%) in Group AI underwent a secondary surgery whereas 30 patients/30 fractures (22.3%) in group S required a secondary surgery. An additional intervention secondary to superior plate placement was highly statistically significant (P < 0.001). Furthermore, because 80% of these subsequent interventions were a result of plate irritation with patient discomfort, the odds ratio for a second procedure was 5 times greater in those fractures treated with a superior plate. CONCLUSIONS This comparative analysis indicates that AI plating of midshaft clavicle fractures seems to lessen clinical irritation and results in significantly fewer secondary interventions. Considering patient satisfaction and a reduced financial burden to the health care system, we recommend routine AI plate application when open reduction internal fixation of the clavicle is indicated. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Ahrens PM, Garlick NI, Barber J, Tims EM. The Clavicle Trial: A Multicenter Randomized Controlled Trial Comparing Operative with Nonoperative Treatment of Displaced Midshaft Clavicle Fractures. J Bone Joint Surg Am 2017; 99:1345-1354. [PMID: 28816894 DOI: 10.2106/jbjs.16.01112] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The treatment of displaced midshaft clavicle fractures remains controversial. METHODS We undertook a multicenter randomized controlled trial to compare effectiveness and safety between nonoperative management and ORIF (open reduction and internal fixation) for displaced midshaft clavicle fractures in adults. Three hundred and one eligible adult patients were randomized to 1 of the 2 treatment groups and followed at 6 weeks, 3 months, and 9 months after recruitment. The primary outcome was the rate of radiographically evident nonunion at 3 months following treatment. Secondary outcomes were the rate of radiographically evident nonunion at 9 months, limb function measured using the Constant-Murley Score and DASH (Disabilities of the Arm, Shoulder and Hand) score, and patient satisfaction. RESULTS There was no difference in the proportion of patients with radiographic evidence of nonunion at 3 months between the operative (28%) and nonoperative (27%) groups, whereas at 9 months the proportion with nonunion was significantly lower (p < 0.001) in the operative group (0.8%) than in the nonoperative group (11%). The DASH and Constant-Murley scores and patient satisfaction were all significantly better in the operative group than in the nonoperative group at 6 weeks and 3 months. CONCLUSIONS Although at 3 months there was no evidence that surgery had reduced the rate of nonunion of displaced midshaft clavicle fractures, at 9 months nonoperative treatment had led to a significantly higher nonunion rate (11% compared with <1%). The rate of secondary surgical intervention during the trial period was 12 (11%) of the 147 patients in the nonoperative group. ORIF is a safe and reliable intervention with superior early functional outcomes and should be considered for patients who sustain this common injury. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Philip M Ahrens
- 1Department of Trauma and Orthopaedics, Royal Free Hampstead NHS Foundation Trust, London, United Kingdom 2Department of Statistical Science, University College London, London, United Kingdom
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Tamaoki MJS, Matsunaga FT, Costa ARFD, Netto NA, Matsumoto MH, Belloti JC. Treatment of Displaced Midshaft Clavicle Fractures: Figure-of-Eight Harness Versus Anterior Plate Osteosynthesis: A Randomized Controlled Trial. J Bone Joint Surg Am 2017; 99:1159-1165. [PMID: 28719554 DOI: 10.2106/jbjs.16.01184] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Most midshaft clavicle fractures affect the economically active population, which is negatively impacted by transient limb impairment during the treatment. There is still debate about the advantages and disadvantages of surgical treatment for these fractures. METHODS In this prospective randomized controlled trial, 117 patients were allocated to 1 of 2 groups: nonsurgical treatment with a figure-of-eight harness or surgical treatment with anteroinferior plate osteosynthesis. The primary outcome was upper-limb limitation measured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire at 6 months. Other outcomes included pain, radiographic findings, satisfaction with the cosmetic result, complications, and time to return to previous work and activities. Participants were assessed at 6 weeks, 6 months, and 1 year after the intervention. RESULTS No difference between the 2 groups was detected in the DASH score at any time point (p = 0.398, 0.403, and 0.877 at 6 weeks, 6 months, and 1 year, respectively), pain levels measured with a visual analogue scale (VAS), time to return to previous activities, or dissatisfaction with the cosmetic result. Seven patients (14.9%) developed nonunion after nonsurgical treatment, a nonunion rate that was significantly higher than that in the surgical group, in which all fractures had healed (p = 0.004). The patients in the nonsurgical group had radiographic evidence of greater clavicle shortening (p < 0.001) and more of the patients in that group answered "yes" when asked if their clavicle felt short (p < 0.001) and if they felt bone prominence (p < 0.001). More patients answered "yes" when asked if they felt paresthesia in the surgical group (7; 13.7%) than in the nonsurgical group (1; 2.1%) (p = 0.036). CONCLUSIONS This study did not demonstrate a difference in limb function between patients who underwent surgical treatment and those nonsurgically treated for a dislocated midshaft clavicle fracture. Meanwhile, surgical treatment decreased the likelihood of nonunion. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Marcel Jun Sugawara Tamaoki
- 1Department of Orthopedics and Traumatology, Universidade Federal de São Paulo-Escola Paulista de Medicina (Unifesp-EPM), São Paulo, Brazil
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Smeeing DPJ, van der Ven DJC, Hietbrink F, Timmers TK, van Heijl M, Kruyt MC, Groenwold RHH, van der Meijden OAJ, Houwert RM. Surgical Versus Nonsurgical Treatment for Midshaft Clavicle Fractures in Patients Aged 16 Years and Older: A Systematic Review, Meta-analysis, and Comparison of Randomized Controlled Trials and Observational Studies. Am J Sports Med 2017; 45:1937-1945. [PMID: 27864184 DOI: 10.1177/0363546516673615] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is no consensus on the choice of treatment of midshaft clavicle fractures (MCFs). PURPOSE The aims of this systematic review and meta-analysis were (1) to compare fracture healing disorders and functional outcomes of surgical versus nonsurgical treatment of MCFs and (2) to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies. STUDY DESIGN Systematic review and meta-analysis. METHODS The PubMed/MEDLINE, Embase, CENTRAL, and CINAHL databases were searched for both RCTs and observational studies. Using the MINORS instrument, all included studies were assessed on their methodological quality. The primary outcome was a nonunion. Effects of surgical versus nonsurgical treatment were estimated using random-effects meta-analysis models. RESULTS A total of 20 studies were included, of which 8 were RCTs and 12 were observational studies including 1760 patients. Results were similar across the different study designs. A meta-analysis of 19 studies revealed that nonunions were significantly less common after surgical treatment than after nonsurgical treatment (odds ratio [OR], 0.18 [95% CI, 0.10-0.33]). The risk of malunions did not differ between surgical and nonsurgical treatment (OR, 0.38 [95% CI, 0.12-1.19]). Both the long-term Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley scores favored surgical treatment (DASH: mean difference [MD], -2.04 [95% CI, -3.56 to -0.52]; Constant-Murley: MD, 3.23 [95% CI, 1.52 to 4.95]). No differences were observed regarding revision surgery (OR, 0.85 [95% CI, 0.42-1.73]). Including only high-quality studies, both the number of malunions and days to return to work show significant differences in favor of surgical treatment (malunions: OR, 0.26 [95% CI, 0.07 to 0.92]; return to work: MD, -8.64 [95% CI, -16.22 to -1.05]). CONCLUSION This meta-analysis of high-quality studies showed that surgical treatment of MCFs results in fewer nonunions, fewer malunions, and an accelerated return to work compared with nonsurgical treatment. A meta-analysis of surgical treatments need not be restricted to randomized trials, provided that the included observational studies are of high quality.
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Affiliation(s)
- Diederik P J Smeeing
- Utrecht Traumacenter, Utrecht, the Netherlands.,Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Tim K Timmers
- Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
| | - Mark van Heijl
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - Moyo C Kruyt
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rolf H H Groenwold
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Roderick M Houwert
- Utrecht Traumacenter, Utrecht, the Netherlands.,Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands
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Lerman DM, Cable MG, Thornley P, Evaniew N, Slobogean GP, Bhandari M, Healey JH, Randall RL, Ghert M. Has the Level of Evidence of Podium Presentations at the Musculoskeletal Tumor Society Annual Meeting Changed Over Time? Clin Orthop Relat Res 2017; 475:853-860. [PMID: 26920571 PMCID: PMC5289162 DOI: 10.1007/s11999-016-4763-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Level of evidence (LOE) framework is a tool with which to categorize clinical studies based on their likelihood to be influenced by bias. Improvements in LOE have been demonstrated throughout orthopaedics, prompting our evaluation of orthopaedic oncology research LOE to determine if it has changed in kind. QUESTIONS/PURPOSES (1) Has the LOE presented at the Musculoskeletal Tumor Society (MSTS) annual meeting improved over time? (2) Over the past decade, how do the MSTS and Orthopaedic Trauma Association (OTA) annual meetings compare regarding LOE overall and for the subset of therapeutic studies? METHODS We reviewed abstracts from MSTS and OTA annual meeting podium presentations from 2005 to 2014. Three independent reviewers evaluated a total of 1222 abstracts for study type and LOE; there were 577 abstracts from MSTS and 645 from OTA. Changes in the distributions of study type and LOE over time were evaluated by Pearson chi-square test. RESULTS There was no change over time in MSTS LOE for all study types (p = 0.13) and therapeutic (p = 0.36) study types during the reviewed decade. In contrast, OTA LOE increased over this time for all study types (p < 0.01). The proportion of Level I therapeutic studies was higher at the OTA than the MSTS (3% [14 of 413] versus 0.5% [two of 387], respectively), whereas the proportion of Level IV studies was lower at the OTA than the MSTS (32% [134 of 413] versus 75% [292 of 387], respectively) during the reviewed decade. The proportion of controlled therapeutic studies (LOE I through III) versus uncontrolled studies (LOE IV) increased over time at OTA (p < 0.021), but not at MSTS (p = 0.10). CONCLUSIONS Uncontrolled case series continue to dominate the MSTS scientific program, limiting progress in evidence-based clinical care. Techniques used by the OTA to improve LOE may be emulated by the MSTS. These techniques focus on broad participation in multicenter collaborations that are designed in a comprehensive manner and answer a pragmatic clinical question.
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Affiliation(s)
- Daniel M Lerman
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Matthew G Cable
- Sarcoma Services, Primary Children's Hospital & Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
- Faculty of Health Sciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Patrick Thornley
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, HHS Hamilton General Hospital, 711 Concession Street Hamilton, Hamilton, ON, L8V 1C3, Canada
| | - Nathan Evaniew
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, HHS Hamilton General Hospital, 711 Concession Street Hamilton, Hamilton, ON, L8V 1C3, Canada
| | - Gerard P Slobogean
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, HHS Hamilton General Hospital, 711 Concession Street Hamilton, Hamilton, ON, L8V 1C3, Canada
| | - John H Healey
- Orthopaedic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - R Lor Randall
- Sarcoma Services, Primary Children's Hospital & Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
- Faculty of Health Sciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Michelle Ghert
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, HHS Hamilton General Hospital, 711 Concession Street Hamilton, Hamilton, ON, L8V 1C3, Canada.
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Clavicle Fractures are Associated With Arthritis of the Glenohumeral Joint in a Large Osteological Collection. J Orthop Trauma 2016; 30:605-611. [PMID: 27525633 DOI: 10.1097/bot.0000000000000654] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Recent data has challenged the historical precedent of nonoperative care for many clavicle fractures; clinical and biomechanical studies have shown altered joint-contact forces occur in the glenohumeral joint (GHJ) after fracture and shortening of the clavicle. However, to date, there have been no analyses documenting the long-term effects of these altered shoulder girdle mechanics on the GHJ. METHODS The clavicles of 2899 cadaveric skeletons were manually inspected for evidence of fracture. Shortening, fracture location, and laterality were recorded along with demographic information. Degenerative joint disease of the GHJ was graded. Correlations between the presence of a clavicle fracture and ipsilateral GHJ osteoarthritis were evaluated with multiple regression analysis using an age-, gender-, race-, and laterality-matched control group of 1154 GHJs. RESULTS One hundred three specimens had 104 clavicle fractures, a prevalence of 3.6% (103/2899) in this collection. There was a strong correlation between the presence of an ipsilateral clavicle fracture (standardized beta 0.108, P < 0.001), age (standardized beta 0.332, P < 0.001), male gender (standardized beta -0.069, P = 0.009), and laterality (right sided, standardized beta 0.056, P = 0.032) on the development of GHJ arthritis. There was a trend toward increased GHJ arthritis in specimens with shortening >20 mm (standardized beta 0.156, P = 0.109), although this subanalysis may have been underpowered. CONCLUSIONS This is the first study to report long-term consequences of clavicle fracture on the development of ipsilateral GHJ osteoarthritis; clavicle fractures were shown to have a higher degree of GHJ osteoarthritis. Future clinical studies are needed to confirm these relationships.
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Abstract
INTRODUCTION This study evaluated the effects that patient demographics, injury, and social characteristics have on functional outcomes after clavicle fracture. METHODS After a mean follow-up of 56 months, 214 patients with a mean age of 44.4 years completed the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form. The effects that age, sex, fracture location, open fracture, associated injuries, tobacco use, employment status, and timing of surgery had on functional outcomes were assessed. RESULTS The mean ASES score for the entire group of 214 patients was 80.5. Seventy-seven patients (36%) were treated surgically and 137 patients (64%) were treated nonsurgically. The mean ASES scores were 84.0 and 78.5, respectively, in the surgical and nonsurgical groups (P = 0.06). Patients with lateral fractures who were treated surgically had better ASES scores than those treated nonsurgically (91.3 versus 72.7, P = 0.011); this was also true of patients with isolated fractures (P = 0.02). Smokers in the surgical and nonsurgical groups had scores of 74.1 and 83.6, respectively (P = 0.003). Patients who were unemployed had the worst ASES scores regardless of surgical or nonsurgical treatment (70.5 and 86.1, respectively; P < 0.001). Surgical timing was not related to outcome; no difference in ASES scores was noted in patients treated surgically within ≤10 weeks versus those treated after 10 weeks after injury and in those treated within <20 weeks versus those treated >20 weeks after injury (both, P > 0.34). DISCUSSION We identified factors associated with better functional outcomes, which could aid in developing treatment recommendations. Additionally, initial nonsurgical management of clavicle fractures may be reasonable because patients had similar functional outcomes even when surgery was delayed. LEVEL OF EVIDENCE Level III retrospective comparative study.
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Weinberg DS, Napora JK, West WH, Grimberg DC, Vallier HA. Factors Associated With Narcotic Use After Clavicle Fractures. Orthopedics 2016; 39:e917-23. [PMID: 27359278 DOI: 10.3928/01477447-20160623-06] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 04/20/2016] [Indexed: 02/03/2023]
Abstract
Clavicle fractures are common in adults. Recent studies have shown that operative treatment of clavicle fractures has benefits in many situations. However, there is controversy about the indications. Data on social outcomes are limited. A total of 434 patients with 436 clavicle fractures treated both operatively and nonoperatively at a level 1 trauma center were identified. Narcotic use was recorded 2, 4, 6, 8, 10, 12, 14, and 16 weeks after injury for both treatment groups. Other descriptive data included age, sex, laterality, hand dominance, rib fractures, smoking, alcohol use, employment, long bone or spine fracture, open clavicle fracture, and mechanism of injury. Logistic regression analysis was performed to determine the independent predictors of narcotic use after clavicle fracture. Open reduction and internal fixation was performed in 105 fractures (24%), and 329 fractures were managed nonoperatively. A total of 154 patients (35%) reported some narcotic use 2 weeks after injury, and 15% were still using narcotics 16 weeks after injury. Narcotic use decreased over time in patients treated with open reduction and internal fixation (10% vs 15% after nonoperative management). Patients treated with open reduction and internal fixation reported reduced narcotic use at 16 weeks (odds ratio [OR], 0.454; P=.070). Concurrent rib fracture (OR, 5.668; P<.001), smoking (OR, 3.095; P=.013), unemployment (OR, 5.429; P<.0005), and long bone or spine fracture (OR, 6.761; P<.001) were predictors of narcotic use. Further studies of the social, economic, and financial outcomes of clavicle fracture and osteosynthesis are warranted. [Orthopedics. 2016; 39(5):e917-e923.].
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Hanselman AE, Murphy TR, Bal GK, McDonough EB. Operative Cost Comparison: Plating Versus Intramedullary Fixation for Clavicle Fractures. Orthopedics 2016; 39:e877-82. [PMID: 27220116 DOI: 10.3928/01477447-20160517-04] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 04/11/2016] [Indexed: 02/03/2023]
Abstract
Although clavicle fractures often heal well with nonoperative management, current literature has shown improved outcomes with operative intervention for specific fracture patterns in specific patient types. The 2 most common methods of midshaft clavicle fracture fixation are intramedullary and plate devices. Through retrospective analysis, this study performed a direct cost comparison of these 2 types of fixation at a single institution over a 5-year period. Outcome measures included operative costs for initial surgery and any hardware removal surgeries. This study reviewed 154 patients (157 fractures), and of these, 99 had intramedullary fixation and 58 had plate fixation. A total of 80% (79 of 99) of intramedullary devices and 3% (2 of 58) of plates were removed. Average cost for initial intramedullary placement was $2955 (US dollars) less than that for initial plate placement (P<.001); average cost for removal was $1874 less than that for plate removal surgery (P=.2). Average total cost for all intramedullary surgeries was $1392 less than the average cost for all plating surgeries (P<.001). Average cost for all intramedullary surgeries requiring plate placement and removal was $653 less than the average cost for all plating surgeries that involved only placement (P=.04). Intramedullary fixation of clavicle fractures resulted in a statistically significant cost reduction compared with plate fixation, despite the incidence of more frequent removal surgeries. [Orthopedics.2016; 39(5):e877-e882.].
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Bond MC, Brown JV, Shaheen SP, Abraham MK. The Orthopedic Literature 2015. Am J Emerg Med 2016; 34:1663-7. [DOI: 10.1016/j.ajem.2016.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 05/13/2016] [Accepted: 05/14/2016] [Indexed: 10/21/2022] Open
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Patient factors influencing return to work and cumulative financial claims after clavicle fractures in workers' compensation cases. J Shoulder Elbow Surg 2016; 25:1115-21. [PMID: 27066964 DOI: 10.1016/j.jse.2016.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 01/25/2016] [Accepted: 02/12/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study analyzed workers' compensation patients after surgical or nonoperative treatment of clavicle fractures to identify factors that influence the time for return to work and total health care reimbursement claims. We hypothesized that return to work for operative patients would be faster. METHODS The International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes and Current Procedural Terminology codes were used to retrospectively query the Workers' Compensation national database. The outcomes of interest were the number of days for return to full work after surgery and total reimbursement for health care-related claims. The primary independent variable was treatment modality. RESULTS There were 169 claims for clavicle fractures within the database (surgical, n = 34; nonoperative, n = 135). The average health care claims reimbursed were $29,136 ± $26,998 for surgical management compared with $8366 ± $14,758 for nonoperative management (P < .001). We did not find a statistically significant difference between surgical (196 ± 287 days) and nonoperative (69 ± 94 days) treatment groups in their time to return to work (P = .06); however, there was high variability in both groups. Litigation was an independent predictor of prolonged return to work (P = .007) and higher health care costs (P = .003). CONCLUSION Workers' compensation patients treated for clavicle fractures return to work at roughly the same time whether they are treated surgically or nonoperatively, with surgery being roughly 3 times more expensive. There was a substantial amount of variability in return to work timing by subjects in both groups. Litigation was a predictor of longer return to work timing and higher health care costs.
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The Cost Effectiveness of Polyetheretheketone (PEEK) Cages for Anterior Cervical Discectomy and Fusion. ACTA ACUST UNITED AC 2016; 28:E482-92. [PMID: 24662283 DOI: 10.1097/bsd.0b013e3182aa3676] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Cost-effectiveness analysis using a Markov model with inputs from published literature. OBJECTIVE To learn which graft or hardware option used in a single-level anterior cervical discectomy and fusion (ACDF) is most beneficial in terms of cost, quality of life, and overall cost effectiveness. Options studied were autograft, allograft, and polyetheretherketone (PEEK) cages for cervical fusion. SUMMARY OF BACKGROUND DATA ACDF is commonly used to treat cervical myelopathy and/or radiculopathy. No study has compared the cost effectiveness of autograft, allograft, and PEEK in 1-level ACDF. MATERIALS AND METHODS A literature review provided inputs into a Markov decision model to determine the most effective graft or hardware option for 1-level ACDF. Data regarding rate of complications, quality-adjusted life years (QALYs) gained, and cost for each procedure type was collected. The Markov model was first run in a base case, using all currently available data. The model was then tested using 1-way and 2-way sensitivity analyses to determine the validity of the model's conclusions if specific aspects of model were changed. This model was run for 10 years postoperatively. RESULTS The cost per QALY for each option in the base case analysis was $3328/QALY for PEEK, $2492/QALY for autograft, and $2492/QALY for allograft. All graft/hardware options are cost effective ways to improve outcomes for patients living with chronic neck pain. For graft/hardware options the most cost-effective option was allograft. The incremental cost-effectiveness ratio for PEEK compared with autograft or allograft was >$100,000/QALY. CONCLUSIONS Allograft is the most cost-effective graft/hardware option for ACDF. Compared with living with cervical myelopathy and/or radiculopathy, ACDF using any graft or hardware option is a cost-effective method of improving the quality of life of patients. PEEK is not a cost-effective option compared with allograft or autograft for use in ACDF.
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Nwachukwu BU, Schairer WW, O'Dea E, McCormick F, Lane JM. The Quality of Cost-Utility Analyses in Orthopedic Trauma. Orthopedics 2015; 38:e673-80. [PMID: 26270752 DOI: 10.3928/01477447-20150804-53] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 10/23/2014] [Indexed: 02/03/2023]
Abstract
As health care in the United States transitions toward a value-based model, there is increasing interest in applying cost-effectiveness analysis within orthopedic surgery. Orthopedic trauma care has traditionally underemphasized economic analysis. The goals of this review were to identify US-based cost-utility analysis in orthopedic trauma, to assess the quality of the available evidence, and to identify cost-effective strategies within orthopedic trauma. Based on a review of 971 abstracts, 8 US-based cost-utility analyses evaluating operative strategies in orthopedic trauma were identified. Study findings were recorded, and the Quality of Health Economic Studies (QHES) instrument was used to grade the overall quality. Of the 8 studies included in this review, 4 studies evaluated hip and femur fractures, 3 studies analyzed upper extremity fractures, and 1 study assessed open tibial fracture management. Cost-effective interventions identified in this review include total hip arthroplasty (over hemiarthroplasty) for femoral neck fractures in the active elderly, open reduction and internal fixation (over nonoperative management) for distal radius and scaphoid fractures, limb salvage (over amputation) for complex open tibial fractures, and systems-based interventions to prevent delay in hip fracture surgery. The mean QHES score of the studies was 79.25 (range, 67-89). Overall, there is a paucity of cost-utility analyses in orthopedic trauma; however, the available evidence suggests that certain operative interventions can be cost-effective. The quality of these studies, however, is fair, based on QHES grading. More attention should be paid to evaluating the cost-effectiveness of operative intervention in orthopedic trauma.
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Zhao JG, Wang J, Long L. Surgical Versus Conservative Treatments for Displaced Midshaft Clavicular Fractures: A Systematic Review of Overlapping Meta-Analyses. Medicine (Baltimore) 2015; 94:e1057. [PMID: 26131821 PMCID: PMC4504624 DOI: 10.1097/md.0000000000001057] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Multiple meta-analyses have been performed to compare surgical and conservative interventions for treating displaced midshaft clavicular fractures. But conclusions are discordant.The purposes of current study were (1) to conduct a systematic review of meta-analyses comparing surgical and conservative interventions for the treatment of displaced midshaft clavicular fractures, (2) to help decision makers interpret and choose among discordant meta-analyses, and (3) to provide treatment recommendations through the best available evidence.We searched the Cochrane library, PubMed, and EMBASE databases to identify meta-analyses comparing surgical and conservative treatments for the displaced midshaft clavicular fractures. Two investigators independently scanned titles and abstracts to exclude irrelevant articles and identify meta-analyses that met the eligibility criteria. The methodological quality of the meta-analysis was independently assessed by the two investigators using the Oxford Centre for Evidence-based Medicine Levels of Evidence and the Assessment of Multiple Systematic Reviews (AMSTAR) tool. The Jadad decision algorithm was applied to determine which of the included studies provided the best available evidence.Six meta-analyses met the eligibility criteria in this systematic review. AMSTAR scores ranged from 5 to 10. The Jadad decision-making tool suggests that the highest quality review should be selected based on the publication characteristics of the primary trials, the methodology of the primary trials, the language restrictions, and whether analysis of data on individual patients was included in the study. As a result, we selected a high-quality Cochrane review.This systematic review of overlapping meta-analyses comparing surgical and conservative treatments suggests that surgical treatment provides a lower rate of overall treatment failure and a better functional outcome, but is associated with more implant-related complications. Hence, treatment should be individualized, with careful consideration of the advantages and disadvantages of each treatment method and of patient preferences.
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Affiliation(s)
- Jia-Guo Zhao
- From the Department of Orthopaedic Surgery, Tianjin Hospital, Tianjin, China (JZ, JW); and Department of Nuclear Medicine, Tianjin Hospital, Tianjin, China (LL)
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Invited commentary related to: A cost analysis of internal fixation versus nonoperative treatment in adult midshaft clavicle fractures using multiple randomized controlled trials. J Orthop Trauma 2015; 29:180-1. [PMID: 25793567 DOI: 10.1097/01.bot.0000462804.63460.e4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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A cost analysis of internal fixation versus nonoperative treatment in adult midshaft clavicle fractures using multiple randomized controlled trials. J Orthop Trauma 2015; 29:173-80. [PMID: 25233160 DOI: 10.1097/bot.0000000000000225] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND To determine whether the cost of nonoperative treatment, including those who require delayed operative treatment, is less than those receiving initial operative management. METHODS We identified 4 recent randomized controlled trials comparing operative and nonoperative treatment of displaced midshaft clavicle fractures in adults with a minimum of 1-year follow-up. A decision tree was then created from these data using reoperation for those treated with surgery or delayed operative treatment of those treated nonoperatively as end points. Actual costs estimated from 2013 Medicare reimbursement rates were applied and adjusted to better reflect private insurance rates. We then performed a 2-way sensitivity analysis to test the stability of our model. RESULTS Based on our decision tree, the expected costs for operative and nonoperative treatment were $14,763.21 and $3112.65, respectively, producing a cost savings of $11,650.56 with nonoperative treatment. After application of a 2-way sensitivity analysis, our model remains valid until delayed operative treatment for nonoperative patients approaches 95% and reoperation after initial operative management falls below 15%. CONCLUSIONS From the perspective of a single payer, initial nonoperative treatment of midshaft clavicle fractures followed by delayed surgery as needed is less costly than initial operative fixation. LEVEL OF EVIDENCE Economic Level III. See Instructions for Authors for a complete description of levels of evidence.
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