Surgical versus conservative treatment of midshaft clavicle fractures .
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OrthoEvidence Journal (OE Journal) - ACE Report
OE Journal. 2013;1(11):226 Dan Med J. 2012 Jul;59(7):A4457This systematic review identified 5 studies (four RCTs and one cohort study: total of 365 patients for all studies) that assessed which treatment modality - surgical or conservative - was the optimal treatment for acute, displaced midshaft clavicle fractures. Results indicated that the surgical treatment led to a better functional outcome (measured with the Constant score) and lower mal- and non-union rates compared to conservative treatment. However, clinical relevance of the observed functional benefits needs to be considered before a definitive conclusion can be made regarding best treatment options.
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Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
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Sí = 1
Incierto = 0,5
No relevante = 0
No = 0
La evaluación de los criterios de información evalúa la transparencia con la que los autores informan de las características metodológicas y del ensayo dentro de la publicación. La evaluación se divide en cinco categorías que se presentan a continuación.
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Introduction
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Accessing Data
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Analysing Data
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Results
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Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
El Índice de Fragilidad es una herramienta que ayuda en la interpretación de hallazgos significativos, proporcionando una medida de fuerza para un resultado. El Índice de Fragilidad representa el número de eventos consecutivos que es necesario añadir a un resultado dicotómico para que el hallazgo deje de ser significativo. Un número pequeño representa un hallazgo más débil y un número grande un hallazgo más fuerte.
¿Por qué se necesitaba ahora este estudio?
In the past five years, there has been a major shift towards primary surgical treatment of acute, displaced midshaft clavicle fractures. However, there has been a lack high quality compelling evidence to support this shift in treatment, and a concern has been raised that primary surgical intervention may lead to overtreatment. Additionally, commonly used shoulder scores have yet to be validated for patients with clavicle fractures. This study aimed to investigate treatment indication for this type of fracture based on the current literature available.
¿Cuál era la pregunta principal de la investigación?
Which treatment modality - surgical or conservative - for acute, displaced midshaft clavicle fractures would lead to better functional outcomes and lower non-union rates?
- In the four studies that compared surgical to conservative treatment, the Constant scores were significantly greater at measure points in the surgical group. A difference in the Constant score of ten points or more has been considered clinically relevant, only one study met this difference at 1 year follow-up.
- A comparison between two operative methods (Ferran et al), intramedullary nailing and plate fixation, found higher Constant scores in the nailing group at all measure points during follow-up (but were found statistically insignificant at the one-year follow-up).
- Three studies reported 100% union in all of the patients who underwent surgical intervention with the lowest union rate being 96% for a surgical intervention. Union in the conservatively treated groups was lower than in the surgery treated groups ranging from 68%-96%.
- Complication rates were lower in the surgically treated group (28%) than those treated conservatively (47%).
- The majority of complications involved prominent hardware causing soft tissue irritation (approximately 26% of all plate-related complications); wound infection (16%) and hardware failure (16%) were other frequent complications.
- The most predominant complication displayed in the conservatively treated group was symptomatic malunion, where it accounted for 67% (40/60) of the complications.
¿Qué es lo que más debo recordar?
The results indicated that surgical treatment of acute, displaced midshaft clavicle fractures led to better functional outcomes and lower mal- and non-union rates than patients receiving conservative treatment. However, clinical relevance of the observed functional benefits still needs to be determined.
¿Cómo afectará esto al cuidado de mis pacientes?
The evidence currently suggests that operative treatment provides slight improvements in functional scores and union rates. There is still a lack of definitive evidence to definitively conclude that primary surgical treatment yields superior results. Future studies should focus more on patients at high risk of non-union as they may benefit more from operative treatment. Additionally, validation of the shoulder outcome scores commonly employed to assess the functional outcome of clavicle fracture treatment needs to be done.
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