Orthopaedic surgeons and their staffs are aware of the paradigm shift that has taken place in the last 10 to 15 years regarding the treatment of clavicle fractures. Interest in the outcome differences between surgical and nonsurgical treatment has grown substantially since the 2007 Canadian Orthopaedic Trauma Society publication in JBJS showed that, relative to nonoperative treatment, plate fixation of displaced midshaft clavicle fractures resulted in improved functional outcomes and fewer malunions in active adult patients. Since that time, The Journal alone has published 14 articles related to management of clavicle fractures. In addition, the orthopaedic literature contains a number of well-conducted meta-analyses on the topic, comparing both nonoperative and surgical treatment as well as different methods of surgical fixation.
So, with all this evidence, why have we published the randomized controlled trial on this topic by King et al. in the April 3, 2019 issue of The Journal? Partly because the authors build upon our knowledge by comparing a relatively new fixation device (a flexible intramedullary locked nail) to a more standard treatment (an anatomically contoured plate). These plate and nail devices are very different from one another in terms of mechanics and surgical technique, and the flexible nail used in this study is much different than the rigid, straight nails or pins that have been used in the past.
A union rate of 100% was observed in both groups, but the authors found that the flexible nail was significantly faster in terms of operative time. (A single surgeon experienced with both devices performed all 72 surgeries.) They also found that the DASH scores between the groups were similar until the 12 month follow-up, at which point the flexible intramedullary nail group had statistically better scores. The authors concede, however, that the 12-month DASH-score difference “might not be clinically relevant.”
There is one other reason why we deemed this article important: The flexible intramedullary device used in this study is substantially more expensive than prior fixation devices that have been shown to effectively treat clavicular fractures. King et al. did not compare device costs, but whenever we study a device that adds to the total cost of care we should attempt to prove that it adds enough patient benefit to warrant the added expense. As the authors conclude, both devices evaluated in this study appear to be effective at treating displaced/shortened clavicular fractures, and there are a number of other factors that both the surgeon and patient should consider (such as surgeon skill and experience and cosmetic results) when deciding which treatment to use.
Marc Swiontkowski, MD
Often in life, when there are many potential solutions for a single problem, none of them is found to be universally better than the others. That certainly seems to be the case when it comes to treating type III- and -IV acromioclavicular (AC) joint dislocations. Multiple studies have tried to clarify whether nonoperative or operative management is superior in this relatively common injury, but it is becoming increasingly clear that there is no single “right” answer. Many patients do fine with nonoperative treatment; others report being highly satisfied with an operation.
In the November 21, 2018 issue of The Journal, Murray et al. try to provide further guidance for treating these injuries. They performed a prospective, randomized controlled trial that compared nonoperative treatment with open reduction and tunneled suspensory device fixation among 60 patients with a type-III or type-IV AC joint dislocation. The authors used DASH, OSS, and SF-12 scores to quantify functional differences between the groups at 6 weeks, 3 months, 6 months, and 1 year post-injury. They found that, while the operative group showed improved radiographic alignment of the AC joint compared to the nonoperative group, there were no differences in functional outcomes between the two groups at any time beyond the 6-week mark (at which point the nonoperative group had better outcomes).
Notably, 5 of the 31 patients allocated to nonoperative treatment ended up requesting surgical treatment for the injury because of persistent discomfort (4 patients) or cosmesis (1 patient). Also, not surprisingly, the mean economic expenditure in the fixation group was significantly greater than that in the nonoperative group.
Whether to provide operative or nonoperative treatment for type-III and -IV acromioclavicular joint dislocations is not an easy decision, and it entails multiple factors. While this study evaluates only one modern surgical technique for treating this injury, the data is valuable nonetheless for informing a shared decision-making process to help patients choose the most appropriate treatment for them. The good news is that, whether managed operatively or not, patients tend to improve significantly after these injuries, and after 1 year end up with a shoulder that functions well. The authors conclude that “the routine use of [this surgical procedure] for displaced AC joint injuries is not justified,” and that “treatment should be individualized on the basis of [patient] age, activity level, and expectations.”
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Every month, JBJS publishes a Specialty Update—a review of some of the most pertinent and impactful studies published in one of 13 orthopaedic subspecialties during the previous year. Click here for a collection of all OrthoBuzz Specialty Update summaries.
This month, OrthoBuzz asked Sanjeev Kakar, MD, the author of the March 15, 2017 Specialty Update on hand and wrist surgery, to select five of the most clinically compelling findings from among the more than 40 he cited in the article.
Carpal Tunnel Syndrome
—The AAOS published updated clinical practice guidelines on the evaluation and treatment of carpal tunnel syndrome (CTS). Among the conclusions are the following:
- Thenar atrophy is strongly associated with ruling in carpal tunnel syndrome but poorly associated with ruling it out.
- High body mass index and repetitive hand and wrist actions are associated with an increased risk of developing CTS.
- Surgical division of the transverse carpal ligament should relieve symptoms and improve function compared with nonoperative treatment.
- There is no benefit to routine postoperative immobilization after CTS surgery.
—If a distal radius fracture is displaced, especially in an elderly patient, should one proceed with nonoperative or operative treatment? A systematic review/meta-analysis1 involving more than 800 patients 60 years of age or older found that operatively treated patients had greater grip strength and better restoration of radiographic parameters than nonoperatively treated patients. However, those who underwent surgery also experienced more complications (primarily hardware-related) that required surgery.
Thumb and Digit Arthritis
—There are a myriad of treatments for the management of basilar thumb arthritis, ranging from trapeziectomy to fusion. Which one is better, especially if the scaphotrapeziotrapezoid joint is not involved? A prospective study was conducted randomizing women older than 40 with basal thumb joint arthritis to trapeziectomy and suspension arthroplasty or carpometacarpal joint arthrodesis. After a mean follow-up of 5.3 years, those in the trapeziectomy-suspension arthroplasty group had significantly better pain reduction and function.2 Researchers halted the study prematurely due to increased complications in the arthrodesis group.
Outcome Measurement Tools
—Among the many patient-reported outcome measures for the upper extremity, which should be used for which conditions? For distal radius fractures, a systematic approach has been proposed3 that captures outcomes across five domains: range of motion and grip strength, patient-reported scores of disability and function, complications, pain, and radiographs.4
—Is there any way to make the collection of patient-reported outcomes easier and less time-consuming? An assessment that compared two forms of computerized adaptive tests (CATs) with the DASH (Disabilities of the Arm, Shoulder and Hand) measure among 379 hand-clinic patients found that the CAT required fewer questions to complete than the DASH, yet maintained excellent reliability.5
- Chen Y, Chen X, Li Z, Yan H, Zhou F, Gao W. Safety and efficacy of operative versus nonsurgical management of distal radius fractures in elderly patients. A systematic review and meta-analysis. J Hand Surg Am. 2016 ;41(3):404–13. Epub 2016 Jan 20.
- Spekreijse KR, Selles RW, Kedilioglu MA, Slijper HP, Feitz R, Hovius SE, Vermeulen GM. Trapeziometacarpal arthrodesis or trapeziectomy with ligament reconstruction in primary trapeziometacarpal osteoarthritis: a 5-year follow-up. J Hand Surg Am. 2016 ;41(9):910–6.
- Teunis T, Ring D. Comprehensive outcome assessment after distal radius fracture. J Hand Surg Am. 2016 ;41(8):e257. Epub 2016 Jun 11.
- Waljee JF, Ladd A, MacDermid JC, Rozental TD, Wolfe SW, Distal Radius Outcomes Consortium. A unified approach to outcomes assessment for distal radius fractures. J Hand Surg Am. 2016;41(4):565–73.
- Beckmann JT, Hung M, Voss MW, Crum AB, Bounsanga J, Tyser AR. Evaluation of the patient-reported outcomes measurement information system upper extremity computer adaptive test. J Hand Surg Am. 2016 ;41(7):739–744.e4. Epub 2016 Jun 3.