Operative management of clavicle fractures changed significantly following the COTS RCT publication

In 2007, a randomized controlled trial (RCT) by the Canadian Orthopaedic Trauma Society (COTS) demonstrated better functional outcomes and a lower proportion of patients who developed malunion or nonunion following operative, compared with nonoperative, treatment of midshaft clavicle fractures.

Aresh Sepehri et al conducted a study to compare the proportion of midshaft clavicle fractures treated operatively prior to and following the publication of the COTS RCT. It was conducted at Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. It has been published in ‘JBJS Open Access.’

This retrospective cohort analysis used population-level administrative health data on the residents of British Columbia, Canada. Cases were identified by International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes and procedure fee codes. Adult patients (>=18 years) with closed middle-third clavicle fractures between 1997 and 2018 were included. Multivariable logistic regression modeling compared the proportion of clavicle fractures treated operatively before and after January 1, 2007, controlling for patient factors. The Pearson chi-square test compared the proportion of fractures treated operatively for malunion or nonunion in the cohorts.

Key findings of the study were:

• A total of 52,916 patients were included (mean age, 47.5 years; 65.6% male).

• The pre-publication cohort included 22,744 patients (15,181 [66.7%] male; mean age, 45.3 years).

• The post-publication cohort included 30,172 patients (19,540 [64.8%] male; mean age, 49.2 years).

• There were significant differences in age and sex (p < 0.001), but no difference in income levels (p = 0.544), between the 2 cohorts.

• More clavicle fractures were treated operatively from 2007 onward: 6.9% compared with 2.2% prior to 2007 (odds ratio [OR] = 3.35, 95% confidence interval [CI] = 3.03 to 3.70, p < 0.001).

• Male sex, moderate-to-high income, and younger age were associated with a greater proportion of operative fixation.

• The rate of surgery for clavicle malunion or nonunion also increased over this time period (to 4.1% from 3.4%, OR = 1.26, 95% CI = 1.15 to 1.38, p < 0.001).

The authors concluded that – “We found a significant change in surgeon practice regarding operative management of clavicle fractures following the COTS RCT publication. These findings are in keeping with orthopaedic surgeons practicing evidence-based medicine. With limited high quality trials comparing operative and nonoperative management, it is important to determine what steps can be taken to increase responsiveness to new clinical studies and guidelines.”

Level of Evidence: Prognostic Level III.

Further reading:

Assessing the Change in Operative Treatment Rates for Acute Midshaft Clavicle Fractures Incorporation of Evidence-Based Surgery Results in Orthopaedic Practice Aresh Sepehri, Pierre Guy et al JBJS Open Access 2023:e22.00096. http://dx.doi.org/10.2106/JBJS.OA.22.00096