Review ArticleComparison between Minimally Invasive Plate Osteosynthesis and Conventional Open Plating for Midshaft Clavicle Fractures: A Systematic Review and Meta-Analysis

Enzhe Zhao ,1 Rui Zhang,1 Dou Wu,2 Yao Guo,1 and Qiang Liu 2

1Shanxi Medical University, Taiyuan, Shanxi 030001, China2Department of Orthopedics, Shanxi Dayi Hospital A�liated to Shanxi Medical University, Shanxi Academy of Medical Science, Taiyuan, Shanxi 030032, China

Correspondence should be addressed to Qiang Liu; sxdyy001@163.com

Received 24 April 2019; Revised 7 August 2019; Accepted 16 August 2019; Published 16 October 2019

Academic Editor: Bryan Cornwall

Copyright © 2019 Enzhe Zhao et al. �is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective. �e aim of this study was to compare the functional outcome and complications in midsha� clavicle fractures receiving minimally invasive plate osteosynthesis and conventional open plating. Methods. Relevant studies were searched in the databases of Medline, EMBASE, Cochrane Library, Ovid, and Web of Science from inception to March 1, 2019. Pooled data were analyzed with Cochrane Collaboration’s Review Manager 5.3. Results. A total of 7 studies were included, of which 2 were randomized controlled trials, 3 were retrospective cohort studies, and 2 were prospective cohort studies including 316 patients. No statistical di�erences in functional outcome (weighted mean di�erence [WMD] = 0.99, � = 0.12), operation time (WMD = −10.44, � = 0.07) and time to bone union (WMD = −0.23, � = 0.70) were observed between the two groups. However, minimally invasive plate osteosynthesis reduced rates of skin numbness (odds ratio (OR) = 0.25, 95% CI : 0.13 to 0.48; � < 0.0001) and complications (OR = 0.33, 95% CI : 0.16 to 0.71; � = 0.005) compared with conventional open plating. Conclusion. �is systematic review and meta-analysis found no di�erences in terms of functional outcomes, operation time, and fracture healing time between minimally invasive plate osteosynthesis and conventional open plating. However, minimally invasive plate osteosynthesis had apparent advantages in rates of skin numbness and complications.

1. Introduction

�e clavicle fractures constitute an estimated 2% to 5% of all fractures in adults [1]. �ese fractures are most common in younger patients, and are o�en associated with direct clavicle injuries such as contact sports and motor vehicle accidents. It is estimated that approximately 80% occur in the middle third of the clavicle, of which half are displaced [2]. Traditionally, midsha� clavicle fractures were treated nonoperatively by closed reduction, sling or §gure-of-8 harness, and physical therapy, with a low rate of nonunion less than 1% [3]. However, several studies illustrated that the nonunion rate with nonsur-gical management is between 15% and 20% [4–6]. Furthermore, a current meta-analysis found that surgical treatment of mid-sha� clavicle fractures presented a signi§cantly lower nonun-ion rate compared with nonoperative treatment [7]. �erefore,

surgical treatment is o�en preferred for midsha� clavicle fractures today.

Open reduction and plate §xation is one of most com-monly performed surgical techniques for midsha� clavicle fractures. However, conventional open plating (COP) may compromise blood supply, so� tissues, and cause several adverse events especially anterior chest numbness or hypoes-thesia [8]. �e minimally invasive plate osteosynthesis (MIPO) technique was widely used for lower extremity fractures owing to its role in protecting periosteal blood supply of the fracture area [9]. Recently, MIPO technique has been utilized for the treatment of midsha� clavicle fractures with satisfactory clin-ical outcomes [10, 11]. To date, several clinical studies indi-cated that MIPO could achieve similar results with fewer complications compared with COP [12, 13]. However, the optimal surgical approach for midsha� clavicle fractures

HindawiBioMed Research InternationalVolume 2019, Article ID 7081032, 9 pageshttps://doi.org/10.1155/2019/7081032

BioMed Research International2

remains controversial. Based on the information all above, this systematic review and meta-analysis aims to compare func-tional outcome and complications of MIPO with COP in the treatment of midsha� clavicle fractures.

2. Methods

2.1. Search Strategy and Article Selection. �e literature searches were performed in the following databases: Medline, EMBASE, Cochrane Library, Ovid, and Web of Science from inception to March 1, 2019. �e key words used were “clavicle/collarbone/clavicular”, “midsha�/mid-sha�”, “fracture/broken”, “plate”, “open”, and “minimally invasive/MIPO” in combination with the Boolean operators “AND” or “OR”. Search the reference lists of selected articles manually as a secondary source. Articles were not restricted by languages and publication type.

Two reviewers (Enzhe Zhao, Rui Zhang) screened title and abstract of the search results independently, and removed duplicate articles. Both reviewers screened potentially relevant articles in full for evaluation. Disagreements were resolved by discussion with a third reviewer (Dou Wu).

2.2. Eligibility Criteria. �e inclusion criteria were as follows: (a) study design: randomized controlled study (RCT) or nonRCT;

(b) patients with midsha� clavicle fractures (15.2 according to AO/OTA classi§cation [14] or type 2 according to the Robinson classi§cation [15]) (Figure 1); (c) intervention: MIPO and COP; (d) at least one of following data were reported: functional outcomes, operative time, union time, and complications.

�e exclusion criteria were as follows: (a) studies without controlled groups; (b) duplicate publication; (c) pathological fractures; (d) unavailable relevant data.

2.3. Quality Assessment. Modi§ed version of the Cochrane Collaboration’s tool was applied to assess the risk of bias in RCTs [16]. �e Methodological Index for Nonrandomized Studies (MINORS) methodology was used to evaluate other nonRCTs [17]. According to the Cochrane Collaboration recommendations, two reviewers (Enzhe Zhao and Yao Guo) assessed the methodological quality of each included study independently, and a third reviewer (Dou Wu) solved any possible inconsistency.

2.4. Data Extraction and Outcome Measurement. A spreadsheet for data extraction was created prior to this study. Two researchers independently extracted the baseline study data as follows: the §rst author’s name, study design, year of publication, interventions, sample size, mean age, follow-up time, operative time, complications, time to bone union, and functional outcomes.

15.2A Simple fracture

15.2B Wedge fracture

15.2C Multifragmentary fracture

AO/OTA classi�cation Robinson classi�cation

Type 2A1 Undisplaced

Type 2A2 Angulated

Type 2B1 Simple or wedge comminuted

Type 2B2 Isolated or comminutedsegmental

Figure 1: AO/OTA classi§cation and Robinson classi§cation of midsha� clavicle fractures.

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�e primary outcome of this meta-analysis was Constant-Murley Shoulder score. Secondary outcomes were operative time, time to bone union, skin numbness/hypoesthesia, and the other complications (e.g., infection, hypertrophic scaring, nonunion, re-fracture, implant failure, skin irritation, and painful shoulder). Fracture union was assessed using radio-graphic evidence, such as callus formation and bony bridging across the fracture site. Nonunion de§ned as a lack of complete osseous bridging a�er 6 months.

2.5. Statistical Analysis. �e Review Manager so�ware (RevMan 5.3, �e Nordic Cochrane Center, �e Cochrane Collaboration, Copenhagen, Denmark) was used for data analysis [18]. �e weighted mean di�erences (WMDs) and odds ratios (ORs) were used to represent continuous and dichotomous outcomes, respectively. Data were pooled using the inverse-variance method for continuous outcomes and Mantel-Haenszel method for dichotomous outcomes. All data were reported with WMD or OR and the 95% con§dence intervals (CI). Heterogeneity between studies was assessed using Chi-square test and I-squared test (�2). Fixed-e�ects model was used if no signi§cant heterogeneity existed (� > 0.1, �2 < 50%). If signi§cant heterogeneity was present (� < 0.1 or �2 > 50%), data were rechecked §rst, then a random-e�ects model was used when heterogeneity persisted. Sensitivity analysis was evaluated by sequentially removing outlier studies, one at a time.

3. Results

3.1. Search Results. A systematic search strategy was created and a total of 114 relevant articles were identi§ed. A�er removal of duplicates, 64 articles were screened based on title and abstract for eligibility, and 7 articles were selected. A�er reading the full text of these 7 articles, no article was excluded based on the selection criteria. �erefore, 7 articles were included in the systematic review [12, 13, 19–23] (Figure 2).

3.2. Quality Assessment. �e quality of RCTs was evaluated by modi§ed version of the Cochrane Collaboration Risk of Bias Tool (Figure 3), and MINORS methodology was used to evaluate nonRCTs (Table 1).

3.3. Study Characteristics. A total of 316 patients with mid-sha� clavicle fractures were involved, including 158 patients treated by COP and 158 patients treated by MIPO. Of the 7 included studies, 2 were randomized controlled trials, 3 were retrospective cohort studies, and 2 were prospective cohort studies. �e full characteristics of the included studies are listed in Table 2.

3.4. Outcomes of Meta-Analysis

3.4.1. Functional Outcome. Five studies [12, 13, 20, 21, 23] reported Constant-Murley scores at one-year follow-up. However, one study [12] was excluded from this analysis,

Additional records identi�edthrough other sources

(n = 0)

Records identi�ed throughdatabase searching

(n = 114)

Records a�er duplicate removed(n = 64)

Records screened(n = 7)

Records excluded bytitle and abstract

(n = 57)

Full-text articles assessed for eligibility

(n = 7)

Full-text articles excluded(n = 0)

Studies included inqualitative synthesis

(n = 7)

Studies included inquantitative synthesis

(meta-analysis)(n = 7)

Iden

ti�ca

tion

Scre

enin

gEl

igib

ility

Incl

uded

Figure 2: Preferred Reporting Items for Systematic Reviews and Meta-Analyses ·ow diagram of study selection process.

BioMed Research International4

follow-up. A §xed-e�ects model was performed without heterogeneity (� = 0.56, �2 = 0%). Overall, the pooled results showed that skin numbness occurred more o�en a�er COP (OR = 0.25, 95% CI : 0.13 to 0.48; � < 0.0001) (Figure 7).

3.4.5. Complications. �e reported complications used for this analysis included infection, hypertrophic scaring, nonunion, re-fracture, implant failure, skin irritation, and painful shoulder except skin numbness/hypoesthesia. A full list of complications can be viewed in Table 3. Two studies [19, 20] reported no complication except skin numbness/hypoesthesia. A §xed-e�ects model was applied without heterogeneity (� = 0.50, �2 = 0%). �e pooled results showed that complications signi§cantly favored COP (OR = 0.33, 95% CI : 0.16 to 0.71; � = 0.005) (Figure 8).

4. Discussion

�e present systematic review and meta-analysis, comparing MIPO versus COP for the treatment of midsha� clavicle frac-tures, found no di�erences in terms of long term functional outcomes, operation time, and time to bone union between MIPO and COP. However, MIPO had apparent advantages in rates of skin numbness and complications. �ese results sug-gested that MIPO is a safe surgical treatment of midsha� clav-icle fractures with fewer complications.

Postoperative functional recovery, one of the most crucial outcomes, is closely related to the quality of life of patients. Clinical scores such as American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score and Disabilities of the Arm, Shoulder, and Hand (DASH) were o�en used to assess the postoperative functional recovery. We also employed the Constant-Murley score, including pain, range of motion and activities of daily living, to evaluate postoperative func-tional recovery. Although several studies [10, 11, 24–26] have reported the good clinical outcomes of MIPO, this meta-anal-ysis found no di�erence in terms of long term functional out-comes at one-year follow-up between MIPO and COP (� = 0.12).

Two studies [20, 23] showed mean operation time of MIPO was shorter than COP. However, Zehir et al. [22] reported the operation time of COP was shorter. Our meta-analysis found no signi§cant di�erence in operation time between MIPO and COP (� = 0.07). �ere was a signif-icant heterogeneity between the two groups (� < 0.00001, �2 = 94%), and sensitive analysis showed the total pooled e�ect size was greatly a�ected by the study of Zehir [22]. Operation time of COP was shorter than MIPO in the study of Zehir [22] might be due to repetitive ·uoroscopy use for fracture reduc-tion and placement of plate and high loss to follow-up (10/32) in the MIPO group.

MIPO technique, used to stabilize acute fractures without extensive so� tissue dissection, was believed to promote bone healing by preserving the enveloped so� tissue and periosteal circulation [10]. However, this meta-analysis found no signi§-cant di�erence in time to bone union between MIPO and COP groups (� = 0.70). �is might be due to low sample size of

for reason that both standard deviation and standard error were not available from the full text. A §xed-e�ects model was used without heterogeneity (� = 0.31, �2 = 17%). Finally, it was found that the Constant-Murley scores at one-year follow-up did not di�er between two groups (WMD = 0.99, 95% CI : −0.25 to 2.23; � = 0.12) (Figure 4).

3.4.2. Operation Time. Six studies [12, 13, 19, 20, 22, 23] which involved 243 cases provided data of operation time. �e random-e�ects model was performed due to a remarkable heterogeneity across studies (� < 0.00001, �2 = 94%). No signi§cant di�erence was found between MIPO and COP in the pooled estimate of operation time (WMD = −10.44, 95% CI : −21.63 to 0.75; � = 0.07) (Figure 5). Sensitive analysis showed that the total pooled e�ect size was greatly a�ected by the study of Zehir [22] (�2 = 93%; WMD = −14.77, 95% CI : −28.63 to −0.91; � = 0.04).

3.4.3. Time to Bone Union. Time to bone union was reported in all seven studies. However, one study [19] only reported the maximum and minimum values of healing time without mean values and standard deviation, thus a total of six studies [12, 13, 20–23] were included in this analysis. A random-e�ects model was applied due to the remarkable heterogeneity across studies (� = 0.03, �2 = 60%). �ere was no signi§cant statistical di�erence between MIPO and COP regarding time to bone union (WMD = −0.23, 95% CI : −1.42 to 0.96; � = 0.70) (Figure 6). In addition, a sensitive analysis by excluding outlier study [22] showed that the result was robust (�2 = 15%; WMD = 0.20, 95% CI : −0.62 to 1.02; � = 0.63).

3.4.4. Skin Numbness. Skin numbness or hypoesthesia was assessed in all seven studies with a minimum of 6 months

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ncea

lmen

t (se

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bias

)

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ding

of p

artic

ipan

ts a

nd p

erso

nnel

(per

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ding

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Inco

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ete

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ome

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(attr

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s)

Sele

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port

ing

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Jiang 2012

Kim 2018

Figure 3:  Risk of bias assessment summary of randomized controlled trials. “+” = risk of bias not present, “−” = risk of bias present, and “?” = insuºcient information to judge risk of bias.

5BioMed Research International

[28, 29]. Several investigations reported MIPO technique sig-ni§cantly reduced the anterior chest wall numbness compared with COP [19, 21]. Similarly, our meta-analysis found that MIPO was superior to OCP in skin numbness (� < 0.0001). Anatomically, no branch of supraclavicular nerve was found within 2.7 cm of the sternoclavicular joint or within 1.9 cm of the acromioclavicular joint [30]. �e medial and lateral inci-sion selected by the MIPO technique was precisely within these two areas with no neural branches. Although an addi-tional central incision on the fracture site is needed for ana-tomical reduction in MIPO (the technique used in studies of

included studies and the careful dissection during COP to avoid damaging blood supply. Although there was a signi§cant het-erogeneity between the two groups (� = 0.03, �2 = 60%), these §ndings were reliable because the result of sensitive analysis did not alter signi§cance by excluding the outlier study [22] (�2 = 15%; WMD = 0.20, 95% CI : −0.62 to 1.02; � = 0.63).

Previous studies have shown that anterior chest wall numbness is one of the most common complications in the treatment of clavicle fracture with plate, by reason of damage to branches of supraclavicular nerve [27, 28]. �e incidence of skin numbness a�er COP has been reported to be 12%–83%

–10 –5 0 5 10Favours COP

Constatnt-Murley score MIPOMean SD Total Total

WeightMean SD

COP Mean di�erence Mean di�erenceStudy or subgroup IV, Fixed, 95% CI IV, Fixed, 95% CI

Kim 2018 [18]Sohn 2015 [13]You 2018 [19]You 2019 [21]

88.4695.7594.1895.3

10.524.253.993.1

15 81.2719 94.7438 93.7420 94.1

8.364.463.714.1

15143520

3.3%16.9%49.4% 30.4%

7.19 [0.39, 13.99]1.01 [–2.01, 4.03]0.44 [–1.33, 2.21]1.20 [–1.05, 3.45]

Total (95% CI) 92 84 100.0% 0.99 [–0.25, 2.23]Heterogeneity: χ2 = 3.60, df = 3 (P = 0.31); I2 = 17%Test for overall e�ect: Z = 1.57 (P = 0.12)

Favours MIPO

Figure 4:  Forest plot diagram of Constant-Murley scores compared between MIPO and COP.

Operation time (min)

Study or Subgroup Mean

MIPO COP

SD Total Mean SD TotalWeight Mean di�erence Mean di�erence

IV, Random, 95% Cl IV, Random, 95% Cl

Beirer 2015 [19]Jiang 2012 [12]Kim 2018 [20]Sohn 2015 [13]You 2019 [23]Zehir 2018 [22]

93.5 26.611.2513.8717.32

6.27.78

6052.3377.1936.7

53.59

12 97.1 24.9 12 11.8% –3.60 [–24.22, 17.02]0.00 [–5.51, 5.51]

–58.00 [–72.64, –43.36]–10.31 [–22.86, 2.24]–5.70 [–9.86, –1.54]

6.69 [3.03, 10.35]

18.9%14.8%15.8%19.3%19.4%

3215142030

11.2525.3918.79

7.24.72

60110.33

87.542.446.9

3215192022

Favours MIPO Favours COP–50 –25 0 25 50

Total (95% CI) 120 123 100.0% –10.44 [–21.63, 0.75]Heterogeneity: τ2 = 164.68; χ2 = 82.34, df = 5 (P <0.00001); I2 = 94% Test for overall e�ect: Z = 1.83 (P = 0.07)

Figure 5:  Forest plot diagram of operation time (min) compared between MIPO and COP.

Time to bone union (weeks)

Study or Subgroup Mean SD Total Mean

COP

SD TotalWeight Mean di�erence Mean di�erence

IV, Random, 95% CI IV, Random, 95% CI

–10 –5 0 5 10Favours MIPO Favours COP

Jiang 2012 [12] 12 3 32 13 4 32 18.9% –1.00 [–2.73, 0.73]4.07 [–2.89, 11.03]1.09 [–1.27, 3.45]0.80 [–0.46, 2.06]

–0.10 [–1.22, 1.02]–2.86 [–4.90, –0.82]

–0.23 [–1.42, 0.96]

2.7%14.1%23.3%24.7%16.4%

1514352030

6.532.932.51.9

4.52

17.1315.6915.314.416.5

1519382022

12.13.98

31.7

2.98

21.216.7816.114.3

13.64

Kim 2018 [20]Sohn 2015 [13]You 2018 [21]You 2019 [23]Zehir 2018 [22]

Total (95% CI)Heterogeneity: τ2 = 1.17; χ2 = 12.35, df = 5 (P = 0.03); I2 = 60%Test for overall e�ect: Z = 0.38 (P = 0.70)

146 146 100.0%

MIPO

Figure 6: Forest plot diagram of time to bone union (weeks) compared between MIPO and COP.

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MIPO

Events Total Events TotalWeight

M-H, Fixed, 95% Cl

Skin numbness

Study or Subgroup

COPOdds ratio Odds ratio

M-H, Fixed, 95% Cl

0.002Favours MIPO Favours COP

0.1 1 10 500

Beirer 2015 [19]Jiang 2012 [12]Kim 2018 [20]Sohn 2015 [13]You 2018 [21]You 2019 [23]Zehir 2018 [22]

10 12 9 12 3.6% 1.67 [0.22, 12.35]0.15 [0.03, 0.74]0.29 [0.03, 3.12]0.06 [0.00, 1.22]0.26 [0.08, 0.82]0.16 [0.02, 1.50]0.28 [0.05, 1.45]

22.7%6.8%

12.1%28.4%11.5%14.9%

321514352030

1034

1358

321519382022

210512

Total (95% CI) 158 158 100.0% 0.25 [0.13, 0.48]Total events 21 52Heterogeneity: χ2 = 4.91, df = 6 (P = 0.56); I2 = 0%Test for overall e�ect: Z = 4.20 (P < 0.0001)

Figure 7: Forest plot diagram of skin numbness compared between MIPO and COP.

0.005 0.1 1 10 200Favours MIPO Favours COP

Complications MIPO COPOdds ratio

M-H, Fixed, 95% CIOdds ratio

M-H, Fixed, 95% CIStudy or Subgroup Events

0 12 06

1226.0%

Not estimable

Not estimable0.67 [0.13, 3.30]0.09 [0.00, 1.75]0.32 [0.01, 8.26]0.53 [0.17, 1.61]

0.06 [0.00, 1.17]

14.8%18.8%5.9%

34.5%

321514352030

0441

17

321519382022

004009

Total Events TotalWeight

Beirer 2015 [19]Jiang 2012 [12]Kim 2018 [20]Sohn 2015 [13]You 2018 [21]You 2019 [23]Zehir 2018 [22]

Total eventsHeterogeneity: χ2 = 3.38, df = 4 (P = 0.50); I2 = 0%Test for overall e�ect: Z = 2.83 (P = 0.005)

Total (95% CI) 15813 32

158 100.0% 0.33 [0.16, 0.71]

Figure 8: Forest plot diagram of complications compared between MIPO and COP.

Table 1: Quality assessment of nonrandomized studies (methodological index for nonrandomized studies).

�e items are scored 0 (not reported), 1 (reported but inadequate), or 2 (reported and adequate).

Beirer 2015 [19] Sohn 2015 [13] You 2018 [21] Zehir 2018 [22] You 2019 [23]A clearly stated aim 2 2 2 2 2Inclusion of consecutive patients 2 2 2 2 2Prospective data collection 2 0 2 0 0End points appropriate to the aim of the study 1 2 2 2 2Unbiased assessment of the study end point 0 0 0 0 0A follow-up period appropriate to the aims of

study 1 2 2 2 2

Less than 5% loss to follow-up 2 2 2 0 2Prospective calculation of the sample size 0 0 0 0 0An adequate control group 2 2 2 2 2Contemporary groups 2 2 2 2 2Baseline equivalence of groups 2 2 2 2 2Adequate statistical analyses 2 2 2 2 2Total score 18 18 20 16 18

7BioMed Research International

Tabl

e 2:

 Cha

ract

erist

ics o

f the

stud

ies.

M =

mal

es, F

= fe

mal

es, R

CT

= ra

ndom

ized

cont

rolle

d tr

ial,

RC =

retr

ospe

ctiv

e coh

ort,

PC =

pros

pect

ive c

ohor

t, M

IPO

= m

inim

ally

inva

sive p

late

ost

eosy

nthe

sis, C

OP

= co

nven

tiona

l ope

n pl

atin

g, O

TA =

orth

opae

dic

Trau

ma

Ass

ocia

tion.

Firs

t aut

hor

Year

Stud

y de

sign

Gro

upTo

tal n

umbe

rM

ean

age (

year

s)G

ende

r (M

/F)

Follo

w-u

p (m

onth

s)Fr

actu

re cl

assifi

catio

nO

pera

tive

tech

niqu

e

Jiang

[12]

2012

RCT

MIP

O32

4020

/12

15Ro

bins

on 2

B1, 2

B2

A ce

ntra

l inc

ision

ove

r the

frac

ture

sit

e (3

cm),

a di

stal

inci

sion

(1 cm

) an

d a

prox

imal

inci

sion

(1 cm

)

CO

P32

4520

/12

15A

tran

sver

se in

cisio

n ov

er th

e fr

ac-

ture

site

(8–1

0 cm

)

Sohn

[13]

2015

RCM

IPO

1946

.79

18/1

17.6

AO

/OTA

15.

2A, 1

5.2B

, 15

.2C

Two

smal

l ski

n in

cisio

ns (t

he m

edi-

al a

nd la

tera

l sid

es o

f the

clav

icle

)

CO

P14

44.1

412

/217

.6A

tran

sver

se in

cisio

n ov

er th

e fr

actu

re si

te

Beire

r [19

]20

15PC

MIP

O12

34.9

211

/16

AO

/OTA

15.

2A, 1

5.2B

, 15

.2C

A ce

ntra

l inc

ision

ove

r the

frac

ture

sit

e, a

med

ial s

tab

inci

sion

and

a la

tera

l sta

b in

cisio

n

CO

P12

41.4

211

/16

A tr

ansv

erse

inci

sion

over

the

frac

ture

site

Kim

[20]

2018

RCT

MIP

O15

38.1

310

/513

.33

AO

/OTA

15.

2A, 1

5.2B

, 15

.2C

Two

smal

l ski

n in

cisio

ns (t

he m

edi-

al a

nd la

tera

l sid

es o

f the

clav

icle

)

CO

P15

38.1

511

/413

.73

A tr

ansv

erse

inci

sion

over

the

frac

ture

site

You

[21]

2018

PCM

IPO

3838

.320

/18

12Ro

bins

on 2

A2,

2B1

, 2B2

Two

smal

l ski

n in

cisio

ns (t

he m

edi-

al a

nd la

tera

l sid

es o

f the

clav

icle

)

CO

P35

36.9

18/1

712

A tr

ansv

erse

inci

sion

over

the

frac

ture

site

Zehi

r [22

]20

18RC

MIP

O22

32.3

212

/10

14.5

6A

O/O

TA 1

5.2B

, 15.

2C

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BioMed Research International8

numbness and complications appear to occur more frequently when COP is used. High quality clinical trials which include larger sample sizes and longer follow-up time are required to con§rm our conclusion.

Conflicts of Interest

�e authors declare that they have no con·icts of interest.

Acknowledgments

We would like to thank Yuehong Ma, MSc for kindly providing statistical consultation.

References

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[2] B. Wiesel, S. Nagda, S. Mehta, and R. Churchill, “Management of midsha� clavicle fractures in adults,” �e Journal of the American Academy of Orthopaedic Surgeons, vol. 26, no. 22, pp. e468–e476, 2018.

[3] N. Hussain, C. Sermer, P. J. Prusick, L. Ban§eld, A. Atrey, and M. Bhandari, “Intramedullary nailing versus plate §xation for the treatment displaced midsha� clavicular fractures: a systematic review and meta-analysis,” Scienti�c Reports, vol. 6, p. 34912, 2016.

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[6] R. C. McKee, D. B. Whelan, E. H. Schemitsch, and M. D. McKee, “Operative versus nonoperative care of displaced midsha� clavicular fractures: a meta-analysis of randomized clinical trials,” �e Journal of Bone and Joint Surgery American, vol. 94, no. 8, pp. 675–684, 2012.

[7] E. Guerra, D. Previtali, S. Tamborini, G. Filardo, S. Za�agnini, and C. Candrian, “Midsha� clavicle fractures: surgery provides better results as compared with nonoperative treatment: a meta-analysis,” �e American Journal of Sports Medicine, 2019.

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Jiang [12], Beirer [19] and Zehir [22]), the incision length and so� tissue forcible retraction in MIPO were still less than COP. �ese might explain the reason why skin numbness occurred more o�en in the COP group.

In this meta-analysis, complications such as infection, hypertrophic scaring, nonunion, refracture, implant failure, skin irritation, and painful shoulder were evaluated also. �e reason why these complications were pooled together was that the sample size would be smaller if each complication was assessed separately. Pooled results indicated that patients receiving COP had more complications than MIPO, and this was found to be signi§cant (� = 0.005). Five of the included studies reported no major complications such as nonunion, re-fracture, and implant failure in both groups [12, 19–21, 23].�is might be due to the low sample size of included studies.

To our knowledge, this is the §rst systematic review and meta-analysis comparing MIPO and COP for the treatment of midsha� clavicle fractures. However, there were several limitations that should be noted. First, there were only two RCTs that met the eligibility criteria, and the sample sizes were small in most studies. Second, the follow-up duration was relatively short and might underestimate the complications. �ird, due to the lack of relevant data, we could not perform subgroup analysis according to fracture classi§cation. Finally, the existence of bias, owing to di�erent surgeons and surgical technologies, might have been inevitable in our research.

5. Conclusion

�is systematic review and meta-analysis found no di�erences in terms of functional outcomes, operation time, and fracture healing time between MIPO and COP. However, skin

Table 3: Reported complications between MIPO and COP groups.

aNeed operation, bnot need operation.

Study MIPO COP

Jiang 2012 [12]5 Hypertrophic

scarring1 Painful shoulder

Sohn 2015 [13]

1 Implant failure or screw looseninga

1 Implant failure or screw looseningb

2 Skin irritation or discomfort due to plate prominence

3 Skin irritation or discomfort due to plate prominence

1 NonunionBeirer 2015 [19]Kim 2018 [20]You 2018 [21] 4 Hypertrophic

scarring

Zehir 2018 [22]

1 Infection 2 Infection3 Skin irritation 4 Skin irritation

4 Painful shoulder 7 Painful shoulder1 Implant failurea 2 Implant failurea

2 NonunionYou 2019 [23] 1 InfectionTotal 13 32

9BioMed Research International

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[12] H. Jiang and W. Qu, “Operative treatment of clavicle midsha� fractures using a locking compression plate: comparison between mini-invasive plate osteosynthesis (MIPPO) technique and conventional open reduction,” Orthopaedics & Traumatology, Surgery & Research, vol. 98, no. 6, pp. 666–671, 2012.

[13] H. S. Sohn, W. J. Kim, and M. S. Shon, “Comparison between open plating versus minimally invasive plate osteosynthesis for acute displaced clavicular sha� fractures,” Injury, vol. 46, no. 8, pp. 1577–1584, 2015.

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[22] S. Zehir, E. Sahin, M. Songür, T. Altunkiliç, and G. ÖZdemir, “Minimal invasive percutaneous plate osteosynthesis (MIPPO) vs. open plating in superior plating of midsha� clavicle fractures,” Acta Orthopaedica Belgica, vol. 84, no. 4, pp. 491–496, 2018.

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