DUAL PLATING

There were three low quality studies evaluating single versus dual plate fixation of midshaft clavicle fractures (Chen 2017, DeBaun 2020, Lee 2020). The studies evaluated differing aspects of clavicle fracture fixation. They compared results between dual mini fragment plates of multiple sizes (DeBaun 2020), dual plating with mini fragment and small fragment plates (Chen 2017), and finally two orthogonal mini-fragment plates (Lee 2020) compared to a single small fragment plate. The small fragment plate type, position, and fixation strategy (lag/neutralize/bridge/compression) was at the discretion of the operating surgeon in the studies with not all details reported (Chen 2017, DeBaun 2020), and not delineated (Lee 2020).

Lee (2020) did not find a significant difference in the need for hardware removal, but 8/89 small fragment plates were removed while no mini fragment plates were removed. Thus, the study favored mini fragment fixation regarding implant removal. This may not be applicable in the non-military population.

In Chen (2017) ten patients elected to undergo plate removal, with 7/10 being small fragment superior placement, favoring mini fragment dual plate fixation in terms of implant removal.  DeBaun (2020) did not find a significant difference in hardware removal.

Benefits/Harms of Implementation

Any reoperation is considered a risk and the reoperation rate varied due to implant type and position. The use of multiple smaller plates rather than a single larger 3.5mm plate may benefit patients by providing similar union rates with a reduced rate of secondary procedures.

Outcome Importance

Dual plate fixation is an acceptable treatment for mid shaft clavicle fractures. There could be selection bias depending upon fracture type.

Cost Effectiveness/Resource Utilization

Higher rates of reoperation were noted for single implant fixation, leading to increased cost. In the one study that reported total operative time, those patients undergoing dual plate fixation took almost an hour longer in the operating room leading to increased cost. Formal cost analysis was not performed in any of the included studies.

Acceptability

These studies represent low quality studies with inconsistent operative details and outcomes. Consideration of dual plating techniques is likely acceptable to most orthopedic surgeons treating clavicle fractures as it within the current standards of care for treatment.

Feasibility

These studies may be useful when planning fixation for specific groups of patients in terms of counseling regarding hardware removal and union rate. Implementation of dual plating techniques in appropriate patients is likely feasible for most orthopedic surgeons as these implants are readily available in most hospitals similar to the single larger plates.

Future Research

Future studies are warranted on single versus dual plate fixation with controlled variables including type of plate, fracture type and positioning of plates. Details regarding duration of surgery and including patient reported outcome measures would be helpful. Large studies of diverse populations are necessary to assist in developing best practices on this topic.