ANTERIOR VS. SUPERIOR PLATING
Anterior inferior plating of midshaft clavicle fractures in adults may lead to lower implant removal rates compared to superior plating.

Rationale

A single low-quality retrospective observational study (Serrano 2017) was included. There were 510 patients with mid-shaft clavicle fractures treated with either anterior-inferior (AI) plating or superior plating at the surgeon’s discretion. The minimum follow up was 24 months. Regarding union rate and time to union, there was no difference between treatment groups. Similarly, regarding infection rate, there was no difference between treatment groups. Regarding implant removal for plate irritation, AI plating was preferred with superior plating carrying a 5 times greater odds ratio. Due to the decreased risk for a secondary intervention, this could be inferred to decrease the financial burden for the patient.

Benefits/Harms of Implementation

There is increased patient satisfaction assumed due to the decreased need for plate removal. Additionally, there are risks to a second operation so reducing the risk of a secondary operation is likely beneficial to patients.

Outcome Importance

There is no difference in union rate or time to union dependent upon plate position for mid shaft clavicle fixation. In addition, the infection rate is not different depending upon plate placement. However, rates of implant removal may vary depending on plate position and surgeons should be aware of this. The plate position for fixation should be at the discretion of the treating surgeon.

Cost Effectiveness/Resource Utilization

Due to decreased need for plate removal with anterior inferior plating, there is decreased burden on the health care system.

Acceptability

Either treatment is acceptable. The patient can be counseled regarding a low-quality study finding a lower need for plate removal and assumed increased patient satisfaction. Many orthopedic surgeons treating clavicle fractures likely already use both plate positions depending on fracture pattern and patient characteristics.

Feasibility

Either plate position should be feasible for most orthopedic surgeons treating clavicle fractures.

Future Research

Future research is needed to increase the number of studies with these two treatment interventions in direct comparison. Research should also focus on patient reported outcome measures to understand the relationship between satisfaction and plate removal.