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• W3112790489 abstract "Where Are We Now? The functional and long-term benefits of displaced midshaft clavicle fixation are unclear. A comprehensive meta-analysis of observational and experimental comparisons of different modes of clavicle fixation reported that plate and screw fixation (open reduction and internal fixation [ORIF]) of displaced midshaft clavicle fractures was associated with faster healing, lower rates of nonunion, and better long-term function than nonoperative treatment [11]. This contrasts with prior meta-analyses including only randomized controlled trials that found no difference in long-term function after ORIF compared with nonoperative care, but an increased risk of nonunion with nonoperative management [2, 12]. A Cochrane review of randomized and quasi-randomized controlled trials concluded that ORIF provided no functional benefit to patients with displaced midshaft clavicle fractures [4]. Therefore, the best currently available evidence on the treatment of displaced midshaft clavicle fractures does not strongly support surgery, lending itself to debate, discussion, and the proposal of innovative prognostic strategies to highlight the subset of patients who might benefit from ORIF. In this study in Clinical Orthopaedics and Related Research®, Qvist et al. [9] retrospectively analyzed the 2-week and 4-week postinjury VAS pain scores of patients who were treated nonoperatively for closed displaced midshaft clavicle fractures. The authors proposed that persistently high pain scores 4 weeks after injury versus those obtained at 2 weeks after injury should be used to predict a patient’s lack of response to nonoperative treatment. Qvist et al.’s [9] work is a fantastic example of the application of the “keep it simple, stupid” principle to orthopaedic surgery. While undeniably useful throughout medicine, in the trauma setting, the use of validated metrics can be limited because of complex polytrauma, potentially altered mental state and memory, and simple logistical challenges. Although a metric-aided patient outcome analysis is beneficial to patients and is here to stay, this work in particular is an example of how a simple pain scale can be just as useful as, and more versatile than, a multicomponent metric. Where Do We Need to Go? By recognizing the diagnostic challenge presented by clavicle fractures, the authors of the present work [9] sought to expand operative decision-making from “whom?” to “when?” Qvist et al. [9] used a simple VAS pain scale ratio 2 and 4 weeks postinjury to predict nonunion, presumably because long-term pain indicates persistent motion at the fracture site, preventing osseous healing. Establishing a temporal threshold for pain improvement as a determinant of operative intervention using entirely postinjury measurements permits the surgeon to arrive at an easy threshold for operative intervention. In a sense, it permits fractures to “declare themselves,” much like burns or other soft tissue injuries. While the present work proposes a plan for timing the indication for clavicle fixation by highlighting whether such fractures are likely to result in nonunion, additional questions remain: (1) is the pain ratio established by the authors predictive of only symptomatic nonunions, which implies a resulting functional deficit, or will asymptomatic patients be indicated as well? By extension, (2) does delayed fixation bestow clinically important long-term benefits to the patient in terms of function and pain? The lack of consensus regarding the merits of acute clavicle fixation presents a clear challenge to the traumatologist. If the functional benefits of ORIF of midshaft clavicle fractures are to be believed, it would logically lead most surgeons to operate on any viable surgical candidate, regardless of other metrics or cutoffs. However, a functionally equal result regardless of treatment suggests that surgery should only be recommended to those who are predisposed to symptomatic nonunion, which implies worse function and social limitations. Nonunion also makes prognostic works such as the present study [9] far more important; the authors’ prior randomized trial suggested that operating on the wrong patient trades a 15% risk of nonunion for a 25% risk of symptomatic hardware removal [12], which must be considered in addition to the pain, inconvenience, cost, and risks of surgery. Such a consideration must ask whether patients who undergo delayed fixation for nonunion or malunion experience long-term pain and loss of function, which is also unclear. Potter et al. [8] noted that patients who underwent delayed fixation for nonunion or malunion had no differences in ROM, DASH scores, and subjective satisfaction compared with those who underwent acute ORIF. However, flexion endurance and Constant scores after acute fixation were superior to those after delayed management. Our current challenge is therefore not so much a question of definitive care, but rather the expediency of providing such care. The methodology used in and the questions asked by the present work [9] are similar to those of previous studies proposing temporal benchmarks. Nicholson et al. [6] measured postinjury function using the QuickDASH upper extremity questionnaire 6 weeks postinjury, noting that patients with scores above 39.8 were at an increased risk of nonunion. The same authors performed a sonographic analysis of the fracture site at 3, 6, and 12 weeks postinjury, noting that the persistent lack of a bridging fibrocartilaginous callus at these timepoints was increasingly associated with nonunion [7]. While these and the pain ratio espoused by the present work [9] require validation studies, doing so with a multifactorial metric or a radiographic procedure is more challenging. It therefore requires us to ask: “are we overthinking this?” How Do We Get There? It is important to differentiate among those who have a risk of nonunion after sustaining a clavicle fracture using the VAS pain ratio if such a nonunion is debilitating to the patient, be it through increased pain or functional limitations. The authors [9] used a pain ratio to predict the incidence of nonunion as assessed radiographically, and noted that 6 weeks after injury, patients who went on to nonunion had worse DASH scores than those who had union. However, that difference may only highlight the measurement differences between patients whose pain improved dramatically and those whose pain only plateaued (as in the nonunion group). Long-term follow-up studies are necessary to measure function at multiple timepoints 1 year and longer after injury, which may indicate whether the nonunion has limited the patient’s return to work and day-to-day function. Similarly, the relative sensitivity and specificity of pain ratios at longer timepoints may be useful to further delineate between asymptomatic and symptomatic nonunions. This may be a challenge given the need to further stratify patients who experience a significant but relatively infrequent event. Multicenter or system-wide studies will be necessary. A particular challenge will be to demonstrate that complying with an operative threshold based on the VAS pain ratio can yield a population-wide clinically important change in complications, not just a statistical difference. Decreasing the incidence of nonunion from 15% to 12% may not be worth the clinical change or the cost of additional incremental follow-up, particularly if delayed fixation is not associated with severe functional limitations. However, a more-substantial improvement would be harder to ignore clinically. Improvements in functional scores must also be evaluated with the same eye toward clinical significance [5]. Achieving this goal will likely rely on continued side-by-side comparisons with validated metrics such as the DASH score and necessitates long-term follow-up to measure functional gains. Given the inherent costs of continued treatment and reoperation in conjunction with lost time at work and quality-adjusted life years, it is important in long-term validation studies to consider whether the application of a VAS pain ratio will predict return to work in the same or a different capacity. Where possible, it will be important (pre-implementation and post-implementation) to assess the health system and cost of surgical delay to the patient with the use of a VAS pain ratio threshold. Although the DASH score of patients with workers compensation insurance predicted return to work [1], it is unclear whether the DASH would be as useful at the early timepoints at which the VAS pain ratio was used. This will be an important focus for future validation studies. Similar to any benchmark proposed via retrospective analyses, the VAS ratio defined by the authors [9] requires external validation. A study ideally would be a multicenter agreement to delay the fixation of all displaced midshaft clavicle fractures until 2-week and 4-week pain scores are obtained. Then, these patients would be followed for 1 year or longer after injury, with a particular focus on changes in functional scores and return to work. The clear challenge here is institutional compliance and patient informed consent, which must be considered in a broader geographic population analysis given the cultural, genetic, and psychosocial differences that exist in reporting pain [3]. To prevent the discarding of a VAS pain ratio model purely because of the inconvenience necessary to validate it, a mixed internal-external validation study performed in independent health system studies may be a viable alternative to the cost and logistical challenges of a multicenter randomized trial [10]. The authors [9] should be praised for their thoughtfulness in the development of a simple, straightforward metric for driving the care of an otherwise challenging injury." @default.
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• W3112790489 date "2020-12-08" @default.
• W3112790489 modified "2023-09-26" @default.
• W3112790489 title "CORR Insights®: Minimal Pain Decrease Between 2 and 4 Weeks after Nonoperative Management of a Displaced Midshaft Clavicle Fracture Is Associated with a High Risk of Symptomatic Nonunion" @default.
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