Superior versus anteroinferior plating for displaced midshaft clavicle fractures: a systematic review and meta-analysis of union, function, and complications.

BACKGROUND

Fixation of clavicular shaft fractures carries risks of nonunion, infection, and functional loss. Although superior and anteroinferior plating have widely been studied, the optimal approach remains debated. Previous literature has relied on indirect comparisons and been limited by early study cutoffs, high heterogeneity, and omission of key outcomes. This meta-analysis directly compared union, function, and complications between superior and anteroinferior plating.

METHODS

This review followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Eligible studies included randomized trials or prospective/retrospective cohort studies of adults. Outcomes of interest included the Disabilities of the Arm, Shoulder, and Hand (DASH) score; Constant-Murley score; and complications (plate removal, infection, nonunion). Risk of bias was assessed using the Risk of Bias in Nonrandomized Studies of Interventions or Cochrane Risk of Bias 2.0 tool, and certainty of evidence was determined with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Analyses were performed in Review Manager 5.4 (Cochrane).

RESULTS

Twelve studies (n=980) were included. Constant-Murley scores did not differ significantly (mean difference [MD]=-1.19; 95% CI, -3.18 to 0.81; P=0.24). Beginning at 2 years, DASH scores showed no difference (MD=1.62; 95% CI, -0.46 to 3.70; P=0.13). Times-tounion (MD=0.41; 95% CI, -0.60 to 1.43; P=0.42) and rates of nonunion (odds ratio [OR]=2.42; 95% CI, 0.59-9.94; P=0.22) were comparable. Plate removal (OR=1.16; 95% CI, 0.82-1.65; P=0.41) and infection (OR=0.81; 95% CI, 0.32-2.06; P=0.66) also showed no significant differences. Heterogeneity was minimal (I2=0).

CONCLUSIONS

Superior and anteroinferior plating of midshaft clavicle fractures provide comparable union rates, functional outcomes, and complication rates. Selection of the surgical approach should depend on fracture morphology, surgeon preference, and patient-specific factors. Level of evidence: III.