Fixation method for treatment of unstable distal clavicle fracture: systematic review and network meta-analysis

Surgical management is recommended for unstable distal clavicle fractures. A variety of methods have been previously reported, but there is no current consensus regarding which method is most suitable. Therefore, we have conducted a systematic review and network meta-analysis to compare postoperative shoulder function and complications between different fixation methods to identify which class of fixation is best for unstable distal clavicle fractures. We searched the literature systematically using eligibility criteria of all comparative studies that compared postoperative outcomes of coracoclavicular fixation (tight rope, screw or endobutton), hook plating, plate and screws, tension band wiring and transacromial pinning fixation for unstable distal clavicle fractures from PubMed, EMBASE, and Scopus databases up to February 10, 2018. Two reviewers independently extracted data. A network meta-analysis was applied to combine direct and indirect evidence and to estimate the relative effects of the treatment options. The probability of being the best treatment was estimated using surface under the cumulative ranking curves (SUCRA). Ten comparative studies (n = 505 patients) with one RCT study (n = 42) met the inclusion criteria. Intervention included coracoclavicular fixation (n = 111 patients), hook plating (n = 300 patients), plate and screws (n = 41 patients), tension band wiring (n = 81 patients) and transacromial pinning (n = 14 patients). A network meta-analysis showed that CM scores of coracoclavicular fixation were significantly higher when compared to hook plate and tension band wiring, with pooled mean of 2.98 (95% CI 0.05-5.91) and 7.11 (95% CI 3.04-11.18). For UCLA, CC fixation and plate and screw fixation had significantly higher scores compared to hook plating fixation with a mean score 2.22 (95% CI 0.44-3.99) and 3.20 (95% CI 0.28-6.12), respectively. In terms of complications, plate and screw fixation had lower risk with RRs of 0.63 (95% CI 0.20-1.98), 0.37 (95% CI 0.19-0.72), 0.11 (95% CI 0.04-0.30) and 0.02 (95% CI 0.002-0.16) when compared to coracoclavicular fixation, hook plating, tension band wiring and transacromial pinning. The SUCRA probabilities of CC fixation were in the first rank with 96.8% for CMS, while plate and screw fixation were in the first rank with 67.7 and 93.8% for UCLA score and complications. We recommend using plate and screw and CC fixation as the first- and second-line treatment of unstable distal clavicle fractures. As the quality of studies for this meta-analysis was not high, larger and higher-quality randomized controlled trials are required to confirm these conclusions for informed clinical decision making.