Surgical enhancement of fracture healing - operative vs. nonoperative treatment

Although the success story of surgical fracture treatment led to a tremendous improvement of treatment outcome for certain fractures such as femur or tibia shaft fractures, the overall benefit of surgical versus conservative treatment remains controversial for several types of fractures. For this sake, we carried out a narrative review of high-level of evidence studies comparing treatment outcomes in fractures with controversial debates on the value of surgical therapy in clavicle, proximal humerus, olecranon, ankle, calcaneus and Jones fractures. We identified eight studies (Level-I and -2) with functional and quality of life outcomes in these fractures. Only in Jones fractures of the fifth metatarsal bone, bone healing and functional outcomes were significantly better after surgical compared to conservative treatment. In terms of patient-related quality of life, surgical treatment was not found to be superior compared to conservative treatment in all the above-mentioned fractures. In many trials, lower nonunion rates after surgical treatment were offset by complications due to the surgical procedure. Nonunion after conservative treatment often seemed to have only limited impact on functional results. However, the comparability of studies was limited due to age-differences between patients. Therefore, we emphasize the need for further investigations to determine which patient-related factors favor a conservative treatment approach and for whom surgery is the best option.