Different internal fixation methods for unstable distal clavicle fractures in adults: a systematic review and network meta-analysis

BACKGROUND: Surgical treatment is advised for unstable distal clavicle fractures (UDCFs). Various kinds of internal fixation methods have been used, but the best fixation is still controversial. METHODS: We systematically searched all studies comparing postoperative outcomes of coracoclavicular (CC) reconstruction (TightRope, EndoButton, Mersilene tape, suture anchor or suture), fracture osteosynthesis (clavicular hook plate (HP), locking compression plate (LCP), Kirschner wire and tension band (KWTB), Kirschner wire (KW)), and a combination of the two methods (LCP + CC or KWTB + CC) for UDCF in PubMed, Web of Science Core Collection via Ovid, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and China Biology Medicine (CBM) databases up to September 16, 2021, with no language restrictions. A network meta-analysis (NMA) was conducted to integrate direct and indirect evidence and assess the relative effects of the internal fixation methods. The probability of being the best treatment was assessed by the surface under the cumulative ranking curve (SUCRA). RESULTS: A total of 41 studies were included, involving 1969 patients and seven internal fixation methods. The NMA showed that LCP + CC fixation was associated with better efficacy (odds ratio (OR) 0.60, 95% CI 0.19–1.02, probability rank = 0.93) and fewer complications (odds ratio (OR) 0.22, 95% CI 0.09–0.51, probability rank = 0.69) than any other internal fixation method for UDCFs. The SUCRA probabilities of LCP + CC fixation were 98.6% for the Constant–Murley score and 93.9% for total complications. CONCLUSIONS: The results of this study indicate that LCP + CC appears to be the best internal fixation method for UDCF. Limited to the quality and quantity of the included studies, much larger and higher-quality RCTs are required to confirm these conclusions. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13018-021-02904-6.