The Evolving Approach to Treating Syndesmotic Injuries in the Elite Athlete: An International Perspective

Category: Ankle, Sports Introduction/Purpose: There exists little consensus regarding optimal treatment protocols for syndesmotic injuries. Orthopaedic clinicians have implemented a variety of treatment strategies, ranging from immobilization to screw fixation to new flexible fixation devices. While the body of literature is growing with regard to both the biomechanics and clinical outcomes for various constructs and rehabilitation protocols, there is little consensus on the optimal treatment and return to sport strategy for these injuries. We endeavored to assess current approaches to syndesmotic injures by orthopedic foot and ankle specialists around the world in 6 athlete scenarios with increasing degree of injury. Commensurate with the lack of available data to guide treatments, we hypothesize that there will be variability in the treatment and management strategies for syndesmotic injuries. Methods: A REDcap survey was created with 27 questions, including respondent demographics, indications for treatment of syndesmotic injuries, preferred treatment, preferred technique for repairing the syndesmosis and post-operative management. Respondents were asked to choose their preferred fixation device and post-operative return to play protocols in six different athlete scenarios (moderate impact, high impact and very high impact and each with/without complete deltoid injury). The survey was disseminated among the memberships of 18 North American and International medical societies. Society members were surveyed via three emails disseminated 2 weeks apart. Frequencies and percentages were calculated for all categorical responses. Results: A total of 596 providers responded to the survey, including 337 American surgeons and 259 members of various international societies. There was a 70% survey completion rate with a wide geographic distribution among respondents. Flexible devices were the preferred fixation construct (48.1%), followed by screws (27.5%), hybrid fixation (18.5%) and other (5.9%). There was a higher preference for flexible devices among sports medicine trained providers. 62% of respondents noted that their rehabilitation protocols would not change for each athlete scenario. Considerable variability was present in anticipated full return to sport, ranging from immediately following injury to 6 months post-op (Fig 1). One-third of respondents indicated that they repair the deltoid greater than 50% of the time when injured. Conclusion: We found a wide variety of indications and treatment constructs employed by orthopaedic surgeons for athletes with ligamentous syndesmotic injuries requiring fixation. Although, flexible fixation devices are the preferred among all respondents but there was a considerable variability in device choices. Fellowship training also appears to affect the preferred fixation device choice. There also exists substantial variability in expected return to play for every athlete scenario (Fig 1). The diversity in approaches and post-operative recommendations underscores the need for evidence-based guidelines to inform management of syndesmotic injuries.

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The Evolving Approach to Treating Syndesmotic Injuries in the Elite Athlete: An International Perspective

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00400 ◽

2020 ◽

Vol 8 (7_suppl6) ◽

pp. 2325967120S0040

Author(s):

Jonathan Bartolomei ◽

Kenneth Hunt ◽

Shanthan Challa

Keyword(s):

Sports Medicine ◽

Return To Sport ◽

High Impact ◽

Optimal Treatment ◽

Return To Play ◽

Considerable Variability ◽

Fixation Device ◽

Flexible Devices ◽

Fixation Devices ◽

Rehabilitation Protocols

Objectives: There exists little consensus regarding optimal treatment protocols for syndesmotic injuries. Orthopaedic clinicians have implemented a variety of treatment strategies, ranging from immobilization to screw fixation to new flexible fixation devices. While the body of literature is growing with regard to both the biomechanics and clinical outcomes for various constructs and rehabilitation protocols, there is little consensus on the optimal treatment and return to sport strategy for these injuries. We endeavored to assess current approaches to syndesmotic injures by orthopedic foot and ankle specialists around the world in 6 athlete scenarios with increasing degree of injury. Commensurate with the lack of available data to guide treatments, we hypothesize that there will be great variability in the treatment and management of syndesmotic injuries. Methods: A REDcap survey was created with 27 questions, including respondent demographics, indications for treatment of syndesmotic injuries, preferred treatment, preferred technique for repairing the syndesmosis and post-operative management. Respondents were asked to choose their preferred fixation device and post-operative return to play protocols in six different athlete scenarios (moderate impact, high impact and very high impact and each with/without complete deltoid injury). The survey was disseminated among the memberships of 18 North American and International medical societies. Society members were surveyed via three emails disseminated 2 weeks apart. Frequencies and percentages were calculated for all categorical responses. Results: A total of 596 providers responded to the survey, including 337 American surgeons and 259 members of various international societies. There was a 70% survey completion rate with a wide geographic distribution among respondents. Flexible devices were the preferred fixation construct (48%), followed by screws (27%), hybrid fixation (19%) and other (6%). There was a higher preference for flexible devices among sports medicine trained providers (58%) relative to non-sports medicine trained providers (44%). 62% of respondents noted that their rehabilitation protocols would not change for each athlete scenario. Considerable variability was present in anticipated full return to sport, ranging from immediately following injury to 6 months post-op (Fig 1). 33% stated that they would repair the deltoid ‘greater than 50%’ of the time if injured. Conclusion: There is a wide variety of indications and treatment constructs employed by orthopaedic surgeons for athletes with ligamentous syndesmotic injuries requiring fixation. Although, flexible fixation devices are the preferred among all respondents but there was a considerable variability in device choices. Fellowship training also appears to affect the preferred fixation device choice. There also exists substantial variability in expected return to play for every athlete scenario (Fig 1). The diversity in approaches and post-operative recommendations underscores the need for evidence-based guidelines regarding management of syndesmotic injuries.

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Current Practices in the Treatment of Syndesmotic Injuries: A Global Perspective

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00113 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0011

Author(s):

Jonathan Bartolomei ◽

Shanthan C. Challa ◽

Kenneth J. Hunt ◽

Daniel K. Moon

Keyword(s):

North American ◽

Sports Medicine ◽

Return To Sport ◽

High Impact ◽

Optimal Treatment ◽

Return To Play ◽

Considerable Variability ◽

Flexible Devices ◽

Fixation Devices ◽

Rehabilitation Protocols

Category: Ankle; Sports Introduction/Purpose: There exists little consensus regarding optimal treatment protocols for syndesmotic injuries. Orthopedic clinicians have implemented a variety of treatment strategies, ranging from immobilization to screw fixation to new flexible fixation devices. While the body of literature is growing with regard to both the biomechanics and clinical outcomes for various constructs and rehabilitation protocols, there is little consensus on the optimal treatment and return to sport strategy for these injuries. We endeavored to assess current approaches to syndesmotic injuries by orthopedic foot and ankle specialists around the world in six athlete scenarios with increasing degrees of injury. Commensurate with the lack of available data to guide treatments, we hypothesize that there will be great variability in the treatment and management of syndesmotic injuries. Methods: A REDcap survey was created with 27 questions, including respondent demographics, indications for treatment of syndesmotic injuries, preferred treatment, preferred technique for repairing the syndesmosis, and post-operative management. Respondents were asked to choose their preferred fixation device and post-operative return to play protocols in six different athlete scenarios (moderate impact, high impact, and very high impact and each with/without complete deltoid injury). The survey was disseminated among the memberships of 18 North American and International medical societies. Society members were surveyed via three emails distributed two weeks apart. Frequencies and percentages were calculated for all categorical responses. Results: A total of 596 providers responded to the survey, including 337 American surgeons and 259 members of various international societies. There was a 70% survey completion rate with a wide geographic distribution among respondents. Flexible devices were the preferred fixation construct (48%), followed by screws (27%), hybrid fixation (19%) and other (6%). There was a higher preference for flexible devices among sports medicine trained providers (58%) relative to non-sports medicine trained providers (44%). 62% of respondents noted that their rehabilitation protocols would not change for each athlete scenario. Considerable variability was present in anticipated full return to sport, ranging from immediately following injury to six months post-op. 33% stated that they would repair the deltoid ‘greater than 50%’ of the time if injured. Conclusion: There is a wide variety of indications and treatment constructs employed by orthopedic surgeons for athletes with ligamentous syndesmotic injuries requiring fixation. Although flexible fixation devices are the preferred choice among all respondents, there was considerable variability in device choices. Fellowship training also appears to affect the preferred fixation method. There was no overall difference between device preference between North American and International respondents (Fig1). There also exists substantial variability in expected return to play for every athlete scenario. The diversity in approaches and post-operative recommendations underscores the need for evidence-based guidelines regarding the management of syndesmotic injuries.

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Results of hip arthroscopy in elite level water polo players with femoroacetabular impingement: return to play and patient satisfaction

Journal of Hip Preservation Surgery ◽

10.1093/jhps/hnz069 ◽

2020 ◽

Vol 7 (1) ◽

pp. 116-121

Author(s):

Nicholas Ramos ◽

Keon Youssefzadeh ◽

Michael Gerhardt ◽

Michael Banffy

Keyword(s):

Patient Satisfaction ◽

Femoroacetabular Impingement ◽

Hip Arthroscopy ◽

Return To Sport ◽

The Body ◽

Return To Play ◽

Water Polo ◽

Study Results ◽

Division 1 ◽

Elite Level

Abstract Water polo places significant stress on the hip joint requiring repetitive hip flexion and rotation to elevate the body out of water for passing, shooting and blocking. Femoroacetabular impingement (FAI) is common in water polo athletes; however, no study to date has investigated the results of hip arthroscopy in this patient population. The purpose of this study was to determine return to play rates and satisfaction following hip arthroscopy for FAI in a cohort of elite level water polo players. A retrospective review of our surgical database was performed. Collegiate water polo players with clinical and radiographic FAI who underwent hip arthroscopy were identified. Pre- and post-operative modified Harris hip scores (mHHSs) were obtained. Patient surveys were administered to determine return to play rates, level of return to play, timing of return and patient satisfaction. A Wilcoxon ranked sum test was performed to compare pre- and post-operative outcome scores. Ten patients met inclusion criteria. Average age was 19.5 years old (SD ±1.08). All patients were male Division 1 collegiate water polo players. Median mHHS improved from 66.0 (SD ±7.9) pre-operatively to 89.5 (SD ±3.2) at average 1.6 years (range: 0.4–3.6 years) post-operatively. Patient survey responses demonstrated a 100% return to water polo and 100% return to the same level of play (NCAA Division 1) at mean 5.75 months (SD ±1.8). All patients (10/10) reported being satisfied with their surgical result. Our study results, suggest that return to sport rates and patient satisfaction are high in water polo players who undergo hip arthroscopy for FAI.

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Stretching for Recovery from Groin Pain or Injury in Athletes: A Critical and Systematic Review

Journal of Functional Morphology and Kinesiology ◽

10.3390/jfmk6030073 ◽

2021 ◽

Vol 6 (3) ◽

pp. 73

Author(s):

José Afonso ◽

João Gustavo Claudino ◽

Hélder Fonseca ◽

Daniel Moreira-Gonçalves ◽

Victor Ferreira ◽

...

Keyword(s):

Groin Pain ◽

Case Series ◽

Return To Sport ◽

Return To Play ◽

Cochrane Library ◽

Eligibility Criteria ◽

Rehabilitation Protocols ◽

Recovery Protocols ◽

Meta Analyses ◽

Specific Contribution

Stretching is usually used as part of rehabilitation protocols for groin pain or injury, but its specific contribution to and within multimodal recovery protocols is unclear. Our goal was to systematically review the effects of stretching for the recovery from groin pain or injury. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, with eligibility criteria defined according to PICOS: (Participants) athletes with groin pain or injuries; (Interventions) interventions with stretching as the differentiating factor; (Comparators) comparators not applying stretching; (Outcomes) symptom remission or improvement and/or time to return to sport and/or return to play; (Study design) randomized controlled trials. Searches were performed on 26 March 2021, in CINAHL, Cochrane Library, EBSCO, EMBASE, PEDro, PubMed, Scielo, Scopus, SPORTDiscus, and Web of Science, with no limitations regarding language or date, and no filters. Of 117 retrieved results, 65 were duplicates and 49 were excluded at the screening stage. The three articles eligible for full-text analysis failed to comply with one or more inclusion criteria (participants, intervention and/or comparators). We then went beyond the protocol and searched for non-randomized trials and case series, but no intervention was found where stretching was the differentiating factor. We found no trials specifically assessing the effects of stretching on recovery or improvement of groin pain or injury in athletes. Currently, the efficacy of these interventions is unknown, and more research is warranted.

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Evolving and Innovative Treatments for Syndesmosis Injuries

Foot & Ankle Orthopaedics ◽

10.1177/2473011418s00256 ◽

2018 ◽

Vol 3 (3) ◽

pp. 2473011418S0025

Author(s):

Kenneth Hunt ◽

Daniel Moon ◽

Phinit Phisitkul ◽

Jeremy McCormick ◽

Annunziato Amendola

Keyword(s):

Online Survey ◽

Treatment Strategies ◽

Return To Sport ◽

High Impact ◽

Return To Play ◽

Free Text ◽

Cross Sectional ◽

Orthopaedic Surgeons ◽

Orthopedic Surgeons ◽

Very High

Category: Sports Introduction/Purpose: Despite extensive research of syndesmotic fixation techniques, there is little consensus regarding optimal treatment and return to play protocols for isolated syndesmotic injuries. As competing treatment goals may exist, orthopedic clinicians have resorted to a wide variety of treatment strategies, ranging from screw fixation to suture fixation in various constructs. Given the myriad techniques and constructs, it is increasingly important to understand the rationale and intended patient setting for selecting particular implants and constructs. Undoubtedly, a multitude of factors contribute to the range of outcomes following syndesmotic fixation. While there are various theoretical arguments made for selecting one construct over another, this study seeks to assess the distribution of current practice approaches to syndesmotic injuries by foot and ankle orthopaedic surgeons at large. Methods: This cross-sectional study collected data from trained, licensed orthopedic surgeons (i.e. MD, DO, etc.) practicing in North America that treat isolated syndesmotic injuries. A one-time online survey was disseminated to the AOFAS membership. The survey contained questions regarding participant demographics, indications for treating syndesmotic injuries, preferred technique for repairing the syndesmosis and post-operative management, as applied to six athlete scenarios (moderate, high, and very high impact athletes with complete syndesmosis injury, with and without complete deltoid injury), and post-operative return to play protocols. Frequencies and percentages were calculated for all categorical responses using STATA 14.2. Free text responses were analyzed for common themes by fellowship trained, licensed orthopedic surgeons. Results: 273 of 337 responses were complete. Radiographic widening of greater than 2 mm at the syndesmosis was a sole indication for surgery for 83% of respondents, and arthroscopic widening of the syndesmosis was a sole indication for 75%. No clinical exam or MRI finding reached a threshold of 50% as a sole indication. In moderate and high-impact athletes with complete syndesmotic injury, the majority of respondents use one or two flexible fixation devices (61.5% and 50.5%, respectively), 25% use screws only, and 23.7% use a combination. More than 70% do not change their treatment construct choice in the presence of a complete deltoid injury. There was considerable variability in anticipated return to sport amongst respondents for all injury scenarios, ranging from 2 weeks to 6 months. Conclusion: There is a wide variety of indications and treatment constructs employed by orthopaedic surgeons for athletes with ligamentous syndesmotic injuries requiring fixation. Despite absent consensus, several trends were evident. Flexible devices were utilized by a majority of respondents in all scenarios, even with ‘very high impact’ scenarios. Hybrid constructs are also common. The presence of a complete deltoid injury impacted fixation constructs for very few respondents. There is substantial variability in expected return to play for all athlete and injury scenarios. The diversity of approaches highlights the need for evidence-based guidelines regarding management of syndesmotic injuries.

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A Comparison of Physical Therapy Protocols Between Open Latarjet Coracoid Transfer and Arthroscopic Bankart Repair

Sports Health A Multidisciplinary Approach ◽

10.1177/1941738119887396 ◽

2020 ◽

Vol 12 (2) ◽

pp. 124-131

Author(s):

Alexander Beletsky ◽

Jourdan M. Cancienne ◽

Brandon J. Manderle ◽

Nabil Mehta ◽

Kevin E. Wilk ◽

...

Keyword(s):

Range Of Motion ◽

Sports Medicine ◽

Return To Sport ◽

Return To Play ◽

Bankart Repair ◽

Level Of Evidence ◽

Arthroscopic Bankart Repair ◽

Rehabilitation Protocols ◽

Level 3 ◽

Tissue Stabilization

Context: Recent studies examining return to sport after traumatic shoulder instability suggest faster return-to-sport time lines after bony stabilization when compared with soft tissue stabilization. The purpose of the current study was to define variability across online Latarjet rehabilitation protocols and to compare Latarjet with Bankart repair rehabilitation time lines. Evidence Acquisition: Online searches were utilized to identify publicly available rehabilitation protocols from Accreditation Council for Graduate Medical Education (ACGME)–accredited academic orthopaedic surgery programs. Study Design: Descriptive epidemiology study. Level of Evidence: Level 3. Results: Of the 183 ACGME-accredited orthopaedic programs reviewed, 14 institutions (7.65%) had publicly available rehabilitation protocols. A web-based search yielded 17 additional protocols from private sports medicine practices. Of the 31 protocols included, 31 (100%) recommended postoperative sling use and 26 (84%) recommended elbow, wrist, and hand range of motion exercises. Full passive forward flexion goals averaged 3.22 ± 2.38 weeks postoperatively, active range of motion began on average at 5.22 ± 1.28 weeks, and normal scapulothoracic motion by 9.26 ± 4.8 weeks postoperatively. Twenty (65%) protocols provided specific recommendations for return to nonoverhead sport–specific activities, beginning at an average of 17 ± 2.8 weeks postoperatively. This was compared with overhead sports or throwing activities, for which 18 (58%) of protocols recommended beginning at a similar average of 17.1 ± 3.3 weeks. Conclusion: Similar to Bankart repair protocols, Latarjet rehabilitation protocols contain a high degree of variability with regard to exercises and motion goal recommendations. However, many milestones and start dates occur earlier in Latarjet protocols when compared with Bankart-specific protocols. Consequently, variability in the timing of rehabilitation goals may contribute to earlier return to play metrics identified in the broader literature for the Latarjet procedure when compared with arthroscopic Bankart repair. Strength of Recommendation Taxonomy (SORT): Level C.

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Design of Free Stalls for Dairy Herds: A Review

Ruminants ◽

10.3390/ruminants1010001 ◽

2021 ◽

Vol 1 (1) ◽

pp. 1-22

Author(s):

Frank van Eerdenburg ◽

Lars Ruud

Keyword(s):

Optimal Design ◽

Dairy Cattle ◽

Animal Welfare ◽

Milk Yield ◽

High Impact ◽

The Body ◽

Dairy Herds ◽

Productive Life ◽

To Come ◽

Available Information

Lying is an important behavior of dairy cattle. Cows should spend more than 50% of a day lying as it has a high impact on their milk yield and animal welfare. The design, size, and flooring properties of the free stalls influence the time cows spend lying, the way they lie down, and their rising movements. The purpose of this review is to provide an overview of the currently available information with the aim to assist farmers and advisors to come to an optimal design of the free stalls. The design of the free stalls should enable the cows to move and lie in positions as natural as possible. Cows should rest, with all parts of the body, on a clean, dry and soft bed, be able to stretch their front legs forward, lie on their sides with unobstructed space for their neck and head, and rest with their heads against their flanks without hindrance from a partition. When they stand, they should not be hindered by neck rails, partitions, or supports. A comfortable place for cows to lie down helps cows to stay healthy, improve welfare, and increase milk yield. Hence, the probability of a longer productive life for the cows increases and the number of replacements per year decreases.

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Essentials for Best Practice: Treatment Approaches for Athletes With Eating Disorders

Journal of Clinical Sport Psychology ◽

10.1123/jcsp.2018-0013 ◽

2018 ◽

Vol 12 (4) ◽

pp. 495-507 ◽

Cited By ~ 2

Author(s):

Jenny H. Conviser ◽

Amanda Schlitzer Tierney ◽

Riley Nickols

Keyword(s):

Eating Disorders ◽

Emotional Regulation ◽

Best Practice ◽

Sport Participation ◽

Emotional Health ◽

Multidisciplinary Treatment ◽

Return To Sport ◽

Multidisciplinary Care ◽

Return To Play ◽

Treatment Team

Eating disorders (EDs) and disordered-eating behaviors (DEBs), pose a high risk of morbidity and mortality, threatening physical health, emotional health, and overall quality of life. Unfortunately, among athletes, prevalence rates continue to increase. This document summarizes the challenges of establishing and navigating the multidisciplinary care needed to effectively treat EDs and DEBs among athletes. The benefits of timely and frequent communication within the multidisciplinary treatment team (MDTT) are emphasized and discussed. Authors advise who should be selected as members of the MDTT and suggest that all personnel, including athletic coaches, athletic trainers, physical therapists, and certified fitness professionals be ED-informed and ED-sensitive. Vital components of care are noted including use of a variety of evidence-based psychotherapeutic modalities, interventions which target emotional regulation, and prioritize values based compassionate care. Authors caution that performance decrements and medical/physiological changes are not always easily observable in individuals with EDs and DEBs and therefore, attuned, consistent, and ongoing monitoring is needed. Consensus regarding previously established parameters for return to play and careful titration of physical activity throughout the ED recovery process are suggested as important for preserving health, preventing re-injury, or relapse and facilitating successful return to sport participation.

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Minimally Invasive Double-Button Fixation of Displaced Lateral Clavicular Fractures in Athletes

The American Journal of Sports Medicine ◽

10.1177/0363546516666816 ◽

2016 ◽

Vol 45 (2) ◽

pp. 462-467 ◽

Cited By ~ 6

Author(s):

Maximiliano Ranalletta ◽

Luciano A. Rossi ◽

Hugo Barros ◽

Francisco Nally ◽

Ignacio Tanoira ◽

...

Keyword(s):

Minimally Invasive ◽

Closed Reduction ◽

Functional Outcomes ◽

Constant Score ◽

Case Series ◽

Return To Sport ◽

Return To Play ◽

Short Version ◽

Level Of Evidence ◽

The Mean

Background: Early union and a rapid return to prior function are the priorities for young athletes with lateral clavicular fractures. Furthermore, it is essential to avoid nonunion in this subgroup of patients, as this is frequently associated with persistent pain, restriction of movement, and loss of strength and endurance of the shoulder. Purpose: To analyze the time to return to sport, functional outcomes, and complications in a group of athletes with displaced lateral clavicular fractures treated using closed reduction and minimally invasive double-button fixation. Study Design: Case series; Level of evidence, 4. Methods: A total of 21 athletes with displaced lateral clavicular fractures were treated with closed reduction and minimally invasive double-button fixation between March 2008 and October 2013. Patients completed a questionnaire focused on the time to return to sport and treatment course. Functional outcomes were assessed with the Constant score and the short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Pain was evaluated with the visual analog scale (VAS). Radiographs were reviewed to identify radiographic union, malunion, and nonunion. Results: Of the 21 study patients, 20 returned to sport after treatment; 100% returned to the same level. The mean time to return to play was 78 days (range, 41-120 days). Four patients (20%) returned to sport less than 6 weeks after surgery, 14 (70%) returned between 6 and 12 weeks after surgery, and 2 (10%) returned after 12 weeks. The mean Constant score was 89.1 ± 4.2 (range, 79-100), the mean QuickDASH score was 0.4 ± 2.6 (range, 0-7.1), and the mean VAS pain score was 0.4 ± 1.0 (range, 0-3) at final follow-up (mean, 41 months). The only complication was asymptomatic nonunion. Hardware removal was not necessary in any patient. Conclusion: Closed reduction and minimally invasive double-button fixation of displaced lateral clavicular fractures in athletes was successful in terms of returning to the previous level of athletic activity regardless of the type of sport, with excellent clinical results and a low rate of complications.

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Functional Outcomes and Complications of Intramedullary Fixation Devices for Midshaft Clavicle Fractures: A Systematic Review and Meta-Analysis.

10.21203/rs.2.13080/v3 ◽

2020 ◽

Author(s):

Paul Hoogervorst ◽

Tess van Dam ◽

Nico Verdonschot ◽

Gerjon Hannink

Keyword(s):

Systematic Review ◽

Functional Outcomes ◽

Meta Analysis ◽

Risk Of Bias ◽

Intramedullary Fixation ◽

Common Complication ◽

Fixation Device ◽

Operative Strategy ◽

Fixation Devices ◽

Clavicle Fractures

Abstract Background An alternative to the current gold standard in operative treatment of displaced midshaft clavicle fractures (DMCF) using plate osteosynthesis, is internal fixation by means of intramedullary fixation devices. These devices differ considerably in their specifications and characteristics. The aim of this systematic review is to generate an overview of functional outcomes and complications in the management of DMCF per available intramedullary device.Methods A systematic review was conducted to identify all papers reporting functional outcomes, union rates and/or complications using an intramedullary fixation device for the management of midshaft clavicle fractures. Multiple databases and trial registries were searched from inception until February 2020. Meta-analysis was conducted based on functional outcomes and type of complication per type of intramedullary fixation device. Pooled estimates of functional outcomes scores and incidence of complications were calculated using a random effects model. Risk of bias and quality was assessed using the Cochrane risk of bias and ROBINS-I tools. The confidence in estimates were rated and described according to the recommendations of the GRADE working group.Results Sixty-seven studies were included in this systematic review. The majority of studies report on the use of Titanium Elastic Nails (TEN). At 12 months follow up the Titanium Elastic Nail and Sonoma CRx report an average Constant-Murley score of 94.4 (95%CI 93-95) and 94.0 (95%CI 92-95) respectively (GRADE High). The most common reported complications after intramedullary fixation are implant-related and implant-specific. For the TEN, hardware irritation and protrusion, telescoping or migration, with a reported pooled incidence 20% (95%CI 14-26) and 12% (95%CI 8-18), are most common (GRADE Moderate). For the Rockwood/Hagie Pin, hardware irritation is identified as the most common complication with 22% (95%CI 13-35) (GRADE Low). The most common complication for the Sonoma CRx was cosmetic dissatisfaction in 6% (95%CI 2-17) of cases (GRADE Very low). Conclusion Although most studies were of low quality, good functional results and union rates irrespective of the type of device are found. However, there are clear device-related and device-specific complications for each. The results of this systematic review and meta-analysis can help guide surgeons in choosing the appropriate operative strategy, implant and informing their patient.

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