Surgical and non-surgical treatment for fully displaced lateral clavicle fractures have similar outcomes: An observational register study of 113 patients.

INTRODUCTION: Whether displaced lateral clavicle fractures should be treated surgically remains controversial. This study aims to compare outcomes after surgical versus non-surgical treatment of such fractures. PATIENTS AND METHODS: 113 patients with lateral clavicle fractures registered in the Swedish Fracture Register (SFR) during 2018 and with complete displacement on radiography were included in this cohort study. Linkage with the National Patient Register provided information on baseline medical comorbidities and further interventions. Patient-reported outcome measures (PROM) were assessed using the European Quality of Life Scale (EQ-5D-3L), the Short Musculoskeletal Function Assessment (SMFA), and the Quick Disabilities of the Arm, Shoulder and Hand (QDASH). The primary outcome was the total number of initial and delayed surgical procedures. The secondary outcome was difference in PROM between surgically and non-surgically treated patient groups. RESULTS: At a mean follow-up of 4.4 (range 3.9-4.9) years, 35 (67 %) of the 52 patients initially treated surgically had undergone a secondary procedure, mostly for implant removal. Of the 61 initially non-surgically treated patients, 3 (5 %) underwent delayed surgical treatment due to non- or malunion. 45 (40 %) patients responded to follow-up questionnaires, but no statistically significant differences were found in any PROM between groups. CONCLUSIONS: Two thirds of surgically treated patients with displaced lateral clavicle fractures underwent two procedures. The need for delayed surgical treatment in non-surgically treated patients was low and PROM was similar in both treatment groups. Nonsurgical treatment should be considered as an option to surgery for fully displaced lateral fractures of the clavicle more often.

Is the Robinson classification of clavicle fractures accurate enough within the setting of the Swedish Fracture Register?

INTRODUCTION: In the Swedish Fracture Register (SFR) clavicle fractures are classified according to the Robinson classification. This study aimed to evaluate the accuracy of the classification of clavicle fractures in the SFR. A secondary aim was to assess inter- and intraobserver agreement. MATERIALS AND METHODS: Clavicle fractures (n = 132) were randomly selected from the SFR and radiographs were requested for each patient from their treating departments. Not all radiographs could be acquired, and after exclusion, 115 fractures were independently classified by three expert raters blinded to patient information. The 115 fractures were classified on two occasions, 3 months apart. The raters' consensus classification was used as a gold standard that was compared to the classification registered in the SFR. The accuracy, defined as the degree of agreement between the gold standard and SFR classifications, was reported, as was the inter- and intraobserver agreement for the expert raters. RESULTS: Agreement between the classification in the SFR and the gold standard classification was fair (kappa = 0.35). Fractures with only partial displacement were often incorrectly classified as fully displaced in the SFR (n = 31 of 78 displaced fractures in the SFR). The inter- and intraobserver agreement among the expert raters was almost perfect (interobserver kappa = 0.81-0.87, intraobserver kappa = 0.84-0.94). CONCLUSIONS: The accuracy of the classification of clavicle fractures in the SFR was only fair, whereas the inter- and intraobserver agreement among the expert raters was almost perfect. Accuracy in the SFR may be improved if the classification instructions in the SFR are updated by incorporating the original classification displacement criteria, both in text and in illustrated form.

Risk Prediction for Locoregional Recurrence in Epidermal Growth Factor Receptor-Mutant Stage III-pN2 Lung Adenocarcinoma after Complete Resection: A Multi-center Retrospective Study.

Background: This study aimed to develop a predictive model based on the risk of locoregional recurrence (LRR) in epidermal growth factor receptor (EGFR)-mutant stage III-pN2 lung adenocarcinoma after complete resection. Methods: A total of 11,020 patients with lung surgery were screened to determine completely resected EGFR-mutant stage III-pN2 lung adenocarcinoma. Patients were excluded if they received preoperative therapy or postoperative radiation therapy (PORT). The time from surgery to LRR was recorded. Clinicopathological variables with statistical significance predicting LRR in the multivariate Cox regression were incorporated into the competing risk nomogram. Patients were then sub-grouped based on different recurrence risk as a result of the nomogram. Results: Two hundred and eighty-eight patients were enrolled, including 191 (66.3%) with unforeseen N2 (IIIA1-2), 75 (26.0%) with minimal/single station N2 (IIIA3), and 22 (7.6%) with bulky and/or multilevel N2 (IIIA4). The 2-year overall cumulative incidence of LRR was 27.2% (confidence interval [CI], 16.3%-38.0%). IIIA4 disease (hazard ratio, 2.65; CI, 1.15-6.07; P=0.022) and extranodal extension (hazard ratio, 3.33; CI, 1.76-6.30; P<0.001) were independent risk factors for LRR and were incorporated into the nomogram. Based on the nomogram, patients who did not have any risk factor (low-risk) had a significantly lower predicted 2-year incidence of LRR than those with any of the risk factors (high-risk; 4.6% vs 21.9%, P<0.001). Conclusions: Pre-treatment bulky/multilevel N2 and pathological extranodal extension are risk factors for locoregional recurrence in EGFR-mutant stage III-pN2 lung adenocarcinoma. Intensive adjuvant therapies and active follow-up should be considered in patients with any of the risk factors.

Multimodality therapy in subclassified stage IIIA-N2 non-small cell lung cancer patients according to the Robinson classification: heterogeneity and management.

BACKGROUND: Non-small cell lung cancer (NSCLC) with mediastinal lymph node involvement (N2) is a heterogeneous entity. The objective of this analysis is to investigate the results of treatment strategies for N2-positive patients. METHODS: Retrospective study (2009-2014) of 104 consecutive patients with stage IIIA-N2 NSCLC classified according to the Robinson classification (IIIA1-IIIA4) and treated within a multimodality treatment regime. RESULTS: The Robinson subgroups were: IIIA1 (n=27), IIIA3 (n=60) and IIIA4 (n=17). We had no stage IIIA2 samples because we did not perform an intraoperative frozen section of lymph nodes. Surgical resection with systematic lymph node dissection was performed in all patients with stage IIIA1 (n=27). After chemotherapy or chemo-/radiotherapy, 53.3% of patients in stage IIIA3 (n=32) and 11.7% of patients in stage IIIA4 (n=2) underwent surgery with curative intention. R0 was achieved in 92.6% in stage IIIA1, 93.8% in stage IIIA3 and 100% in stage IIIA4. The 30-day mortality was 3.2%. The overall median survival was 31.7 months (5-year survival was 30.5%). There were no significant differences (P=0.583) in survival regarding the Robinson subgroups. Patients who underwent tumour resection had significantly better median survival (39.8 vs. 19.6 months; P=0.014) compared to patients treated conservatively. Deviation from the interdisciplinary recommended therapy (12%) led to a reduced median survival (11.4 vs. 31.8 months; P=0.137). CONCLUSIONS: N2-patients should be subclassified according to the Robinson classification and discussed in the tumour board. Surgical resection should be recommended in specific cases of N2-disease (non-bulky, sensitivity to systemic treatment).