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Letters to the Editor   |    
M.D. McKee replies:
Michael D. McKee, MD1
1 St. Michael's Hospital, 55 Queen Street East, Suite 800, Toronto, ON M5C 1R6, Canada. E-mail: mckeem@smh.toronto.on.ca
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These letters originally appeared, in slightly different form, on jbjs.org. They are still available on the web site in conjunction with the article to which they refer.

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Aug 01;89(8):1866-1867
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Extract

We thank Dr. Bernstein for his interest in our recent article. We have the following comments to make in response:Our study did not contain an economic analysis. While we agree that the short-term costs of operative treatment are greater than those of nonoperative care, this is offset by the much more rapid return to gainful employment and everyday activities and the lack of dependence on others that we found in the operative group.It is unlikely that there will ever be a randomized study in orthopaedics where the two treatments (one operative and one nonoperative) are "completely identical in terms of cost and risk." Therefore, practically speaking, we must do the best we can with the methods at our disposal. We felt that a randomized trial comparing operative and nonoperative treatment in this area would be appropriate.These procedures were performed at seven university hospitals and one community hospital. We feel that plating of an acute clavicular shaft fracture is within the technical grasp of the typical orthopaedic fracture surgeon.While it would be ideal to blind the patients as to their chosen treatment method, practically speaking, this is impossible to do in a surgery-no surgery trial. While we are aware of the phenomenon that patients who deliberately choose or elect to have a surgical intervention may represent an intrinsically different subgroup than those who choose not to undergo surgery, patients in our study did not "subject themselves" to surgery: they were randomized to surgery and thus were no more "psychologically inclined" to surgery than the group that was randomized to nonoperative care.We did have a substantial prevalence of surgical complications in our group and listed them—they included hardware failure, nonunion, and infection. We point out specifically that this procedure is not without risk. Fortunately, the patients did not experience any of the catastrophic complications (pneumothorax or neurovascular injury) that have traditionally been associated with this procedure. However, they are, of course, (remotely) possible as with any surgical procedure.6. We hope this initial foray into a randomized trial comparing nonoperative and operative care is not the "last word" on this topic. We are aware of several other similar randomized trials planned or in progress. We encourage other authors to investigate the same topic and feel strongly that there is still much more information to be obtained regarding this injury and its treatment. This would include the timing of surgery, prognostic indicators, the use of intramedullary fixation devices compared with plates, etc. We eagerly look forward to other similar studies being presented and published.
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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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