title: Operative versus nonoperative interventions for common fractures of the clavicle: a meta-analysis of randomized controlled trials.
abstract: BACKGROUND
  The popularity of surgery for acute displaced midshaft clavicle fractures has been fuelled by early randomized controlled trials (RCTs) showing improved rates of radiographic union and perceived functional benefits compared with nonoperative approaches. We performed a meta-analysis to determine the effect of operative and nonoperative interventions on the risk of secondary operation and complications and on long-term function.
  
  
  METHODS
  We search MEDLINE, Embase and the Cochrane Central Register of Controlled Trials for reports of relevant RCTs published to Mar. 7, 2014. Two reviewers assessed eligibility of potential reports and the risk of bias of included trials. The Grading of Recommendations Assessment, Development and Evaluation approach was used to summarize the quality of evidence for all outcomes.
  
  
  RESULTS
  We included 15 RCTs (9 trials comparing operative and nonoperative interventions, 5 comparing implants for operative treatment, and 1 comparing nonoperative treatments). Nonoperative treatments did not differ from operative treatments in the risk of secondary operation (risk ratio [RR] 1.16, 95% confidence interval [CI] 0.58 to 2.35) or all complications (RR 0.90, 95% CI 0.55 to 1.50). One in 4 patients had a complication regardless of the treatment approach. Differences in functional outcomes, although smaller than the threshold for minimal important differences at 1 year, favoured operative interventions (standardized mean difference 0.38, 95% CI 0 to 0.75). Evidence for the type of implant or approach to nonoperative treatment remained inconclusive.
  
  
  CONCLUSIONS
  Current evidence does not support the routine use of internal fixation for the treatment of displaced midshaft clavicle fractures. Complication rates were high regardless of the treatment approach.
authors.affiliation: Department of Clinical Epidemiology and Biostatistics (Devji, Evaniew, Khoudigian, Bhandari) and Division of Orthopaedic Surgery (Kleinlugtenbelt, Evaniew, Riskevski, Bhandari), McMaster University, Hamilton, Ont.
authors.forename: Tahira
authors.initials: T
authors.lastname: Devji
authors.affiliation: Department of Clinical Epidemiology and Biostatistics (Devji, Evaniew, Khoudigian, Bhandari) and Division of Orthopaedic Surgery (Kleinlugtenbelt, Evaniew, Riskevski, Bhandari), McMaster University, Hamilton, Ont.
authors.forename: Ydo
authors.initials: Y
authors.lastname: Kleinlugtenbelt
authors.affiliation: Department of Clinical Epidemiology and Biostatistics (Devji, Evaniew, Khoudigian, Bhandari) and Division of Orthopaedic Surgery (Kleinlugtenbelt, Evaniew, Riskevski, Bhandari), McMaster University, Hamilton, Ont.
authors.forename: Nathan
authors.initials: N
authors.lastname: Evaniew
authors.affiliation: Department of Clinical Epidemiology and Biostatistics (Devji, Evaniew, Khoudigian, Bhandari) and Division of Orthopaedic Surgery (Kleinlugtenbelt, Evaniew, Riskevski, Bhandari), McMaster University, Hamilton, Ont.
authors.forename: Bill
authors.initials: B
authors.lastname: Ristevski
authors.affiliation: Department of Clinical Epidemiology and Biostatistics (Devji, Evaniew, Khoudigian, Bhandari) and Division of Orthopaedic Surgery (Kleinlugtenbelt, Evaniew, Riskevski, Bhandari), McMaster University, Hamilton, Ont.
authors.forename: Shoghag
authors.initials: S
authors.lastname: Khoudigian
authors.affiliation: Department of Clinical Epidemiology and Biostatistics (Devji, Evaniew, Khoudigian, Bhandari) and Division of Orthopaedic Surgery (Kleinlugtenbelt, Evaniew, Riskevski, Bhandari), McMaster University, Hamilton, Ont.
authors.forename: Mohit
authors.initials: M
authors.lastname: Bhandari