title: Plate fixation or intramedullary fixation for midshaft clavicle fractures: a systematic review and meta-analysis of randomized controlled trials and observational studies.
abstract: BACKGROUND
  The last decade has shown a shift toward operative treatment of a subset of midshaft clavicle fractures. However, it is unclear whether there are differences between plate fixation and intramedullary fixation regarding complications and functional outcome. The aim of this systematic review and meta-analysis was to compare plate fixation and intramedullary fixation for midshaft clavicle fractures.
  
  
  METHODS
  The Medline, Embase, and Cochrane databases were searched for both randomized controlled trials and observational studies. The methodologic quality of all included studies was assessed using the Methodological Index for Non-Randomized Studies.
  
  
  RESULTS
  Twenty studies were included. Ten of the 20 included studies used a fracture classification. Seven of these studies reported exclusion of patients with comminuted fractures. No difference in the total re-intervention rate was found (odds ratio [OR], 1.21; 95% confidence interval [CI], 0.71 to 2.04). Major re-interventions occurred more often after plate fixation (OR, 1.88; 95% CI, 1.02 to 3.46). The mean implant removal rates were 38% after plate fixation and 73% after intramedullary fixation. Re-fracture after implant removal occurred more often after plate fixation (OR, 3.42; 95% CI, 1.12 to 10.42). The Constant-Murley scores showed no differences at both short term (mean difference, -1.18; 95% CI, -13.41 to 11.05) and long term (mean difference, 0.15; 95% CI, -1.57 to 1.87). No differences were observed regarding nonunion (OR, 1.50; 95% CI, 0.82 to 2.75). The rate of infections showed no differences when outlier studies were excluded (OR, 1.54; 95% CI, 0.88 to 2.69).
  
  
  CONCLUSIONS
  Major re-intervention and re-fracture after implant removal occurred more frequently after plate fixation of non-comminuted, displaced midshaft clavicle fractures. No differences in terms of function and nonunion between plate fixation and intramedullary fixation were observed.
authors.affiliation: Utrecht Traumacenter, Utrecht, The Netherlands; Department of Surgery, St Antonius Hospital, Nieuwegein, The Netherlands. Electronic address: marijnhouwert@hotmail.com.
authors.forename: Roderick M
authors.initials: RM
authors.lastname: Houwert
authors.affiliation: Utrecht Traumacenter, Utrecht, The Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Diederik P J
authors.initials: DP
authors.lastname: Smeeing
authors.affiliation: Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Usama
authors.initials: U
authors.lastname: Ahmed Ali
authors.affiliation: Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Falco
authors.initials: F
authors.lastname: Hietbrink
authors.affiliation: Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Moyo C
authors.initials: MC
authors.lastname: Kruyt
authors.affiliation: Department of Orthopaedics, VU Medical Center, Amsterdam, The Netherlands.
authors.forename: Olivier A
authors.initials: OA
authors.lastname: van der Meijden
mesh_terms: D001860:Bone Plates; D002968:Clavicle / Q000293:injuries* / Q000601:surgery; D020878:Device Removal; D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000295:instrumentation; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects; D050723:Fractures, Bone / Q000601:surgery*; D006801:Humans; D064887:Observational Studies as Topic; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D012086:Reoperation
keywords: Midshaft clavicle fracture; ORIF; intramedullary fixation; meta-analysis; plate fixation; systematic review