title: Surgical Versus Nonsurgical Treatment for Midshaft Clavicle Fractures in Patients Aged 16 Years and Older: A Systematic Review, Meta-analysis, and Comparison of Randomized Controlled Trials and Observational Studies.
abstract: BACKGROUND
  There is no consensus on the choice of treatment of midshaft clavicle fractures (MCFs).
  
  
  OBJECTIVE
  The aims of this systematic review and meta-analysis were (1) to compare fracture healing disorders and functional outcomes of surgical versus nonsurgical treatment of MCFs and (2) to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies.
  
  
  METHODS
  Systematic review and meta-analysis.
  
  
  METHODS
  The PubMed/MEDLINE, Embase, CENTRAL, and CINAHL databases were searched for both RCTs and observational studies. Using the MINORS instrument, all included studies were assessed on their methodological quality. The primary outcome was a nonunion. Effects of surgical versus nonsurgical treatment were estimated using random-effects meta-analysis models.
  
  
  RESULTS
  A total of 20 studies were included, of which 8 were RCTs and 12 were observational studies including 1760 patients. Results were similar across the different study designs. A meta-analysis of 19 studies revealed that nonunions were significantly less common after surgical treatment than after nonsurgical treatment (odds ratio [OR], 0.18 [95% CI, 0.10-0.33]). The risk of malunions did not differ between surgical and nonsurgical treatment (OR, 0.38 [95% CI, 0.12-1.19]). Both the long-term Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley scores favored surgical treatment (DASH: mean difference [MD], -2.04 [95% CI, -3.56 to -0.52]; Constant-Murley: MD, 3.23 [95% CI, 1.52 to 4.95]). No differences were observed regarding revision surgery (OR, 0.85 [95% CI, 0.42-1.73]). Including only high-quality studies, both the number of malunions and days to return to work show significant differences in favor of surgical treatment (malunions: OR, 0.26 [95% CI, 0.07 to 0.92]; return to work: MD, -8.64 [95% CI, -16.22 to -1.05]).
  
  
  CONCLUSIONS
  This meta-analysis of high-quality studies showed that surgical treatment of MCFs results in fewer nonunions, fewer malunions, and an accelerated return to work compared with nonsurgical treatment. A meta-analysis of surgical treatments need not be restricted to randomized trials, provided that the included observational studies are of high quality.
authors.affiliation: Utrecht Traumacenter, Utrecht, the Netherlands.|Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Diederik P J
authors.initials: DPJ
authors.lastname: Smeeing
authors.affiliation: Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands.
authors.forename: Denise J C
authors.initials: DJC
authors.lastname: van der Ven
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 Surgery, Meander Medical Center, Amersfoort, the Netherlands.
authors.forename: Tim K
authors.initials: TK
authors.lastname: Timmers
authors.affiliation: Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.|Department of Surgery, Diakonessenhuis, Utrecht, the Netherlands.
authors.forename: Mark
authors.initials: M
authors.lastname: van Heijl
authors.affiliation: Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Moyo C
authors.initials: MC
authors.lastname: Kruyt
authors.affiliation: Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Rolf H H
authors.initials: RHH
authors.lastname: Groenwold
authors.affiliation: Department of Orthopedic Surgery, SpaarneGasthuis, Hoofddorp, the Netherlands.
authors.forename: Olivier A J
authors.initials: OAJ
authors.lastname: van der Meijden
authors.affiliation: Utrecht Traumacenter, Utrecht, the Netherlands.|Department of Surgery, St Antonius Hospital, Nieuwegein, the Netherlands.
authors.forename: Roderick M
authors.initials: RM
authors.lastname: Houwert
mesh_terms: D000293:Adolescent; D000328:Adult; D002968:Clavicle / Q000293:injuries*; D005260:Female; D017102:Fracture Healing; D050723:Fractures, Bone / Q000601:surgery / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D064887:Observational Studies as Topic; D016032:Randomized Controlled Trials as Topic; D055815:Young Adult
keywords: clavicle fracture; meta-analysis; nonoperative; quality assessment; surgical; systematic review