Operative Versus Nonoperative Treatment For Displaced Midshaft Clavicular Fractures:a Systematic ReVIEW

Background:Traditionally,displaced midshaft clavicular fractures have been mainly managed nonoperatively.However,more and more studies have shown that surgery for displaced midshaft clavicular fractures can produce better outcomes than nonsurgical management.It is still controversial for the choice of treatment for displaced midshaft clavicular fractures.Objective:Perform a systematic review to evaluate the effectiveness of operative versus nonoperative treatment for displaced midshaft clavicular fracture.Methods:We searched the literatures including randomized controlled trials(RCTs) and quasi-randomized controlled trials(q-RCTs) that investigated th e effects of operative versus nonoperative treatment for displaced midshaft clavi cular fractures using PUBMED(January1966to March2014),E-MBASE(Januar y1974to March2014),Cochrane Library(Issue3,2014),CBM(January1978to March2014) and CNKI(January1981to March2014). Hand searching of relate d journals was carried out.The primary outcome was incidence of nonunion,inci dence of malunion,mean time to union.The secondary outcome was incidence of complications,DASH scores,rate of p-atient satisfaction.The quality of the eligi ble studies were assessed accordi-ng to the Cochrane Handbook5.0.We used Re vMan5.2.4to do Meta-an-alysis.We used the relative risk for dichotomous varia bles.For the continu-ous variables, the weighted mean difference was used.Result:8published RCTs were eligible for our study,including653patients,325were received surgery and328to nonoperative treatment.The results of meta-analysis demonstrated that:compared with nonoperative treatment,operative treatment can reduce the rate of nonunion [RR=0.16;95%CI(0.07,0.35), P<0.001],the rate ofmalunion [RR=0.18;95%CI(0.10,0.34), P<0.001],and mean time to union [WMD=-7.40;95%CI(-10.72,4.07), P<0.001].the incidents of complications after surgery using plates was less than that in nonoperative cases [RR=0.55;95%CI(0.42,0.73), P <0.001].DASH scores at one year postoperatively were more lower in operative group [WMD=-2.70;95%CI(-3.19,-2.22),P<0.001],and operative treatment can increase the rate of patient satisfaction [RR=1.59;95%CI(1.16,2.18), P=0.004]. Conclusions:Compared with nonoperative treatment,operative treatment for displaced midshaft clavicular fractures can effectively reduce the rate of nonunion,the rate of malunion,the incidents of complications and the mean time to union. Surgery is superior to nonoperative treatment for displaced midshaft clavicular fractures.