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The Clavicle Trial: A Multicenter Randomized Controlled Trial Comparing Operative with Nonoperative Treatment of Displaced Midshaft Clavicle Fractures

Ahrens, Philip M. FRCS(Tr&Orth)1,a; Garlick, Nicholas I. FRCS(Tr&Orth)1; Barber, Julie PhD2; Tims, Emily M. MSc1; The Clavicle Trial Collaborative Group

Journal of Bone & Joint Surgery - American Volume: 16 August 2017 - Volume 99 - Issue 16 - p 1345–1354
doi: 10.2106/JBJS.16.01112
Scientific Articles
Disclosures

Background: The treatment of displaced midshaft clavicle fractures remains controversial.

Methods: We undertook a multicenter randomized controlled trial to compare effectiveness and safety between nonoperative management and ORIF (open reduction and internal fixation) for displaced midshaft clavicle fractures in adults. Three hundred and one eligible adult patients were randomized to 1 of the 2 treatment groups and followed at 6 weeks, 3 months, and 9 months after recruitment. The primary outcome was the rate of radiographically evident nonunion at 3 months following treatment. Secondary outcomes were the rate of radiographically evident nonunion at 9 months, limb function measured using the Constant-Murley Score and DASH (Disabilities of the Arm, Shoulder and Hand) score, and patient satisfaction.

Results: There was no difference in the proportion of patients with radiographic evidence of nonunion at 3 months between the operative (28%) and nonoperative (27%) groups, whereas at 9 months the proportion with nonunion was significantly lower (p < 0.001) in the operative group (0.8%) than in the nonoperative group (11%). The DASH and Constant-Murley scores and patient satisfaction were all significantly better in the operative group than in the nonoperative group at 6 weeks and 3 months.

Conclusions: Although at 3 months there was no evidence that surgery had reduced the rate of nonunion of displaced midshaft clavicle fractures, at 9 months nonoperative treatment had led to a significantly higher nonunion rate (11% compared with <1%). The rate of secondary surgical intervention during the trial period was 12 (11%) of the 147 patients in the nonoperative group. ORIF is a safe and reliable intervention with superior early functional outcomes and should be considered for patients who sustain this common injury.

Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

1Department of Trauma and Orthopaedics, Royal Free Hampstead NHS Foundation Trust, London, United Kingdom

2Department of Statistical Science, University College London, London, United Kingdom

E-mail address for P.M. Ahrens: philip.ahrens@nhs.net

Copyright 2017 by The Journal of Bone and Joint Surgery, Incorporated