***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES To evaluate the outcome and satisfaction of closed treatment versus open reduction and internal fixation in comminuted clavicular fractures . METHODS Sixty patients with displaced clavicular fractures were r and omized into operative ( 29 patients ) and nonoperative ( 31 patients ) groups . Three patients in the operative group did not accept the surgery , and seven patients in the nonoperative group did not complete the one-year follow-up . Outcomes were assessed using the Disability of the Arm , Shoulder and H and ( DASH ) score , Constant shoulder score , specific questions regarding patients ' final satisfaction , physical examination , measurement of the shortening of the clavicular length , and plain radiographs . RESULTS There was one nonunion in the operative group and one in the nonoperative group . The nonunion in operative group was the result of the only infection in this group . Four malunions were developed in the operative group and nineteen malunions in the nonoperative treatment , ( p<0.001 ) . Three patients in the operative group were completely dissatisfied with their treatment . Eighteen patients in the nonoperative group were partially satisfied . Pain was the main reason for dissatisfaction in this group . The mean shortening of the clavicle was 26.5 mm in the nonoperative group and 4.0 mm in the operative group . The mean DASH score for the operative and nonoperative groups were 8.6 and 21.3 , respectively ( p<0.001 ) ; and the Constant shoulder scores were 89.8 and 78.8 ( p<0.001 ) . CONCLUSION Open reduction and internal fixation of comminuted fractures of the clavicle using a reconstruction plate is an effective treatment modality . Despite the variety of complications , this method has a higher satisfaction rate than conservative treatment OBJECTIVE Our purpose was to measure the agreement , reliability , construct validity , and feasibility of a measurement tool to assess  systematic review s ( AMSTAR ) . STUDY DESIGN AND SETTING We r and omly selected 30 systematic review s from a data base . Each was assessed by two review ers using : ( 1 ) the enhanced quality assessment question naire ( Overview of Quality Assessment Question naire [ OQAQ ] ) ; ( 2 ) Sacks ' instrument ; and ( 3 ) our newly developed measurement tool ( AMSTAR ) . We report on reliability ( interobserver kappas of the 11 AMSTAR items ) , intraclass correlation coefficients ( ICCs ) of the sum scores , construct validity ( ICCs of the sum scores of AMSTAR compared with those of other instruments ) , and completion times . RESULTS The interrater agreement of the individual items of AMSTAR was substantial with a mean kappa of 0.70 ( 95 % confidence interval [ CI ] : 0.57 , 0.83 ) ( range : 0.38 - 1.0 ) . Kappas recorded for the other instruments were 0.63 ( 95 % CI : 0.38 , 0.78 ) for enhanced OQAQ and 0.40 ( 95 % CI : 0.29 , 0.50 ) for the Sacks ' instrument . The ICC of the total score for AMSTAR was 0.84 ( 95 % CI : 0.65 , 0.92 ) compared with 0.91 ( 95 % CI : 0.82 , 0.96 ) for OQAQ and 0.86 ( 95 % CI : 0.71 , 0.94 ) for the Sacks ' instrument . AMSTAR proved easy to apply , each review taking about 15 minutes to complete . CONCLUSIONS AMSTAR has good agreement , reliability , construct validity , and feasibility . These findings need confirmation by a broader range of assessors and a more diverse range of review We conducted a prospect i ve , r and omized study to determine if patients with midshaft clavicle fractures would benefit from immediate operative stabilization with a modified Hagie pin in comparison with a matched group treated with nonoperative therapy . At a level II trauma center , patients with closed midshaft clavicle fractures were prospect ively r and omized to receive either operative or nonoperative treatment . Fifty-seven ( 29 operative , 28 nonoperative ) patients were enrolled in the study . Operative patients underwent open reduction and internal fixation of the clavicle using a modified Hagie pin ; nonoperative patients were treated with a sling for comfort . All patients were followed at regular intervals for 1 year . They were evaluated for radiographic healing and complications and were scored with the Single Assessment Numeric Evaluation and L'Insalata instruments .  Injury severities  and radiographs were not statistically significantly different between the 2 groups . Functional scores in the operative group were slightly higher at 3 weeks , and the nonoperative group had slightly higher scores at 6 months and 1 year . The only statistically significant difference between the groups was at 3 weeks . Percentage follow-up at 1 year was 93 % for the operative group and 82 % for the nonoperative group . One patient in each group developed a nonunion , and 1 patient in each group had a refracture . Complications were higher in the operative group , and most were related to pin prominence at the posterior shoulder . Results of this study suggest that , though patients with midshaft clavicle fractures had higher functional scores at short-term follow-up after internal fixation , functional scores were similar at 6 months and 1 year . In addition , internal fixation with a modified Hagie pin was associated with a higher complication rate BACKGROUND Recent literature supports surgical intervention for shortened , displaced , mid-shaft clavicle fractures . We present the results of a r and omized clinical trial comparing locked intramedullary fixation and plate fixation for short , displaced , mid-shaft clavicle fractures . MATERIAL S AND METHODS Local ethical approval was obtained and power analysis and sample size calculations were performed prior to commencement . Patients r and omized to 2 groups to be treated with either locked intramedullary fixation or plating .  Patients regularly followed up to clinical and radiographic union . The primary outcome measure was the Constant score , secondary outcome measures included the Oxford shoulder score , union rate , and complication rates . RESULTS Seventeen patients were r and omized to locked intramedullary fixation and 15 r and omized to plating . Mean age was 29.3 years . Mean follow-up was 12.4 months . There was no significant difference in either Constant scores ( P = .365 ) or Oxford scores ( P = .773 ) . There was 100 % union in both groups . In the intramedullary group , 1 case of soft tissue irritation settled after the pin removal ; 1 pin backed out and was revised . Three superficial wound infections result ed in plate removal and 8 plates ( 53 % ) were removed . DISCUSSION Intramedullary fixation has the theoretical advantage of preserving the periosteal blood supply , but carries the morbidity of pin removal . Clavicle plates are not routinely removed but require greater exposure and may compromise periosteal blood supply . CONCLUSION Both locked intramedullary fixation and plating produce good functional results ; however , metalwork may need to be removed as a second procedure Objectives : To determine the cost-effectiveness of open reduction internal fixation ( ORIF ) of displaced , midshaft clavicle fractures in adults . Design : Formal cost-effectiveness analysis based on a prospect i ve , r and omized , controlled trial . Setting : Eight hospitals in Canada ( seven university-affiliated and one community hospital ) . Patients / Participants : One hundred thirty-two adults with acute , completely displaced , midshaft clavicle fractures . Intervention : Clavicle ORIF versus nonoperative treatment . Main Outcome Measurements : Utilities derived from SF-6D . Results : The base case cost per quality -adjusted life-year ( QALY ) gained for ORIF was $ 65,000 . Cost-effectiveness improved to $ 28,150/QALY gained when the functional benefit from ORIF was assumed to be permanent with cost per QALY gained falling below $ 50,000 when the functional advantage persisted for 9.3 years or more . In other sensitivity analyses , the cost per QALY gained for ORIF fell below $ 50,000 when ORIF cost less than $ 10,465 ( base case cost $ 13,668 ) or the long-term utility difference between nonoperative treatment and ORIF was greater than 0.034 ( base case difference 0.014 ) . Short-term disutility associated with fracture healing also affected cost-effectiveness with the cost per QALY gained for ORIF falling below $ 50,000 when the utility of a fracture treated nonoperatively before union was less than 0.617 ( base case utility 0.706 ) or when nonoperative treatment increased the time to union by 20 weeks ( base case difference 12 weeks ) . Conclusions : The cost-effectiveness of ORIF after acute clavicle fracture depended on the durability of functional advantage for ORIF compared with nonoperative treatment . When functional benefits persisted for more than 9 years , ORIF had a favorable value compared with many accepted health interventions INTRODUCTION Elastic stable intramedullary nailing ( ESIN ) of displaced mid-shaft clavicular fractures is a minimally invasive technique which was reported to be an easy procedure with low complication rates , good cosmetic and functional results , restoration of clavicular length and fast return to daily activities . Recent studies , however , also report on higher complication rates and specific problems with the use of this technique . This prospect i ve study compares ESIN with non-operative treatment of displaced mid-shaft clavicular fractures . METHODS Between December 2003 and August 2007 , 120 patients volunteered to participate . Of these , 112 patients completed the study ( 60 in the operative and 52 in the non-operative group ) . Patients in the non-operative group were treated with a simple shoulder sling . In the operative group , intramedullary stabilisation was performed within 3 days of the trauma . Clavicular shortening was determined after trauma and after osseous consolidation on thorax posteroanterior radiographs as the proportional length difference between the left and right side with the uninjured side serving as a control for clavicular length ( 100 % ) . Radiographic union was assessed every 4 weeks on 20 degrees cephalad anteroposterior and posteroanterior radiographs of the clavicle . Constant shoulder scores and DASH scores ( DASH , disabilities of the arm , shoulder and h and ) were assessed at final follow-up after 2 years . RESULTS ESIN led to faster osseous healing and better restoration of clavicular length in simple fractures . We were not able to restore clavicular length in comminuted fractures using ESIN .  Functional outcome at a mean follow-up of 24 months ( range : 22 - 27 months ) was better in the operative group . Delayed union and non-union accounted for the majority of complications in the non-operative group . In the operative group , telescoping was the main complication , which occurred in complex fractures with severe post-traumatic shortening only . CONCLUSION We recommend ESIN for all simple displaced mid-shaft clavicular fractures in order to minimise the rate of delayed union , non-union and symptomatic mal-union . We also recommend ESIN in comminuted fractures with moderate ( < or = 7 % ) post-traumatic shortening , as they will heal with moderate shortening . In comminuted fractures with severe shortening , however , we recommend plate osteo synthesis in order to provide for stability , clavicular length and endosteal blood supply BACKGROUND Few r and omized controlled trials have compared operative with nonoperative treatment of clavicular fractures . METHODS Patients with displaced midshaft clavicular fractures were r and  omized  either to nonoperative treatment with a sling or to operative treatment with a stainless steel 3.5-mm reconstruction plate . Outcome measures were the Constant shoulder score , DASH ( Disabilities of the Arm , Shoulder and H and ) score , pain , fracture-healing , and complications . The null hypothesis was that the Constant and DASH scores would not differ between the groups at the one-year follow-up evaluation . RESULTS In accordance with the power analysis , we included sixty patients in the study ; thirty-two were r and omized to the nonoperative group and twenty-eight to the operative group . We found no difference in the Constant score ( p = 0.75 ) , the DASH score ( p = 0.89 ) , or pain ( p = 0.98 ) between the groups at the one-year follow-up evaluation . All fractures in the operative group healed , but six nonunions ( 24 % ) occurred in the nonoperative group . CONCLUSIONS One year after a displaced midshaft clavicular fracture , nonoperative treatment result ed in a higher nonunion rate but similar function and disability compared with operative treatment BACKGROUND Recent studies have shown a high prevalence of symptomatic malunion and nonunion after nonoperative treatment of displaced midshaft clavicular fractures . We sought to compare patient-oriented outcome and complication rates following nonoperative treatment and those after plate fixation of displaced midshaft clavicular fractures . METHODS In a multicenter , prospect i ve clinical trial , 132 patients with a displaced midshaft fracture of the clavicle were r and omized ( by sealed envelope ) to either operative treatment with plate fixation ( sixty-seven patients ) or nonoperative treatment with a sling ( sixty-five patients ) . Outcome analysis included st and ard clinical follow-up and the Constant shoulder score , the Disability of the Arm , Shoulder and H and ( DASH ) score , and plain radiographs . One hundred and eleven patients ( sixty-two managed operatively and forty-nine 
    Output:
    
As a result , we selected a high- quality Cochrane review .This systematic review of overlapping meta-analyses comparing surgical and conservative treatments suggests that surgical treatment provides a lower rate of overall treatment failure and a better functional outcome , but is associated with more implant-related complications .