Treatment for unstable distal clavicle fractures (Neer 2) with locking T-plate and additional PDS cerclage

Outcomes following fixation of distal clavicle fractures utilizing arthroscopically assisted coracoclavicular ligament stabilization with a suspensory endobutton and cerclage tape

Background

Distal one-third clavicle fractures are frequently unstable and often require surgical fixation due to high rates of nonunion. Many common methods of fixation have high rates of union but are associated with hardware discomfort and need for secondary surgery. The purpose of this study was to evaluate the outcomes of a fixation technique involving arthroscopically assisted open reduction internal fixation of unstable distal clavicle fractures via a coracoclavicular (CC) suspensory endobutton and cerclage tape.

Methods

This was a retrospective case series evaluating patients who underwent fixation of unstable distal clavicle fractures via arthroscopically assisted CC stabilization by a single fellowship-trained shoulder and elbow surgeon between 2020 and 2022. Demographic and injury-related data were collected via chart review. Preoperative and postoperative radiographs were reviewed to evaluate for signs of radiographic union. Primary outcome measures included fracture union, complications, and need for additional procedures. Patients were also contacted via telephone to obtain American Shoulder and Elbow Surgeons scores.

Results

Six patients were eligible for inclusion in this study with a mean age of 52.8 ± 14.0 and a mean follow-up of 2.0 years (range 1.6-2.7 years). Mean American Shoulder and Elbow Surgeons scores were 86.2 ± 21.8 (range 52-100). There were no postoperative complications, signs of symptomatic hardware, or need for secondary surgery at the final follow-up among this cohort of patients. All patients had achieved and maintained full radiographic union at a mean radiographic follow-up of 5.5 months (range 2.0-12.9 months).

Conclusion

Arthroscopically assisted CC stabilization of distal clavicle fractures demonstrated high union rates while limiting complications or need for secondary hardware removal. Further analysis on a larger scale is recommended to determine long-term outcomes and direct comparison to other surgical techniques.

Mid-term outcome of arthroscopic TightRope fixation of displaced lateral end clavicular fractures: Average follow-up of 6.1 years

PURPOSE

Various surgical modalities are available to treat Neer types 2 and 5 unstable fractures of lateral end clavicle but none of them are standardized. Arthroscopic fixation of the displaced lateral end clavicle fractures provides good short-term results but mid- to long-term outcomes are not available. The purpose of this study was to show the mid- to long-term radiological and functional outcomes of these fractures treated arthroscopically by a TightRope device, and to show the complications associated with this procedure.

METHODS

A retrospective study was conducted over 2 years from January 2014 to December 2015 with a minimum 5-year follow-up. Active patients aged 18-50 years with acute (less than 3 weeks) displaced fracture of lateral end of the clavicle, with a minimum 5-year follow-up were included in the study. Patients with associated fractures of the proximal humerus, glenoid, scapula and acromioclavicular joint injuries were excluded from the study along with open fractures and neurovascular injuries. The outcomes were assessed by objective (complications and radiographic examination) and subjective criteria (quick disabilities of the arm, shoulder and hand score, the Constant-Murley score and the visual pain analogue scale). The data were analyzed by SPSS version 21.0.

RESULTS

Totally, 42 patients were operated during the study period and 37 were available with a minimum 5-year follow-up. Thirty were male and 7 were female with a mean age of 29.5 years and a mean follow-up of 6.1 years. The mean quick disabilities of the arm, shoulder and hand score was 68.2 ± 4.6 preoperatively and 1.27 ± 2.32 at final follow-up (p < 0.001); the mean visual pain analogue scale score was 6.85 ± 2.2 preoperatively and 0.86 ± 1.60 at final follow-up (p < 0.001). The average Constant-Murley score was 93.38 ± 3.25 at the end of the follow-up. There were 2 fixation failures, with established non-union and 3 patients developed radiographic acromioclavicular joint arthritis.

CONCLUSIONS

Arthroscopic TightRope fixation of displaced lateral end clavicular fractures provides good radiological and functional outcomes at mid- to long-term follow-up. With the low complication rates and high patient satisfaction, this technique can be considered as a primary option in the surgical treatment of these fractures.

A systematic review and meta-analysis comparing the use of hook plates and superior plates in the treatment of displaced distal clavicle fractures

INTRODUCTION

Non-operative treatment of displaced distal clavicle fractures results in high non-union and yet there is no consensus on superior treatment modality. While there are a number of different techniques available for fixation, hook plate (HP) has been used most commonly. A number of modern techniques, including superior plate (SP), have shown less complications but equivocal union rate and shoulder function. The aim of this systematic review and meta-analysis is to compare the outcome of HP fixation with superior plate in surgical fixation of displaced distal clavicle fractures.

PATIENTS AND METHODS

A review of the online databases MEDLINE and Embase was conducted on 15 January 2021 according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies reporting union rate, complications and shoulder function were included. The studies were appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool.

RESULTS

The search strategy identified 42 studies eligible for inclusion with a total of 1,261 patients. These included 17 hook-plate case series (n = 573), 18 superior plate case series, of which 6 used SP alone (n = 223) and 12 SP and simultaneous CCLR case series (n = 189), and 7 studies comparing HP and SP (n = 276). The overall complication rate was significantly higher with HP when compared to SP [(32.7% vs 12.7%; OR 6.31 (95% CI: 2.67-14.91)]. The overall union rates in the case series appeared comparable in the current SR; HP 96.4%, SP 96.9% and SP with simultaneous CCLR 97.9%. Shoulder function was most commonly assessed using CM score and the mean ranged from 83.8 to 97.2 in HP, 89 to 98 in SP group and 90.6 to 97.6 in SP with CCLR. Meta-analysis of CM score failed to show a significant difference for HP versus SP (pooled weighted mean difference was 2.67 (95% CI: - 0.09 to 5.43) with a trend to favour SP fixation.

CONCLUSION

The current review has demonstrated that HP, SP alone or with CCLR all offer excellent union rate and appear to provide comparative functional outcomes. However, HP is associated with significantly higher complication rates.

Triple Endobutton technique for the treatment of Neer type II lateral clavicle fractures: 2-year findings

BACKGROUND

Although various kinds of operative procedures have been reported in the literature, there is still no undisputed gold standard technique for the treatment of Neer type II lateral clavicle fractures. This trauma is classified as a bone fracture, but it is primarily a ligamentous problem due to the instability it generates. This study analyzed the clinical and radiological results of treatment for Neer type II lateral clavicle fractures using the triple Endobutton (Smith & Nephew) technique in 20 patients with at least 2 years of follow-up.

METHODS

This study enrolled 20 patients with Neer type II distal clavicle fractures who underwent the triple Endobutton technique using 3 Endobuttons (1 with a closed loop and 2 without) and 3 No. 5 Ethibond sutures (Ethicon Inc.) from October 2017 to May 2020. Patients were assessed with clinical and radiological follow-up at 3, 6, 12, and 24 months postoperatively. Clinical assessments consisted of the visual analog scale and the Constant score. Radiological evaluation was achieved by measuring the coracoclavicular distance.

RESULTS

The mean follow-up was 35 ± 9 months (range, 24-55 months). The visual analog scale and Constant scores revealed significant improvements from 6 ± 1 (range, 4-8) and 42 ± 4 (range, 35-48) scores preoperatively to 1 ± 1 (range, 0-1) and 94 ± 2 (range, 90-98) scores at the final evaluation, respectively (P < .001). The coracoclavicular distance of the injured side was an average of 9 ± 1 mm (range, 7-12 mm) at the final follow-up radiograph which was not significantly different from that of the contralateral side (P = .75).

CONCLUSIONS

In this study, the triple Endobutton technique was a safe, reliable, and novel surgical technique that yielded good to excellent short-term clinical and radiological outcomes for the treatment of Neer type II distal clavicle fractures.

A modified method of augmented distal clavicle fracture osteosynthesis with a Fibertape coracoclavicular cerclage

BACKGROUND

Unstable distal clavicles experience high non-union rates, prompting surgeons to recommend surgery for more predictable outcomes. There is a lack of consensus on the optimal method of surgical fixation, with an array of techniques described in the literature. We describe an alternative method of fixation involving the use of a distal clavicular anatomical locking plate with Fibertape cerclage augmentation in our series of patients.

METHODS

Nine patients (8 males and 1 female), with a mean age of 36 years, who sustained unstable fracture of the distal clavicle in our institution were treated with our described technique. Postoperative range of motion, functional and pain scores, and time to radiographic union were measured over a mean follow-up period of 10 months. Incidences of postoperative complications were also recorded.

RESULTS

At the last patient consult, the mean visual analog scale score was 0.88±0.35, with a mean Disabilities of the Arm, Shoulder, and Hand (DASH) score of 1.46±0.87 and American Shoulder and Elbow Surgeons (ASES) score of 94.1±3.57. The mean range of motion achieved was forward flexion at 173°±10.6°, abduction at 173°±10.6°, and external rotation at 74.4°±10.5°. All patients achieved internal rotation at a vertebral height of at least L2 with radiographical union at a mean of 10 weeks. No removal of implants was required.

CONCLUSIONS

Our described technique of augmented fixation of the distal clavicle is effective, produces good clinical outcomes, and has minimal complications.

The use of Tightrope device as the sole method of fixation in treating lateral end clavicle fractures

BACKGROUND

Lateral end clavicle fractures can be challenging due to the small and often comminuted lateral fragment, problems with union and stability and implant morbidity. We retrospectively reviewed outcomes of Tightrope device in isolation to treat lateral end clavicle fractures.

METHODS

Subjective and objective measures were assessed for 29 patients. The subjective comprised of functional clinical scores: Oxford shoulder score and EuroQoL5D. The objective measures were maintenance of fracture reduction, bone healing and complications.

RESULTS

Median age was 36 years and 72% of cases were male patients. Average clinical follow up time was 21 months. Evaluation of latest radiographs showed that all reductions were maintained post-operatively. Twenty-two fractures had united and one patient had established non-union. Functional outcomes showed predominantly good results with Oxford shoulder score average of 41, EuroQoL5D index score of 0.78 and EuroQol Visual Analogue Scale 76. The overall post-operative complication rate was 10%; only one case requiring a secondary procedure.

DISCUSSION

In our series, using the Tightrope as the sole device to treat displaced lateral end of clavicle fractures resulted in good radiological and functional outcomes, with minimal complications requiring secondary procedures. We believe the Tightrope device is a good method of fixing these challenging fractures and advocate its use.

Comparing the locking screw direction of three locking plates for lateral clavicle fractures: a simulation study

BACKGROUND

The locking plate is a useful treatment for lateral clavicle fractures, however, there are limits to the fragment size that can be fixed. The current study aimed to measure the screw angles of three locking plates for lateral clavicle fractures. In addition, to assess the number of screws that can be inserted in different fragment sizes, to elucidate the size limits for locking plate fixation.

METHODS

The following three locking plates were analyzed: the distal clavicle plate [Acumed, LLC, Oregon, the USA], the LCP clavicle plate lateral extension [Depuy Synthes, LLC, PA, the USA], and the HAI clavicle plate [HOMS Engineering, Inc., Nagano, Japan]. We measured the angles between the most medial and lateral locking screws in the coronal plane and between the most anterior and posterior locking screws in the sagittal plane. A computer simulation was used to position the plates as laterally as possible in ten normal three-dimensional clavicle models. Lateral fragment sizes of 10, 15, 20, 25, and 30 mm were simulated in the acromioclavicular joint, and the number of screws that could be inserted in the lateral fragment was assessed. Subsequently, the area covered by the locking screws on the inferior surface of the clavicle was measured.

RESULTS

The distal clavicle plate had relatively large screw angles (20° in the coronal plane and 32° in the sagittal plane). The LCP clavicle lateral extension had a large angle (38°) in the sagittal plane. However, the maximum angle of the HAI clavicle plate was 13° in either plane. The distal clavicle plate allowed most screws to be inserted in each size of bone fragment. For all locking plates, all screws could be inserted in 25 mm fragments. The screws of distal clavicle plate covered the largest area on the inferior surface of the clavicle.

CONCLUSIONS

Screw angles and the numbers of screws that could be inserted in the lateral fragment differed among products. Other augmented fixation procedures should be considered for fractures with fragment sizes < 25 mm that cannot be fixed with a sufficient number of screws.

Residual coracoclavicular separation after plate fixation for distal clavicle fractures: comparison between fracture patterns

Background

Plate fixation is an established treatment for Neer type II and V distal clavicle fractures; however, residual coracoclavicular (C-C) separation after osteosynthesis for unstable distal clavicle fractures has rarely been discussed. This study aimed to reveal the extent of postoperative C-C separation after plate fixation for distal clavicle fractures and to evaluate the relationship between residual C-C separation and the risk of postoperative complications.

Methods

We retrospectively reviewed 60 patients with a displaced distal clavicle fracture that was treated with a Scorpion plate without C-C reconstruction and successfully united. Distal clavicle fractures were divided as per the Neer classification into type IIA (12 patients), IIB (36 patients), and V (12 patients) groups. The modified C-C distance ratio at the time of injury and after bone union, and the postoperative complications (plate-related pain, delayed union, infection, and contracture) were compared among the three groups.

Results

The mean postoperative modified C-C distance ratio was 115.0% ± 12.0%; this ratio was significantly larger in the type IIB and V groups than in the type IIA group (P = .021 and P = .006, respectively). However, there was no significant difference in the frequency of postoperative complications among the three groups.

Conclusions

Our study demonstrated that a certain degree of C-C separation remained after plate fixation for Neer type II and V distal clavicle fractures, even when bone union was achieved. The postoperative residual C-C separation was greater for the type IIB and V groups than for the type IIA group; however, this difference may not affect postoperative complications.

Osteosynthesis Using the Anatomical Plate With Grasping Arms for Unstable Distal Clavicle Fractures: A Technical Trick and Clinical Experience

SUMMARY

Plate fixation is an established method of treating distal clavicle fractures. However, it is often difficult to maintain the reduction of distal fragments with conventional plates, especially in cases where the distal fragments are small or comminuted. This study aimed to introduce a technical trick and clinical experience of osteosynthesis using an anatomical nonlocking plate with grasping arms (SCORPION NEO plate) for unstable distal clavicle fractures. During fixation, distal fragments are grasped by the plate arms and fixed with 2 screws. We retrospectively reviewed 41 patients who underwent osteosynthesis for unstable distal clavicle fractures (Neer type 2 and 5) using a SCORPION NEO plate. Patients were divided into 2 groups: type unstable 1, where the trapezoid ligament adhered to a distal fragment, and type unstable II (UII), where the trapezoid ligament adhered to a third fragment detached from a distal fragment. Although delayed union, plate loosening, plate-related pain, infection, and stiffness were observed in 2 (4.9%), 2 (4.9%), 3 (7.3%), 1 (2.4%), and 1 patient (2.4%), respectively; all fractures united at the time of final follow-up. Operating time for the UII group was significantly longer than that for the UI group. There were no significant differences between the 2 groups in postoperative complications and coracoclavicular distance ratios at the time of bone union. Our results demonstrated that osteosynthesis with the anatomical plate with grasping arms could be a viable option in the treatment of unstable distal clavicle fractures, especially in cases where distal fragments are not contiguous with the trapezoid ligament.

The emergency medicine management of clavicle fractures

BACKGROUND

Clavicle fractures are common. An emergency physician needs to understand the diagnostic classifications of clavicle fractures, have a plan for immobilization, identify associated injuries, understand the difference between treating pediatric and adult patients, and have an approach to multimodal pain control. It is also important to understand when expert orthopedic consultation or referral is indicated.

OBJECTIVE OF THE REVIEW

To provide an evidence-based review of clavicle fracture management in the emergency department.

DISCUSSION

Clavicle fractures account for up to 4% of all fractures evaluated in the emergency department. They can be separated into midshaft, distal, and proximal fractures. They are also classified in terms of their degree of displacement, comminution and shortening. Emergent referral is indicated for open fractures, posteriorly displaced proximal fractures, and those with emergent associated injuries. Urgent referral is warranted for fractures with greater than 100% displacement, fractures with >2 cm of shortening, comminuted fractures, unstable distal fractures, and floating shoulder. Nondisplaced or minimally displaced fractures with no instability or associated neurovascular injury are managed non-operatively with a sling. Pediatric fractures are generally managed conservatively, with adolescents older than 9 years-old for girls and 12 years-old for boys being treated using algorithms that are similar to adults.

CONCLUSIONS

When encountering a patient with a clavicle fracture in the emergency department the fracture pattern will help determine whether emergent consultation or urgent referral is indicated. Most patients can be discharged safely with sling immobilization and appropriate outpatient follow-up.

Precontoured Locking Compression Plate with Titanium Alloy Cable System: In Treatment of Neer Type IIb Distal Clavicle Fracture

Objective

To describe a new method which involves anatomical distal clavicle plate fixation and titanium alloy cable system‐augmented coracoclavicular ligament reconstruction to manage Neer type IIb distal clavicle fracture.

Methods

Between January 2013 and June 2018, 28 patients with acute Neer type IIb lateral clavicle fracture were treated by a new method – precontoured locking compressive distal clavicular plate fixation of the fracture combined with titanium alloy cable system‐augmented reconstruction of the coracoclavicular ligament. There were 11 females and 17 males treated in this way. There were 15 cases of the right side and 13 of the left. The mean age of the patients was 48.5 years (range, 18–78 years). The mean time from injury to surgery was 3.9 days (range, 1–7 days). After completing the preoperative examinations and evaluations, surgeries were performed for all these patients, anatomical distal clavicle plates were used for fractures, and titanium alloy cables were implanted for the augmented reconstruction of coracoclavicular ligaments. Postoperative protocols, including arm sling management and rehabilitative activities, were unified and recommended to all the patients. These patients were followed up for at least 1 year. The mean duration of postoperative follow‐up was 23.3 months (range, 12–52 months). At the last follow‐up, the coracoclavicular distances were recorded and shoulder functional outcomes were assessed by the Constant scores and the Fudan University Shoulder Scores (FUSSs) questionnaires.

Results

Radiographic bony unions were achieved in all patients within 20 weeks. Functional and radiographic outcomes were retrospectively evaluated. The mean coracoclavicular distance was 9.61 ± 0.61 mm on the injured side vs 9.62 ± 0.57 mm on the contralateral uninjured side. The mean Constant score and mean FUSS were 90.1 ± 6.6 (range, 68–98) and 86.1 ± 7.2 (range, 64–95) respectively, which indicating good restoration of function and high level of satisfaction for both the patients and their physical therapists. There were a few major complications, including one delayed healing of the skin, one severe shoulder stiffness, three incidences of moderate shoulder stiffness, and five incidences of symptomatic hardware. There is no deep infections, neurovascular injuried, delayed union or nonunion, peri‐implant fracture, loss of reduction, implant malposition or failure, or other severe complications.

Conclusion

This combined method for the treatment of Neer type IIb distal clavicle fracture could yield high bony union rate, good functional outcome, and low complication rate. Further prospective randomized controlled studies are needed to confirm the benefits of this method of treatment.

Under Coracoid-through Clavicle Suture Fixation in Type 2 Distal Clavicle Fracture

Introduction

Surgical management of Neer type 2 distal clavicle fractures may include tension band wiring, pre-contoured plate, hook plate or indirect fixation of coracoclavicular space by Endobutton, suture anchors, or Tightrope devices. We present our technique of suture and Mersilene tape fixation by passing them through the clavicle and under the coracoid which is a form of indirect fixation.

Technique

The fracture and the coracoid are exposed through a horizontal skin incision. The Mersilene tape and Ethibond suture are looped under the coracoid and then one limb of each is passed through the medial hole and then through the lateral hole to exit inferiorly and then tied underneath the clavicle, while the fracture is reduced.

Conclusion

Direct fixation by means of plate has good outcomes though high complication rate. Indirect fixation by means of Endobutton and Tightrope devices has shown successful outcome with less side effects. Our method of fixation by Ethibond suture and Mersilene tape is inexpensive while having the same principles of internal fixating the clavicle to the coracoid while the fracture heals.

Treatment of distal clavicle fractures using a Scorpion plate and influence of timing on surgical outcomes: a retrospective cohort study of 105 cases

Background

Plate fixation is an established method for treating unstable distal clavicle fractures. However, the appropriate timing of surgery for acute distal clavicle fractures remains unclear. The present study aimed to evaluate the clinical outcomes of osteosynthesis using a Scorpion plate and to assess the influence of surgery timing on the surgical outcomes for acute unstable distal clavicle fractures.

Methods

We retrospectively reviewed 105 patients who underwent fixation for acute unstable distal clavicle fractures (Neer type II and V) using the Scorpion plate between 2008 and 2018. Patients were divided into early (45 patients) and delayed (60 patients) treatment groups based on the timing of the surgical intervention (within or after 7 days). The outcomes were postoperative complications (nonunion, peri-implant fracture, plate loosening, plate-related pain, and stiffness). We evaluated the outcomes from X-ray radiographs and clinical notes.

Results

Among the 105 patients, nonunion, plate loosening, plate-related pain, and stiffness were observed in six patients (5.7%), four patients (3.8%), seven patients (6.7%), and one patient (1.0%), respectively. The nonunion rate was significantly higher in the delayed treatment group than that in the early treatment group (P = 0.036). Although the difference was not significant, plate loosening and stiffness were only observed in the delayed treatment group.

Conclusion

Our results demonstrated that osteosynthesis using Scorpion plates achieved satisfactory surgical outcomes for unstable distal clavicle fractures. In addition, this study suggested that performing surgery within 6 days after injury is recommended to reduce postoperative complications.

Comparison of four different internal fixation methods in the treatment of distal clavicle fractures

This study compared the clinical efficacy of four internal fixation methods in the treatment of distal clavicle fractures, in an effort to guide appropriate selection and application in the clinic. Eighty-four patients with distal clavicle-comminuted fractures were treated with a distal clavicle anatomic plate (group A), clavicular hook plate (group B), double-plate vertical fixation (group C), or T-shaped steel plate internal fixation (group D). The Constant-Murley scoring system was used to evaluate the shoulder joint function. The fracture healing time, VAS, and postoperative complications were compared and analyzed among the four groups. According to the Constant-Murley evaluation standard, the excellent and good rates of the four groups were 94.4, 73.1, 95 and 80% in groups A-D, respectively. The excellent and good rates of Constant-Murley evaluation standard in groups A and C were significantly better than those in groups B and D (P<0.05). VAS in the distal clavicle anatomic plate group (group A), double-plate vertical fixation group (group C), and T-shaped steel plate internal fixation group (group D) were significantly better than the clavicular hook plate group (group B) (P<0.05). The incidence of postoperative complications in the clavicular hook plate group (group B) was 15.4% and in the T-shaped steel plate internal fixation group (group D) was 15%, which were significantly higher than those of the distal clavicle anatomic plate group (group A) and double-plate vertical internal fixation group (group C) (P<0.05). The treatment of distal clavicle fractures using either one of the four internal fixation techniques can obtain better clinical results. The distal clavicle anatomic plate and double-plate vertical internal fixation techniques are associated with a decreased incidence of shoulder pain, an increase in the range of motion of the shoulder, and a reduction in complications, and thus, are preferable for the early functional recovery of limbs.

Treatment of unstable distal-third clavicule fractures using minimal invasive closed-loop double endobutton technique

Background

Clavicle fractures are common clinical problems, accounting for approximately 10% of all fractures. Neer’s type II fractures disrupt the integrity of the coracoclavicular ligament and, therefore, are inherently unstable, requiring an extended period time to achieve bone union and being associated with a high rate of non- or malunion. Restoration of the stability of the distal clavicle is an important factor to decrease the rate of non- or malunion. As such, the aim of our study was to describe our technique of indirect osteosynthesis, using a minimally invasive closed-loop double endobutton (TightRope) technique for fixation of unstable (Neer’s type II) distal clavicle factures, and to evaluate the short-term clinical outcomes.

Methods

Fifteen patients with a Neer’s type II fracture of the distal clavicle were treated surgically using the TightRope fixation, between January 2016 and December 2017. Clinical and radiological results were assessed using the American Shoulder and Elbow Surgeons Shoulder Score (ASES) and the Constant score.

Results

Definitive fracture healing was achieved in most of the patients. No major complication was identified over a mean follow-up of 9 months, and none of the patients required additional surgery related to the index procedure. At the last follow-up, all patients had recovered functional range of motion of the shoulder, with high Constant and ASES scores, and low pain score.

Conclusion

The use of TightRope fixation provided sufficient stability to reduce the medially displaced fragment of the Neer’s type II fracture, with satisfactory radiological and clinical outcomes achieved over a mean follow-up of 9 months. Future studies on the long-term outcomes are needed.

Retrospective study of superior anterior plate as a treatment for unstable (Neer type 2) distal clavicle fractures

Objective

To analyze the sequelae of Neer type 2 distal end clavicle fractures treated with superior anterior locking plate.

Methods

From June 2012 to February 2015 a study was conducted with 14 male patients; 12 with unilateral and two with bilateral distal clavicle fractures treated with superior anterior plate. They were evaluated at intervals, with mean follow up of 16 months (14–18 months). All patients were evaluated clinically by both the Oxford Shoulder Score and the QuickDASH score.

Results

Union was seen in all fractures within 7–9 weeks (mean time: 8.2 weeks). All patients had good shoulder range-of-motion. The average Oxford Shoulder Score and QuickDASH score were 45.6 and 7.1, respectively. All patients returned to work within 3–4 months of the postoperative period.

Conclusion

Displaced distal clavicle fractures treated with superior anterior plates accomplished superlative results in terms of bony union, with rarely any complications.

Comparative analysis of locking plate versus hook plate osteosynthesis of Neer type IIB lateral clavicle fractures

INTRODUCTION

Controversy exists on optimal operative treatment of vertically unstable Neer IIB lateral clavicle fractures. Aim of this study was to analyse and compare clinical and radiological results and complications of locking plate osteosynthesis (LPO) versus hook plate osteosynthesis (HPO) with acromioclavicular joint (ACJ) stabilization. The hypothesis was, that HPO would recreate coracoclavicular stability more effectively and potentially lead to a superior outcome.

METHODS

This retrospective, observational cohort study included 32 patients (19 HPO, 13 LPO) with a mean age of 44.1 ± 14.2 years at surgery. The mean follow-up period was 54.2 months (range 25.2-111.4 months). Besides standard radiography, bilateral coracoclavicular distances were assessed by means of preoperative and follow-up stress radiographs after implant removal. Clinical outcome measures included the Constant score (CS), the Oxford shoulder score (OSS), the subjective shoulder value (SSV) and the Taft score (TS).

RESULTS

Bone union occurred in all but one patient and proved to occur delayed in five patients (15.6%). Radiographical healing required a mean of 4.2 ± 4.0 months irrespective of the type of osteosynthesis. At follow-up, mean coracoclavicular distance was increased by 34% (±36) without significant differences between both groups. HPO patients obtained a significantly lower TS (HPO: 9.5 ± 1.5 points, LPO: 11.1 ± 1.3 points; p = 0.005). Other mean score values did not differ (CS: 90.1 ± 7.4 points, OSS: 43.2 ± 9.2 points, SSV: 91.1 ± 14.7%). Sixteen patients (50.0%) experienced complications. Overall prevalence of complications was significantly higher in the HPO group (p = 0.014).

CONCLUSIONS

Both HPO and LPO were equally effective in relation to restoration of vertical stability, overall functional outcome and fracture consolidation in treatment of Neer IIB fractures. Contrary to our hypothesis, HPO was not associated with superior recreation of the coracoclavicular distance. Considerable drawbacks of HPO were an inferior ACJ-specific outcome (Taft-Score) and a higher overall complication rate. Level of evidence IV.

Plate fixation and bone grafting of distal clavicle nonunions: radiologic and functional outcomes

INTRODUCTION

The optimal treatment for distal clavicle nonunions remains unknown. Small series have reported outcomes following distal fragment excision and various fixation techniques. We present the clinical, radiographic and functional outcomes after superior plating or double (superior and anteroinferior) plating in combination with bone grafting as treatment for distal clavicle nonunions.

METHODS

We collected demographic and radiographic data from a consecutive series of ten patients with symptomatic nonunion of the distal clavicle treated since 1998. Functional outcomes were assessed, as well as the visual analogue scale (VAS) score.

RESULTS

The mean clinical follow-up was 41.4 months (range of 12-158 months). The mean radiological follow-up was 30.6 months (range of 3-158 months). All nonunions healed as demonstrated by subsidence of clinical symptoms and radiographic criteria. The average time to union was 3.7 months (range of 2-8 months). The mean The Disabilities of the Arm, Shoulder and Hand (DASH) score was 11.9 (range of 0-62.5) and mean VAS score was 0.9 at follow-up.

CONCLUSION

This study illustrates good clinical, radiologic and functional outcomes in ten patients with distal clavicle nonunion treated with superior or double (superior and anteroinferior) plating in combination with bone grafting. Double-plating can be considered an alternative to superior plating offering better resistance against the pulling effect of the arm with the use of smaller fixation plates.

Treatment of distal-third clavicular fractures (Neer type ii-b) with a triple button device

OBJECTIVE

The purpose of this study is to describe the outcomes of using a triple button device for the treatment of displaced distal-third clavicle fractures (Neer, type ii-b).

MATERIAL AND METHOD

A retrospective review was conducted on a series of patients between November 2011 and December 2014. Fourteen patients initially met the inclusion criteria, but 2 were excluded, leaving 12 patients (83.3% male; mean age 32.2 years) for the final analysis at a mean follow-up of 26±11.24 months (range, 12-48). Post-operative follow-up was performed at 2 weeks (two first months), and monthly thereafter, until was achieving clinically and radiological healing. The functional outcome was evaluated using the Constant score, and DASH score in the last follow-up.

RESULTS

The mean Constant Score was 95.5±5.2 points (range, 85-100), with a mean DASH score of 3.3±4.4 points (range, 0-12.5). The mean time to clinical healing was10.3±3.1 weeks (range, 8-16), and the mean time to radiological healing was 13.6±2.6 weeks (range, 12-20). There were no major complications. There were 5 minor complications without clinical impact: 2 coracoclavicular calcifications, 1 hypertrophic scar, 1 patient with discomfort due to the device, and 1 superficial wound infection. All patients returned their previous activity.

CONCLUSION

Good clinical results can be achieved with the triple button device in unstable distal fractures of the clavicle, without the need to remove the hardware.

Return to sport following clavicle fractures: a systematic review

INTRODUCTION

This review aims to provide information on the return rates and return times to sport following clavicle fractures.

SOURCES OF DATA

A systematic search of Medline, EMBASE, CINAHAL, Cochrane, Web of Science, PEDro, SPORTDiscus, Scopus and Google Scholar was performed using the keywords 'clavicle', 'clavicular', 'fractures', 'athletes', 'sports', 'non-operative', 'conservative', 'operative', 'return to sport'.

AREAS OF AGREEMENT

Twenty-three studies were included: 10 reported on mid-shaft fractures, 14 on lateral fractures. The management principles for athletic patients were to attempt non-operative management for undisplaced fractures to undertake operative intervention for displaced lateral fractures and to recommend operative intervention for displaced mid-shaft fractures.

AREAS OF CONTROVERSY

The optimal surgical modality for mid-shaft and lateral clavicle fractures.

GROWING POINTS

Operative management of displaced mid-shaft fractures offers improved return rates and times to sport compared to non-operative management. Suture fixation and non-acromio-clavicular joint (ACJ)-spanning plate fixation of displaced lateral fractures show promising results.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future prospective studies should aim to establish the optimal treatment modalities for clavicle fractures.

Closed-Loop Double Endobutton Technique for Repair of Unstable Distal Clavicle Fractures

BACKGROUND

Displaced fractures of the distal clavicle are inherently unstable and lead to nonunion in a high percentage of cases. The optimal surgical management remains controversial.

HYPOTHESIS

Indirect osteosynthesis with a closed-loop double endobutton construct would result in reliable fracture union and obviate the need for additional surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Eight patients with an acute unstable Neer type IIB distal clavicle fracture were treated with a closed-loop double endobutton implant. Mean follow-up averaged 3.4 years (range, 1-9 years). Two patients were lost to follow-up. The remaining 6 patients underwent a detailed functional and radiologic evaluation.

RESULTS

Definitive fracture healing was achieved in all patients. There were no complications, and no patients required additional surgery related to the index procedure. The mean Constant score was 97 at final follow-up.

CONCLUSION

The closed-loop double endobutton technique was reliable and effective in achieving fracture union in all patients with unstable Neer type IIB fractures of the distal clavicle. This technique obviates the need for late hardware removal that is often necessary when direct osteosynthesis is used and avoids potential complications associated with coracoclavicular cerclage constructs that require knot fixation.

Outcome of arthroscopic treatment for displaced lateral clavicle fractures using a double button device

PURPOSE

The purpose of this study was to assess the clinical and radiological outcomes of an arthroscopically assisted fixation of type IIB fractures using a double button device.

METHODS

Twenty-one patients with a type IIB displaced fracture of the clavicle who received an arthroscopically assisted fixation using a double button device were enrolled from 2009 to 2011. Clinical assessment included the patient's demographics, cause of injury, delay before surgery, time for surgery, time before resuming work and sports, the Shoulder and Hand (QuickDASH) score, the Constant-Murley score and the visual pain analogue scale (VAS). Radiological examination consisted of anteroposterior and axillary radiographs.

RESULTS

The median age of patients was 33 years (range 18-67). Mean follow-up was 35 ± 8.9 months (range 24-51 months). The average delay before surgery was 3 days (range 1-7). At final follow-up, the mean QuickDASH score, Constant score and VAS were respectively 3.2 ± 6 (range 0-25), 94.8 ± 9.9 (range 62-100) and 0.5 ± 1.2 (range 0-4). Seventeen (81 %) patients were able to resume work, including heavy manual labour, and to resume their sport activities as well. Postoperative complications included one transient adhesive capsulitis, a symptomatic acromioclavicular joint osteoarthritis and an implant failure with nonunion. Bony union was achieved in all other patients.

CONCLUSION

This study has demonstrated that the arthroscopic treatment using a double button device was effective at providing a satisfactory functional outcome, minimizing the risk of complications and presenting low implant failure and low nonunion rates in patients with Neer type IIB fractures of the distal clavicle. Such results lead us to consider this minimally invasive technique as a first-choice treatment.

LEVEL OF EVIDENCE

IV.

Clinical and radiological outcome following treatment of displaced lateral clavicle fractures using a locking compression plate with lateral extension: a prospective study

Background

Treatment of lateral fractures of the clavicle is challenging and has been controversially discussed for a long time due to high non-union rates in non-operative treatment and high complication rates in surgical treatment. Acromioclavicular joint instability due to the injury of the closely neighbored coraco-clavicular ligaments can result in a cranialization of the medial clavicle shaft. A recently developed implant showed a promising functional outcome in a small collective of patients.

Methods

In this prospective study, 20 patients with a mean age of 40.7 ± 11.3 years with a dislocated fracture of the lateral clavicle (Jäger&Breitner I-III, Neer I-III) were enrolled. All patients were surgically treated using the locking compression plate (LCP) for the superior anterior clavicle (Synthes®). Functional outcome was recorded using the Munich Shoulder Questionnaire (MSQ) allowing for qualitative self-assessment of the Shoulder Pain and Disability Index (SPADI), of the Disability of the Arm, Shoulder and Hand (DASH) score and of the Constant Score. Acromioclavicular joint stability was evaluated using the Taft-Score.

Results

The mean follow-up was 14.2 ± 4.0 months. The mean MSQ was 87.0 ± 7.4 points, the mean SPADI 91.1 ± 11.3 points, the mean DASH score 7.6 ± 7.3 points and the mean normative age- and sex-specific Constant Score 85.6 ± 8.0 points. The mean Taft Score resulted in 10.7 ± 1.0 points. The mean Taft Score in lateral clavicular fractures with fracture gap between the coracoclavicular ligaments in combination with a rupture of the conoid ligament (J&B II a, Neer II B; n =11) was with 10.3 ± 0.9 points significantly lower than the mean Taft Score of all other types of lateral clavicle fractures (J&B I, II b, III; n =9) which resulted in 11.3 ± 0.9 points (p < 0.05).

Conclusions

The Synthes® LCP superior anterior clavicle plate allows for a safe stabilization and good functional outcome with high patient satisfaction in fractures of the lateral clavicle. However, in fractures type Jäger&Breitner II a, Neer II B a significant acromioclavicular joint instability was observed and additional reconstruction of the coracoclavicular ligaments should be performed.

Trial registration

ClinicalTrials.gov NCT02256059. Registered 02 October 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-380) contains supplementary material, which is available to authorized users.

[Distal clavicle fracture]

OBJECTIVE

Reposition and fixation of unstable distal clavicle fractures with a low profile locking plate (Acumed, Hempshire, UK) in conjunction with a button/suture augmentation cerclage (DogBone/FibreTape, Arthrex, Naples, FL, USA).

INDICATIONS

Unstable fractures of the distal clavicle (Jäger and Breitner IIA) in adults. Unstable fractures of the distal clavicle (Jäger and Breitner IV) in children. Distal clavicle fractures (Jäger and Breitner I, IIB or III) with marked dislocation, injury of nerves and vessels, or high functional demand.

CONTRAINDICATIONS

Patients in poor general condition. Fractures of the distal clavicle (Jäger and Breitner I, IIB or III) without marked dislocation or vertical instability. Local soft-tissue infection.

SURGICAL TECHNIQUE

Combination procedure: Initially the lateral part of the clavicle is exposed by a 4 cm skin incision. After reduction of the fracture, stabilization is performed with a low profile locking distal clavicle plate. Using a special guiding device, a transclavicular-transcoracoidal hole is drilled under arthroscopic view. Additional vertical stabilization is arthroscopically achieved by shuttling the DogBone/FibreTape cerclage from the lateral portal cranially through the clavicular plate. The two ends of the FibreTape cerclage are brought cranially via adjacent holes of the locking plate while the DogBone button is placed under the coracoid process. Thus, plate bridging is achieved. Finally reduction is performed and the cerclage is secured by surgical knotting.

POSTOPERATIVE MANAGEMENT

Use of an arm sling for 6 weeks.

RESULTS

Due to the fact that the described technique is a relatively new procedure, long-term results are lacking. In the short term, patients postoperatively report high subjective satisfaction without persistent pain.

Fracture of distal end clavicle: A review

Management of fracture distal end clavicle has always puzzled the orthopaedic surgeons. Now-a-days with a relatively active lifestyle, patients want better results both cosmetically and functionally. Despite so much literature available for the management of this common fracture, there is no consensus regarding the gold standard treatment for this fracture. In this article, we reviewed the literature on various techniques of management for this fracture, both conservative as well as surgical, and their merits and demerits.

Comparison of the efficacy of a distal clavicular locking plate versus a clavicular hook plate in the treatment of unstable distal clavicle fractures and a systematic literature review

PURPOSE

The purpose of this study was to retrospectively compare and review the clinical outcomes between the distal clavicular locking plate and clavicular hook plates in the treatment of unstable distal clavicle fractures; moreover, the relevant literature of the two fixation methods was reviewed systematically to identify the non-union, complications, or functional scores, according to the treatment methods and determine which treatment method is better.

METHODS

Sixty-six patients with 66 unstable distal clavicle fractures who underwent open reduction and internal fixation with either a distal clavicular locking plate (36 patients) or a clavicular hook plate (30 patients ) were evaluated. The main outcome comparisons included Constant score, rate of non-union, rate of complication, and rate of returning to work three months postoperatively.

RESULTS

No significant difference was found between locking plate and hook plate groups in union rate and Constant score (P > 0.05). However, the results indicated that the distal clavicular locking plate group had a significantly lower rate of complications (P < 0.05) and symptomatic hardware (P < 0.05). In addition, the distal clavicular locking plate facilitated the return to work better than the clavicular hook plate (P < 0.05).

CONCLUSIONS

Both distal clavicular locking plate and clavicular hook plate achieved good results in the treatment of unstable distal clavicle fractures; however, internal fixation with a distal clavicular locking plate had greater ability to return to their previous work after surgery in three months and fewer complications than the clavicular hook plate.

[Bony injuries of the shoulder girdle in snowboarding]

BACKGROUND

The fracture of the clavicle is the second most common fracture in snowboarding after the distal radius fracture. Nonsurgical treatment is frequently the treatment of first choice. For displaced fractures, surgical treatment is recommended.

METHODS

In general, internal fixation can be performed with a plate osteosynthesis or an intramedullary nail. Clinical studies were able to show similar and even slightly better functional results of the intramedullary nail in comparison to plate osteosynthesis. Because of less surgical trauma and better cosmetic results, intramedullary systems are increasingly preferred.

RESULTS

Lateral clavicular fractures are more complex regarding surgical treatment due to their potential for concomitant ligamentous injuries. The hooked plate shows good clinical results with the advantage of addressing the fracture as well as the ligament injury in one step. The limitation of mobility during the first few postoperative weeks is the technique's main disadvantage.

CONCLUSIONS

Ligament reconstruction with suture pulley systems as a stand-alone treatment or in combination with a locking plate osteosythesis are increasingly used due to their excellent clinical results with early postoperative mobilization.

Fractures of the clavicle: an overview

Fractures of the clavicle are a common injury and most often occur in younger individuals. For the most part, they have been historically treated conservatively with acceptable results. However, over recent years, more and more research is showing that operative treatment may decrease the rates of fracture complications and increase functional outcomes. This article first describes the classification of clavicle fractures and then reviews the literature over the past decades to form a conclusion regarding the appropriate management.

A thorough literature review was performed on assessment of fractures of the clavicle, their classification and the outcomes following conservative treatment. Further literature was gathered regarding the surgical treatment of these fractures, including the methods of fixation and the surgical approaches used. Both conservative and surgical treatments were then compared and contrasted.

The majority of recent data suggests that operative treatment may be more appropriate as it improves functional outcome and reduces the risk of complications such as non-union. This is particularly evident in mid shaft fractures, although more high grade evidence is needed to fully recommend this, especially regarding certain fractures of the medial and lateral clavicle.

Under-coracoid-around-clavicle (UCAC) loop in type II distal clavicle fractures

In Neer type II (Robinson type 3B) fractures of the distal clavicle the medial fragment is detached from the coracoclavicular ligaments and displaced upwards, whereas the lateral fragment, which is usually small, maintains its position. Several fixation techniques have been suggested to treat this fracture. The aim of this study was to assess the outcome of patients with type II distal clavicle fractures treated with coracoclavicular suture fixation using three loops of Ethibond. This prospective study included 14 patients with Neer type II fractures treated with open reduction and coracoclavicular fixation. Ethibond sutures were passed under the coracoid and around the clavicle (UCAC loop) without making any drill holes in the proximal or distal fragments. There were 11 men and three women with a mean age of 34.57 years (29 to 41). Patients were followed for a mean of 24.64 months (14 to 31) and evaluated radiologically and clinically using the Constant score. Fracture union was obtained in 13 patients at a mean of 18.23 weeks (13 to 23) and the mean Constant score was 96.07 (91 to 100). One patient developed an asymptomatic fibrous nonunion at one year. This study suggests that open reduction and internal fixation of unstable distal clavicle fractures using UCAC loops can provide rigid fixation and lead to bony union. This technique avoids using metal hardware, preserves the acromioclavicular joint and provides adequate stability with excellent results.

Cite this article: Bone Joint J 2013;95-B:983–7.

Arthroscopic treatment of comminuted distal clavicle fractures (latarjet fractures) using 2 double-button devices

Complex distal clavicle fractures associated with a rupture of the coracoclavicular ligaments (Latarjet fractures) can result in delayed union or nonunion. There is no standard treatment for a clavicle fracture. This report introduces an arthroscopic technique for treating distal clavicle fractures associated with ruptured coracoclavicular ligament using 2 double-button devices. By use of posterior and anterior standard arthroscopic portals, the base of the coracoid process is exposed through the rotator interval. A 4-mm hole is drilled through the clavicle and the coracoid process with a specific ancillary drill guide. The first button is pushed through both holes down the coracoid process. The device is tightened, and the second button is fixed on top of the clavicle, allowing reduction and fixation of the proximal part of the fracture. Then, the undersurface of the lateral clavicle is dissected through standard posterior and lateral subacromial approaches. The inferior clavicle fragment is reduced and fixed to the clavicle body by a double button fixed down and at the top of the clavicle. With this technique, the arthroscopic treatment of distal clavicle fracture has been extended to comminuted fractures.