Locking plate osteosynthesis of clavicle fractures: complication and reoperation rates in one hundred and five consecutive cases

Evaluating the Outcomes of Managing Displaced Clavicular Fractures by Using Precontoured Clavicular Plates

Background and objective Midshaft clavicular fractures were managed conservatively in the past, with a significant incidence of nonunion and poor functional outcomes in displaced fractures. Anatomically precontoured clavicle plates, since their introduction, have proved to be a superior method for managing these fractures. While open reduction and internal fixation of displaced clavicular fractures with plates have produced successful functional outcomes, complications like plate prominence, scar, postoperative numbness, wound dehiscence, refracture, and infection continue to discourage surgeons from plating these fractures. This study aimed to evaluate whether the precontoured 3.5-mm locking compression plate (LCP) for the clavicle is effective in the management of displaced clavicular fractures with minimum risk of complications. Methods A prospective observational study was conducted among 26 patients with displaced clavicular fractures that were managed with 3.5-mm precontoured LCP. The functional outcome was assessed by using the Constant-Murley Score (CMS) and healing was assessed radiographically six months postoperatively. Results Twenty-five patients were available for the final follow-up at the end of 24 weeks. All of them achieved excellent functional scores. The mean CMS was 94.9. No complication was observed in 85% of the cases. Implant failure was observed in both fractures of a bilateral clavicle fracture patient within a month of surgery. Implant irritation without prominence was seen in one patient and another had a prominent postoperative scar. The mean time for the radiological union was 13.8 weeks with union time ranging from three to five months. Conclusions Based on our findings, employing 3.5-mm precontoured clavicular LCPs is a useful technique that can provide good functional outcomes in displaced clavicular fractures.

Comparison of the use of biocompatible materials and titanium in the treatment of midshaft clavicle fractures with a patient-specific plate: a finite element analysis study

BACKGROUND

Clavicular midshaft fractures treated with titanium plates may encounter complications like implant failure. We assess if alternative biocompatible materials suchs as PLA, PLA/HA, PEEK offer comparable stability. Our study evaluates the biomechanical performance of these materials in surgical management of midshaft clavicle fractures.

METHODS

We simulated a personalized fixation implant with four different materials and conducted finite element analysis in ANSYS to assess maximum von Mises stress (MvMs).

RESULTS

The MvMs occurring on the plates, screws, clavicle, and fracture site were recorded. MvMs on titanium material at the 6th hole level (764.79 MPa) and the 6th screw level (503.38 MPa), with the highest stresses observed at 48.52 MPa on the lateral clavicle at the 1st hole level and 182.27 MPa on the medial clavicle at the 6th hole level. In PLA material analyses, the highest MvMs were observed at the 3rd hole level (340.6 MPa) and the 3rd screw level (157.83 MPa), with peak stresses at 379.63 MPa on the lateral clavicle fracture line and 505.44 MPa on the medial clavicle fracture line. In PLA/HA material analyses, the highest MvMs were at the 3rd hole (295.99 MPa) and 3rd screw (128.27 MPa), with peak stresses at 220.33 MPa on the lateral clavicle and 229.63 MPa on the medial clavicle fracture line. In PEEK material analyses, the highest MvMs were at the 3rd hole (234.74 MPa) and 6th screw (114.48 MPa), with peak stresses at 184.36 MPa on the lateral clavicle and 180.1 MPa on the medial clavicle.

CONCLUSION

Our findings indicate that titanium material shows significantly higher stresses on plates and screws compared to those on the clavicle, suggesting a risk of implant failure. PLA and PLA/HA were inadequate for fixation. Although stress on the plate with PEEK material is higher than on the clavicle, it remains lower than titanium, indicating potential stability at fracture site. Further research is needed to confirm these findings.

Intramedullary fixation versus plate fixation in the treatment of midshaft clavicle fractures: a meta-analysis of randomized controlled trials

Objective

The aim of this systematic review and meta-analysis is to assess the clinical efficacy of intramedullary fixation (IF) vs. plate fixation (PF) in the treatment of midshaft clavicle fractures.

Methods

We conducted a computerized search of the electronic databases (PubMed, EMBASE, Cochrane Library, Medlineand Chinese Journal Full-text Database) from the establishment of the database to the end of November 2022. The quality of the included studies was assessed according to the Cochrane Collaboration's "Risk of bias". Comparisons between the two groups were based on 8 variables, including Constant score, disabilities of the arm, shoulder and hand (DASH) score, surgery time, length of incision, hospital stay; time to union, blood loss and infection.

Results

Thirteen randomized controlled trials (RCTs) comprising a total of 928 patients were included in our meta-analysis. The pooled results showed that IF can benefit midshaft clavicle fractures with a reduced surgery time and hospital stay, a smaller incision, a better shoulder function (DASH score), shorter time to union and lower rate of infection compared with PF. However, there was no significant difference between the two groups in terms of Constant score at 12-month follow-up.

Conclusion

IF is superior to PF for the treatment of midshaft clavicle fractures.

Usefulness of double plate fixation after failed ORIF for clavicle shaft fracture

PURPOSE

We aimed to evaluate the clinical and radiological outcomes of double plate fixation for failed clavicle shaft fracture surgery.

MATERIALS AND METHODS

We analyzed 14 patients who underwent double plate fixation due to plate failure after clavicle shaft fracture surgery from March 2016 to March 2021. The study used 3.5 mm locking compression plates for superior clavicle and anterior reconstruction in all patients. In addition, moldable allograft bone was used to fill the bone defect. Clinical and radiological evaluation was performed immediately, at 2 and 4 weeks, and 3, 6, 9, and 12 months postoperatively. The visual analog scale (VAS), University of California at Los Angeles (UCLA) shoulder scale, and American Shoulder and Elbow Surgeons (ASES) scores and range of motion of the shoulder were evaluated as clinical results. For radiological evaluation, anteroposterior, caudal, and cephalad views of both clavicles were used. Successful bone union was defined as complete adjoining of the fracture site through callus formation.

RESULTS

Successful bone union was achieved in all patients, and the mean time to bone union was 16.7 ± 1.2 weeks (range, 12-24 weeks). Statistically significant improvement in forward flexion and external and internal rotation was observed from 135.5° ± 6.3, 45.2° ± 5.3, and 13° ± 2.3 preoperatively to 157.0° ± 9.3, 68.7° ± 6.3, and 9.8° ± 3.1 at the final follow-up, respectively. The VAS score improved from an average of 6.2 ± 2.8 preoperatively to 1.3 ± 0.7 at the final follow-up, which was statistically significant (P = 0.018). In addition, the ASES score significantly increased from a mean of 52.1 ± 6.3 points preoperatively to 83.6 ± 7.8 points at the final follow-up (P = 0.001). The average UCLA shoulder score was 16.7 ± 1.4 and 31.4 ± 2.2 points preoperatively and at the final follow-up, respectively, which was statistically significant (P = 0.001).

CONCLUSION

Double plate fixation has shown good results after failed open reduction and internal fixation (ORIF) for clavicle shaft fractures. Therefore, in complicated situations after ORIF, double plate fixation is considered a surgical treatment option.

Canceling Notch Improves the Mechanical Safety of Clavicle Locking Plate: A 3D Finite Element Study

OBJECTIVE

Implant failure is a disastrous complication of the operative treatment of midshaft clavicle fractures, and improving the osteosynthesis plate is a strategy for preventing this. We aimed to investigate whether canceling the notch and adding screw-hole inserts enhanced the mechanical properties of the plate.

METHODS

A clavicle model was generated based on the CT images of six adult volunteers (age range, 20-40 years; three males and three females; height range 160-175) using dedicated software, and a midshaft fracture model was created. The domestically made seven-hole locking plate commonly used for midshaft clavicle fractures was simulated (Model I); modifications were made to the plate (Model II). Using 3D finite element analysis, we simulated the fracture construct under three different load conditions-downward cantilever bending, axial compression, and axial torsion-and compared the stress distribution.

RESULTS

We found that under axial compression, Model II experienced its maximum stress on the plate at 551.9MPa, which was less than that in Model I (790.4 MPa). Moreover, a greater stress concentration at the fracture site was observed under axial torsion, despite the maximum stress of both the models being similar.

CONCLUSION

Canceling the notch and filling the screw holes near the fracture can ameliorate stress concentration on the internal fixation construct and enhance its reliability under axial compression. This improvement has substantial effects on the mechanical properties of implants and potentially prevents implant failure. Modern osteosynthesis anatomical implants need to be improved.

Biomechanical and clinical evaluation of minimal invasive plate osteosynthesis for two-part clavicle shaft fractures

BACKGROUND

Many surgical treatment methods exist for clavicle shaft fractures. A locking compression plate (LCP) fixation with three screws per fracture side is commonly used. For certain fractures a stabilization with 2 screws per side is potentially suitable, offering the advantage of reduced soft tissue approach, while avoiding the disadvantages of minimally-invasive nailing at the same time. This hypothesis was evaluated biomechanically and clinically.

METHODS

Four treatment procedures were investigated biomechanically using composite human clavicle specimens. A load-to-failure test was performed using a three-point cantilever test. In group 1, a simple shaft fracture was simulated and stabilized with 2 screws per fracture side (5-hole LCP). In the second group 3 screws per side (7-hole LCP) were used. In group 3, a non-reduced fracture zone was simulated and treated with 3 screws per side (7-hole LCP). In group 4, an anatomically reduced fracture zone was simulated and treated with 3 screws per side (7-hole LCP). Furthermore 27 patients treated with a short plate and 2 screws per side (similar to group 1) were assessed after a minimum follow-up of 12 months (Constant and DASH Score).

RESULTS

The maximum load-to-failure of group 1 was 367N. We observed the highest load-to-failure in group 2 with 497N and the lowest in group 3 with 90N. In group 4 a maximum load-to-failure of 298N could be evaluated. There was no significant difference in load-to-failure between the treatment of a simple clavicle fracture using 5- or 7-hole LCP (p = 0.121). However, we found a significant difference of load-to-failure between the simple and anatomically reduced fracture using a 7-hole plate (p = 0.014). The mean constant score of the surgically treated patients was 95 and the DASH score 3.0. Fracture consolidation was observed in 96.3%.

CONCLUSIONS

For certain non-fragmented and well interlocking 2-part fractures, a plate osteosynthesis fixed with only 2 screws per fracture side might offer sufficient biomechanical stability, better soft tissue preservation and comparable fusion rates compared to the operative treatment with 3 screws per side. However, the maximum load-to-failure of the 7-hole LCP was higher than of the 5-hole LCP, but this difference was not statistically significant.

TRIAL REGISTRATION

Approval from the ethics committee of the Technical University of Dresden was retrospectively obtained (EK 588122019).

Operative stabilisation versus non-operative management of mid-shaft clavicle fractures

INTRODUCTION

Fractures of the mid-shaft clavicle are commonly encountered in clinical practice. These can be managed either by conservative method or operative by internal fixation. This study aims to compare the outcomes of conservative and operative management.

METHODS

Forty patients with displaced and comminuted mid-shaft clavicle fractures were included in the study, among which twenty-five patients were treated conservatively and 15 patients underwent surgery and were followed up for a period of 1 year. Time taken for union, functional outcome, complications, and patient satisfaction were compared.

RESULTS

In the non-operative group, 28% of the fractures took less than twelve weeks to unite, whereas in the operative group 60% of them took less than 12 weeks to unite. At the end of 1 year, there was no statistical difference in mean UCLA (University of California and Los Angeles) score and the mean DASH score of the non-operative group and operative group. There were more complications in the operative group. Re-operative rate in the operative group was 40%. Patient satisfaction was 80% in the non-operative group, whereas 48% of patients were satisfied in the operative group.

CONCLUSION

Displaced and comminuted mid-shaft clavicle fractures treated conservatively have more advantages when compared to surgically treated fractures.

Closed midshaft clavicle fractures

Aims

The management of mid-shaft clavicle fractures (MSCFs) has evolved over the last three decades. Controversy exists over which specific fracture patterns to treat and when. This review aims to synthesize the literature in order to formulate an appropriate management algorithm for these injuries in both adolescents and adults.

Methods

This is a systematic review of clinical studies comparing the outcomes of operative and nonoperative treatments for MSCFs in the past 15 years. The literature was searched using, PubMed, Google scholar, OVID Medline, and Embase. All databases were searched with identical search terms: mid-shaft clavicle fractures (± fixation) (± nonoperative).

Results

Using the search criteria identified, 247 studies were deemed eligible. Following initial screening, 220 studies were excluded on the basis that they were duplicates and/or irrelevant to the research question being posed. A total of 27 full-text articles remained and were included in the final review. The majority of the meta-analyses draw the same conclusions, which are that operatively treated fractures have lower nonunion and malunion rates but that, in those fractures which unite (either operative or nonoperative), the functional outcomes are the same at six months.

Conclusion

With regard to the adolescent population, the existing body of evidence is insufficient to support the use of routine operative management. Regarding adult fractures, the key to identifying patients who benefit from operative management lies in the identification of risk factors for nonunion. We present an algorithm that can be used to guide both the patient and the surgeon in a joint decision-making process, in order to optimize patient satisfaction and outcomes. Cite this article: Bone Jt Open 2022;3(11):850–858.

Intramedullary nailing versus plating fixation for the treatment of midshaft clavicular fractures: A meta-analysis of randomized controlled trials

PURPOSE

This study was to test the hypothesis that intramedullary (IM) nailing fixation of midshaft clavicle fractures could result in better clinical outcomes and lower complications rates than plating fixation.

METHODS

PubMed, Embase, and the Cochrane Library database were used to search all English language published randomized controlled trials (RCTs) of midshaft clavicle fractures using plating versus IM nailing. The characteristics of the study participants were collected. Outcomes of postoperative shoulder functional measurements, operative data and complications rates were meta-analyzed.

RESULTS

Eight hundred and ninety-five patients in ten RCTs and three quasi-RCTs were involved in the meta-analysis. The results of meta-analysis of these studies showed that the functional outcome evaluated by the Constant Shoulder and Disabilities of the Arm, Shoulder and Hand (DASH) scores after accepting IM nailing was significantly better than that of plating fixation at one year post-operatively (P < 0.01), with the heterogeneity of 43% and 91%, respectively. Sensitivity analyses of the pooled results of Constant and DASH scores displayed that the functional advantage of IM nailing fixation comes from the subgroup of locked IM nailing. Further, regarding the operative statistics, operative time, blood loss and wound length were significantly less in the IM nailing group than the plating group (P < 0.001). The rates of infection, major complications and complications-related revision surgery were significantly higher in the plating group than the IM nailing group; however, there were no significantly statistical differences in other complications, e.g., nonunion, refracture after hardware removal, implant failure, symptomatic hardware, etc. (P > 0.05).

CONCLUSION

The observations in this review suggested that IM nailing, especially locked IM nailing, could provide better shoulder functional outcome at one-year follow-up. Moreover, IM nailing fixation could effectively reduce operative time, blood loss, rates of infection, major complications, and revision surgery than plating. Further high-quality clinical trials with large samples and consistent designs are still needed to verify the long-term functional advantage of locked and unlocked IM nailing for midshaft clavicle fractures.

LEVEL OF EVIDENCE

Level II.

Prospective evaluation of early functional recovery of displaced fractures of the middle third of the clavicle whether operated or not

INTRODUCTION

Several studies have analyzed the functional recovery after plate fixation of a displaced fracture of the middle third of the clavicle beyond the 6th week. The aim of this study was to assess the early functional recovery in the first 6 weeks, which has not yet been investigated.

HYPOTHESIS

Functional recovery in the first 6 weeks after surgical treatment is better than in the first 6 weeks of functional (non-operative) treatment.

METHODS

Any patient who had a closed displaced fracture of the middle third of the clavicle - Edinburgh types 2B1 or 2B2 - was informed of the treatment options within a week of their fracture: surgical fixation by anatomic plate or functional treatment. A QuickDASH score was filled out weekly for 6 weeks and at 3 and 6 months. Similarly, the Constant score was determined at 3 and 6 weeks and at 3 and 6 months. Any complications were documented and time to union was determined.

RESULTS

Sixty-five fractures in 65 patients were followed for 6 months. Twenty-six patients chose surgical treatment (S) and 39 chose functional treatment (F). The Constant and QuickDASH scores were significantly better in the S group from the 2nd to the 6th week. At 3 weeks, we found a Constant score of 57.7 in group F versus 74.9 in group S (p<0.01) and a QuickDASH of 55.9 in group F versus 27.4 in group S (p<0.001). At 6 weeks, the Constant score was 71.3 versus 86.1 (p<0.001) and the QuickDASH was 28.3 versus 10.6 (p<0.01), respectively. At 3 and 6 months, the recovery was comparable in both groups for these two scores. Return to work was earlier in the S group (34.3 versus 59.7 days; p<0.05).

DISCUSSION

This is the first study reporting the functional results during the first 6 weeks after a displaced fracture of the middle third of the clavicle in adults. Further studies should be conducted to better identify target patients for whom fracture fixation may be beneficial.

CONCLUSION

This study supports open reduction and internal fixation with an anatomical plate of displaced fractures of the middle third of the clavicle since the functional recovery is better in the first 6 weeks.

LEVEL OF EVIDENCE

III; prospective case-control study.

CLINICAL EVALUATION OF THE TREATMENT OF CLAVICLE FRACTURES: INTRAMEDULLARY NAIL × PLATE

Objective:

Studies confirm the benefit of surgical treatment for fixation of displaced midshaft clavicle fractures. Plate fixation and intramedullary nail are the two most used techniques. Our study seeks to compare these two surgical techniques.

Methods:

This is a retrospective study, conducted by the evaluation of patients treated for displaced midshaft clavicle fracture with intramedullary nail, and plate and screws. Socioeconomic variables were collected, a visual pain scale questionnaire was applied, the shoulder function was measured using CONSTANT and UCLA scores, and radiography was performed to verify the consolidation and evaluation of the final clavicle shortening.

Results:

Sixty-five patients were evaluated, 36 (55.4%) of which were subjected to clavicle fixation with plate and screws and 29 (44.6%) with intramedullary nail. The median shortening was 0.1mm for plate and 5.8mm for nail (p = 0.001). The UCLA score shows an average of 35 in the plate group and 35 in the intramedullary group. The median CONSTANT scores were 96.5 for plate and 95 for nail, without significance. In all groups, 13 (20%) complications were registered, 9 fixed with plate and 4 fixed with intramedullary nail. The most common complication was skin erosion with exposure of the synthetic material. Conclusion: The two techniques present satisfactory results for the treatment of displaced midshaft clavicle fractures. Level of Evidence III, Therapeutic Studies Investigating the Results of Treatment.

Can 3D-printing avoid discomfort-related implant removal in midshaft clavicle fractures? A four-year follow-up

INTRODUCTION

Due to the variation in shape and curvature of the clavicle, plates often have to be adjusted during surgery to acquire a good fit. Poorly fitted plates can cause discomfort, eventually requiring implant removal. 3D-printed replicas of the fractured clavicle can assist in planning of the surgical approach, plate selection and, if necessary, adjustment of the plate prior to surgery. We hypothesized this method of preoperative preparation would reduce implant-related discomfort resulting in a reduced reoperation rate MATERIALS AND METHODS: In a prospective cohort study, perioperative plate handling and clavicle fixation were timed and follow-up data were collected from participants undergoing operative treatment for a midshaft clavicle fracture. The control group (n = 7) received conventional surgery with standard precontoured plates. For the intervention group (n = 7), 3D-printed replicas of the fractured clavicle and a mirrored version of the healthy contralateral clavicle were available prior to surgery for planning of the surgical approach, and for plate selection and contouring. Primary outcome was reoperation rate due to implant-related discomfort. Secondary outcomes were complications and time differences in the different surgical phases (reduction, fixation and overall operation time) RESULTS: More participants in the control group had the plate removed due to discomfort compared to the intervention group (5/7 vs. 0/6; P = 0.012). One participant was excluded from the intervention group due to a postoperative complication; an infection occurred at the implant site. No relevant time difference in surgical plate handling was found between both groups.

CONCLUSIONS

Preoperative preparation using 3D-printed replicas of the clavicle fracture may reduce implant removal caused by plated-related discomfort. No relevant effect on surgery time was found.

TRIAL REGISTRATION

Registered with 'toetsingonline.nl', trial number NL51269.075/14, 17-02-2015.

Clinical outcome and operative cost comparison: Locked compression plate versus reconstruction plate in midshaft clavicle fractures

OBJECTIVE

The aim of this study was to compare the clinical outcomes and operative cost of a locked compression plate (LCP) and a nonlocked reconstruction plate in the treatment of displaced midshaft clavicle fracture.

METHODS

From January 2013 till March 2018, a total of 55 patients with acute unilateral closed midshaft clavicle fracture were treated with either a 3.5-mm pre-contoured LCP [32 patients; 25 men and 7 women; mean age: 35 years (range: 19-63 years)] or a 3.5-mm nonlocked reconstruction plate [23 patients; 20 men and 3 women; mean age: 31.4 years (range: 17-61 years)]. The clinical outcomes in terms of fracture union, Quick Disability of Arm, Shoulder and Hand (DASH) score, implant irritation, failure rate, and reoperation rate were evaluated retrospectively. The patient billing records were reviewed to obtain primary operation, reoperation, and total operative cost for midshaft clavicle fracture. These values were analyzed and converted from Malaysia Ringgit (RM) to United States Dollar (USD) at the exchange rate of RM 1 to USD 0.24. All patients were followed up for at least one-year duration.

RESULTS

The mean time to fracture union, implant irritation, implant failure, and reoperation rate showed no significant difference between the two groups of patients. The mean Quick DASH score was significantly better in the reconstruction plate group with 13 points compared with 28 points in the LCP group (p=0.003). In terms of total operative cost, the LCP group recorded a cost of USD 391 higher than the reconstruction plate group (p<0.001).

CONCLUSION

The 3.5-mm reconstruction plate achieved not only satisfactory clinical outcomes but was also more cost-effective than the LCP in the treatment of displaced midshaft clavicle fractures.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Comparison of radiological and clinical outcomes, complications, and implant removals in anatomically pre-contoured clavicle plates versus reconstruction plates - a propensity score matched retrospective cohort study of 106 patients

Background

Plate fixation is frequently used to treat displaced midshaft clavicular fractures, however the ideal plate choice remains subject to discussion; reconstruction locking compression plates (RLCPs) are cheaper and can be easily contoured, whereas anatomically pre-contoured locking compression plates (ALCPs) are thought to provide better stability and therefore lower rates of mechanical failure.

To compare the incidence of mechanical failures, functional and radiological outcomes in patients with midshaft clavicular fractures treated with ALCPs versus RLCPs.

Methods

A propensity score matched retrospective cohort study was conducted across two centers. One hundred and six consecutively recruited patients with displaced midshaft clavicular fractures, who were treated with plate fixation and had a minimum follow-up of 6 months, were matched on gender, age, fracture grading, energy of injury, and fracture location. The resulting groups included 53 ALCP-treated fractures and 53 matched controls treated with RLCPs.

Results

During a mean follow-up of 20.5 months, there were no implant deformities in the ALCP group whereas the RLCP group had 6 patients (11.3%, p = 0.012) with implant deformities (5 occurrences of plate bending with fracture union, and 1 plate breakage with nonunion). Despite the higher rate of plate deformities in the RLCP group, there were no statistically significant differences in number of patients recovering full shoulder range of motion (ALCP 90.6%, RLCP 88.7%, p = 0.751), incidence of rest pain (ALCP 13.2%, RLCP 9.4%, p = 0.542), or implant removals (ALCP 49.1%, RLCP 56.6%, p = 0.439).

Conclusion

ALCPs may be superior to RLCPs in terms of implant stability but appear to produce similar clinical results.

Clinical outcomes following conservative and surgical management of floating shoulder injuries: a systematic review

BACKGROUND

Floating shoulder is an uncommon injury characterized by fractures of the clavicle and ipsilateral scapular neck. No consensus exists on management. The purpose of this study was to analyze the existing literature on treatment and clinical outcomes of floating shoulder injuries to provide a baseline understanding of current treatment strategies of this injury.

METHODS

A systematic review was performed to identity published literature on outcomes and management of floating shoulder injuries. Searches were performed using PubMed, Embase, and SCOPUS.

RESULTS

Seventeen studies were identified that included data for 371 shoulders. The mean reported age was 39.4 years (range, 16-82) and the mean follow-up was 49.4 months (range, 6-312). The major mechanism of injury was motor vehicle accident (51%) followed by fall from height (16%). Of the 371 shoulders, 215 (58%) were treated surgically, whereas 156 shoulders (42%) were managed nonoperatively. The most commonly reported outcome score was the Constant-Murley score (9 studies), followed by the Herscovici Floating Shoulder Injury score (5 studies). The mean Constant-Murley score was 80% of ideal maximum for both shoulders treated surgically and those treated nonoperatively.

CONCLUSION

Satisfactory outcomes can be expected following both surgical fixation and nonoperative management of floating shoulder injuries when appropriately individualized to the patient, as evidenced by clinical outcome scores. Floating shoulder injuries with significant displacement of the scapular neck may benefit from surgical fixation of both the clavicle and scapula fractures. In those with minimal or nondisplaced scapular neck fractures, good outcomes may be achieved when treated nonoperatively or with surgical fixation of the clavicle alone.

Clavicle nonunion and plate breakage after locking compression plate fixation of displaced midshaft clavicular fractures

Open reduction and plate fixation have been widely used for the treatment of displaced midshaft clavicular fractures (DMCF). The nonunion rate after plate fixation of DMCF has been reported to be between 0.1 and 15% and the construct failure rate is approximately 5%. Few studies have discussed the risk factors of construct failure. The aim of the present study was to identify possible risk factors of construct failure in plate fixation of DMCF and discuss the subsequent treatment strategies. Six patients who experienced plate breakage and clavicle nonunion between 2015 and 2017 were evaluated. All these patients were treated with open reduction and plate fixation of DMCF using a 3.5-mm locking compression plate. The plate breakage occurred 3-6 months after the initial injury. After the diagnosis of plate breakage, four patients underwent surgical management and two patients underwent nonoperative treatment. Potential risk factors for construct failure and efficacy of the subsequent treatment strategies were analyzed. We found that a risk factor for plate breakage was the increased stress in free hole area around the fracture zone. A second surgery for plate renewal and bone grafting may be necessary in a large percentage of these individuals. Based on the results of this study, our recommendation is that monocortical screws or simple obturators for the holes around the fracture zone should be used to protect the comminuted fragment for further damage and enhance plate strength. If a clavicle nonunion and plate breakage does occur, surgical repair and bone grafting provide high union rates and should be a necessary remedy.

Finite element analysis comparison between superior clavicle locking plate with and without screw holes above fracture zone in midshaft clavicular fracture

Background

Midshaft clavicular fractures are common fractures and generally treated conservatively. Among the surgical options, plate fixation is the most popular and has been biomechanically and clinically proven in numerous studies. However, implant failures caused by plate deformations or breakage still occur in up to 16.7% of cases, and recent studies showed that screw holes above fracture zone (SHFZ) might be the at-risk location. Using finite element analysis, this study aimed to test the biomechanical property of the superior clavicle locking plate (SCLP) with and without SHFZ in comminuted midshaft clavicular fracture.

Methods

Finite element models of comminuted midshaft clavicular fracture fixed with standard 8-hole titanium SCLP with screw holes (SHFZ plate) and without screw holes above fracture zone (No-SHFZ plate) were built. Both groups were tested under three different loading models (100-N cantilever bending, 100-N axial compression, and 1-Nm torsion). The average peak stress on medial clavicle, fracture zone, and lateral clavicle, and the peak stress on each screw hole (or the same position in the No-SHFZ plate) were measured and compared.

Results

The highest average peak stress on the fracture zone was higher than those on medial and lateral clavicles under all loading conditions in both plates. However, the No-SHFZ plate significantly reduced the average peak stress value on the fracture zone, compared to the SHFZ plate (45.0% reduction in cantilever bending, 52.2% reduction in axial compression, and 54.9% reduction in axial torsion). The peak stress value on the maximal stress point in the SHFZ and No-SHFZ plates with cantilever bending, axial compression, and torsion loads were 1257.10 MPa vs. 647.21 MPa, 186.42 MPa vs. 131.63 MPa, and 111.86 MPa vs. 82.41 MPa, respectively.

Conclusion

The weakest link of the SCLP construct in comminuted midshaft clavicular fracture fixation is the SHFZ, especially in the cantilever bending load. Additionally, the biomechanical property of the SCLP without SHFZ model (No-SHFZ plate) is superior to the standard SCLP model (SHFZ plate), with a significantly lower peak stress on the SHFZ location in all loading conditions. We recommend a new SCLP design with SHFZ to prevent implant failure and improve surgical outcomes.

[Clavicular fractures : Diagnostics, management and treatment]

Clavicular fractures account for approximately 6% of bony injuries of the shoulder girdle. Patients suffering from this type of injury show 2 peaks (at the 2nd and 8th decades of life) where the majority occur in young active patients during recreational and sports activities. Besides an accurate patient history with a focus on the trauma mechanism, the clinical and radiological investigations are the cornerstones of the diagnostics. Slightly displaced fractures in a pediatric population as well as non-displaced fractures in adults can be treated conservatively. In cases of shortening and/or displacement and high functional demands, operative treatment of clavicular fractures, stable fixation and the possibility of early mobilization and therapy can be achieved; however, the indications for the procedure also depend on other factors. Surgical stabilization can substantially reduce the danger of non-union, which is why it is becoming more important.

Postoperative chest radiograph after open reduction internal fixation of clavicle fractures: a necessary practice?

HYPOTHESIS/BACKGROUND

Iatrogenic pneumothorax is a rare but serious complication of open reduction and internal fixation (ORIF) of clavicular fractures. Many institutions use postoperative chest radiographs to evaluate for this complication despite a lack of data to support this routine practice. Due to concerns of radiation exposure and health care costs, this practice may not be necessary. This study determined the rate of iatrogenic pneumothorax after clavicular ORIF with plate fixation at a single institution over 8 years. We hypothesized that postoperative chest radiographs would identify a very low rate of pneumothorax in patients with isolated clavicular fractures with no serious preoperative pulmonary injury.

METHODS

A retrospective review was performed identifying all patients undergoing clavicular ORIF with plate fixation at a single Level I trauma center by 3 board-certified orthopedic surgeons from 2009 to 2017. Patients without at least 1 postoperative chest radiograph were excluded. We determined patient demographics and rate of preoperative and postoperative pneumothorax.

RESULTS

We identified 89 patients without preoperative pneumothorax who underwent clavicular ORIF with at least 1 postoperative chest radiograph. Within this group, no patients (0%) had a new postoperative iatrogenic pneumothorax.

DISCUSSION/CONCLUSION

Within this series of 89 patients with isolated clavicular fractures without preoperative pneumothorax, no iatrogenic pneumothoraces occurred after plate fixation. Therefore, for patients undergoing ORIF of isolated clavicular fractures obtaining a postoperative chest radiograph may be an unnecessary practice, especially given their low sensitivity. Future high-powered studies are needed to validate this finding.

Precontoured Locking Plate Treatment in Mid-Shaft Clavicle Fractures: Outcomes and Complications with a Minimun of 2- ears Follow up

BACKGROUND

The aim of this study was to evaluate functional outcome and complications with a long term follow up (minimum of 2 years post-operative) in patients with mid-shaft clavicle fractures treated with precontoured locking plates.

METHODS

We included 41 patients. Goniometric measurement of shoulder range of motion (ROM) was performed, as well as functional evaluation using the rating scale shoulder of the University of California (UCLA), the Constant scale, score of disability of the arm, shoulder and hand (DASH) and visual analog scale (VAS). Postoperative complications, implants removal rates and new x-rays were analized.

RESULTS

The mean postoperative follow-up was 41.5 (24; 69. SD 13.4) months. Mean shoulder anterior elevation was 168.5º (120; 180. SD 22.9). The average value obtained for abduction was 175.2° (150; 180. SD 27.8), as to internal and external rotations, these were not affected. DASH 1.27% (0%; 25%. SD 4.3), UCLA 33.6 points (20; 35. SD 3.5), Constant 90.5 points (50; 100. SD 11.2) and VAS was 0 in 34 patients (83%). Complications: mild residual pain (3), hypoesthesia of the infraclavicular area (2), and rupture (1) and loosening (1) of the implant. hardware removal due to intolerance (2 cases) and new osteosynthesis due to acute implant rupture (1 case).

CONCLUSION

Our experience after a mean follow-up of 41.5 months with precontoured locking plates for the treatment of displaced mid-shaft clavicle fractures has shown good functional results, with low complication and reoperation rate.

Surgery for the fractured clavicle: factors predicting nonunion

BACKGROUND

This study identifies the reasons for failure after plate osteosynthesis of midshaft clavicle fractures, complication rates, and time to radiographic union.

METHODS

A retrospective review of 84 consecutive patients who had undergone surgical fixation for a midshaft clavicle fracture was performed.

RESULTS

There were 82 patients who were included for analysis and operated on by 11 different surgeons using a mixture of locking (63%) and nonlocking (37%) plates. The rate of osteosynthesis failure was 12.2%. A logistical regression analysis found that failure of osteosynthesis had no relationship to type of plate used (P = .82), gender (P = .42), number of proximal (P = .96) or distal (P = .63) screws to the fracture, or length of plate (P = .42). Smoking was found to be the only risk factor (P = .02) that increased failure rates after midshaft clavicle osteosynthesis.

CONCLUSION

Smoking was the only identifiable risk factor to increase failure rates in clavicle osteosynthesis. Preoperative counseling can identify those at increased risk of implant failure and can help improve clinical results by implementing a smoking cessation plan.

Complications associated with plate fixation of acute midshaft clavicle fractures versus non-unions

An important consideration when counselling patients with midshaft clavicle fractures is whether operative treatment of non-union, if it develops after non-operative treatment, is associated with higher complication rate than acute fracture fixation. The aim of this study is to compare complications and re-operations after open reduction and plate fixation for acute midshaft clavicle fractures versus non-unions. The study was retrospective. There were 90 patients in the acute fixation group and 20 patients in the non-union group. The mean follow-up was 8 and 15 months, respectively, Logistic regression analysis was used to assess whether 'non-union surgery' was a predictor of complications and re-operations. Of 90 patients, 23 had complications in acute fixation group. Of 20, 7 developed 8 complications in the non-union group (p = 0.4). Of 90, 12 required re-operations in the acute fixation group compared to 5/20 requiring 7 re-operations in the non-union group (p = 0.19). When any complication or re-operation was considered, 'non-union surgery' was not significant predictor for complications (p = 0.78) or re-operations (p = 0.99). The complication and re-operation rates were not higher after non-union surgery compared to acute fracture fixation and were mostly related to persistent delayed or non-union, rather than operative complications. When counselling patients about treatment of midshaft clavicle fractures, a 'higher complication rate after surgery for non-union, should it happen' should not be an argument against non-operative treatment.

Plating for midshaft clavicular fractures: The impact on quality of life and functional outcome

INTRODUCTION

Several studies report on functional outcome after operative treatment for midshaft clavicular fractures. According to the published data not much is known about the quality of life after operative treatment. The purpose of this study is to investigate long term patient reported quality of life (QoL) and functional outcome after plating for midshaft clavicular fractures.

METHODS

Patients between 16 and 65 years of age, with a midshaft clavicular fracture which were treated with plate fixation between 2006 and 2014, were included. Information was extracted from hospital records and all patients were asked to participate in an online survey. Primary outcome was QoL (SF-36 and EQ-5D-5L). Secondary outcomes were complications, reoperation rate, patient- and cosmetic satisfaction, pain, and functional outcome (DASH).

RESULTS

In a retrospective cohort design, 164 patients were included, 101 completed the online survey. Patients reported a good QoL and functional outcome. The mean physical- and mental SF36 score were 53.9±7.3 and 52.3±9.9 (0-100), the EQ-5D-5L score was 0.88±0.17 (-0.59 to 1.0) and the average DASH was 8.45±14.0 (0-100). Furthermore, there was a strong correlation between the functional outcome and QoL (p<0,001). Seventeen patients developed at least one complication (10%) and seventy-seven patients got a reoperation, with isolated implant removal as the leading cause of reoperation (80,5%).

CONCLUSION

Patients which received operative treatment for a midshaft clavicle fracture have an excellent QoL, and a good functional outcome. Furthermore, there is a strong relationship between functional outcome and the QoL.

Functional recovery following early mobilization after middle third clavicle osteosynthesis for acute fractures or nonunion: A case-control study

BACKGROUND

Good outcomes have been reported after surgical treatment for acute or nonunion of displaced midshaft clavicle fractures. However, the postoperative rehabilitation and timeline for a complete functional recovery are poorly documented. The purpose of the current study was to evaluate the efficacy of an immediate motion protocol following plate fixation of a midshaft clavicle fracture and to compare functional recovery between acute and nonunion cases.

METHODS

Between October 2011 and July 2015, all patients above the age of 18, having either an acute or a nonunion of the midshaft clavicle fracture, were considered as potentially eligible for inclusion in this prospective case-control study. Postoperatively, no immobilization was recommended and patients were to undergo rehabilitation protocol consisting of hourly stretching.

RESULTS

Forty-two patients were included (31 with acute and 11 with delayed fixation) at a mean follow-up of 33months (range, 12 to 78months). Surgical complications consisted of one transient frozen shoulder, one delayed union, and two superficial infections. All patients returned to work, retrieved full shoulder range of motion (ROM), and returned to heavy sports and activities. Function returned faster in the acute group compared to the nonunion group based on the SANE score at 2weeks (73±21 vs. 45±26 respectively, P=0.01), SANE score at 6weeks (89±15 vs. 66±23 respectively, P=0.01), SANE score at 3months (96±10 vs. 85±14 respectively, P=0.03), and based on return of full ROM (17±25 vs. 44±31 days respectively, P=0.01). A trend was observed for nonunion cases needing more time to return to work and sports activities.

CONCLUSION

Functional outcome is excellent following the treatment of both acute and non-united clavicle fractures, but recovery occurs earlier following acute treatment. An early mobilization rehab protocol can be safely recommended for both types of conditions and may result in substantial healthcare cost-savings, without increasing complication rate and decreasing patient satisfaction.

LEVEL OF EVIDENCE

Level III; case-control study; treatment study.

The Influence of Incision Type on Patient Satisfaction After Plate Fixation of Clavicle Fractures

BACKGROUND

Open reduction and internal fixation (ORIF) of the clavicle is a common procedure that has been shown to have improved outcomes over nonoperative treatment. Several incisions can be used to approach clavicle fractures, the decision of which is variable among surgeons.

PURPOSE

To compare patient satisfaction and subjective outcomes between patients with a longitudinal incision versus those with a necklace incision for the treatment of diaphyseal clavicle fractures.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Thirty-six patients with a diaphyseal clavicle fracture (Orthopaedic Trauma Association type 15-B) were treated by 1 of 7 orthopaedic surgeons. The intervention was ORIF with anatomic contoured plates. Patients were divided into a necklace incision group and a longitudinal incision group depending on the surgical approach used. Medical records were reviewed, and participants completed an online survey with questions related to pain, numbness, scar appearance, and satisfaction. Function was assessed using the American Shoulder and Elbow Surgeons score. Statistical significance was determined with P < .05.

RESULTS

There were 16 patients in the necklace incision group and 20 in the longitudinal incision group. Patients in the necklace incision group were significantly more satisfied with the appearance of their scars (P = .01), which correlated with overall satisfaction (P = .05). There were no differences in overall satisfaction, pain, numbness, or reoperation rates for hardware removal between the necklace (6%) and longitudinal groups (15%).

CONCLUSION

Patients undergoing clavicle ORIF with a necklace incision are more satisfied with their scar appearance than those with a longitudinal incision. The overall satisfaction, rate of numbness, and plate removal were similar in both groups.

Construct failure after open reduction and plate fixation of displaced midshaft clavicular fractures

INTRODUCTION

Worldwide, implants mostly used for fixation of displaced midshaft clavicular fractures (DMCF) are the easily to bend reconstruction plate and the stiffer small fragment locking compression plate. Construct failure rates after plate fixation of DMCF are reported around 5 percent. Possible risk factors for construct failure are implant type and fracture type. However, little is known about the influence of fracture fixation method on construct failure. The aim of this study was to assess construct failure in plate fixation of DMCF and to identify possible risk factors.

METHODS

All consecutive patients treated in a level 1 trauma centre with open reduction and fixation of DMCF using a 3.5-mm reconstruction plate or 3.5-mm small fragment locking compression plate between 2007 and 2015 were evaluated. Potential risk factors for construct failure were analysed using univariate analysis.

RESULTS

Two hundred and fifty-nine patients were analysed. Fifty DMCF (19%) were fixated with a reconstruction plate and 209 (81%) with a small fragment locking compression plate. Construct failure was seen in 18 patients (6.9%), including 5 broken plates and 13 with screw loosening. Eight percent of all reconstruction plates broke in contrast to 0.5 percent of all small fragment locking compression plates (p=0.001). All broken implants were used as a bridging plate. Loosening of screws was seen in older patients and when the plate was fixated with less than three bicortical screws on one side of the fracture (p=0.002).

CONCLUSIONS

Overall construct failure after open reduction and plate fixation of DMCF occurred in 6.9 percent. Risk factors for plate breakage were the use of a reconstruction plate and a bridging method for fracture fixation. Risk factors for screw loosening were an increasing patient age and plate fixation with less than three bicortical screws on one side of the fracture.

RECOMMENDATIONS

Based on the results of this study our recommendation is to use a small fragment locking compression plate for open reduction and internal fixation of DMCF. The surgeon should always strive to fixate the plate on both sides of the fracture with at least three bicortical screws.

Complications during removal of conventional versus locked compression plates: is there a difference?

BACKGROUND

Osteosynthesis plate removal is one of the most commonly performed procedures in orthopaedic surgery. Due to technological advances and the quality of increasing osteosynthesis material, more and more locked plates have been implanted over the last 20 years. The aim of this study was to determine whether the complication rate during plate removal differs between conventional and locked plates.

MATERIAL AND METHODS

In this retrospective cohort study, 620 patients were included and divided into two groups based on the type of plate (locked and conventional). Technical complications during implant removal included screw breakage, destroyed screw head, implant breakage, remaining implant material, refracture, bony or soft tissue overgrowth. The following plate-associated complications were identified: osteosynthesis plate not detachable, plate bent or broken, necessity of special tools or plate loosened. Three types of screw-related complications were observed: screw not detachable, screw broken or screw dislocated.

RESULTS

Overall, complications related to the plate or screws were documented in 110 of the 620 cases. These complications occurred in 48 of the 382 cases involving conventional osteosynthesis (7.7% of all removals, 12.6% of all conventional removals) and in 62 of the 238 cases involving locked plate osteosynthesis (10.0% of all removals, 26.1% of all locked plate removals). The statistical analysis showed a significantly higher implant-related complication rate with locked plates compared to the conventional plates (p < 0.01).

CONCLUSIONS

Hardware removal can be a complication-afflicted operation, especially cases involving locked-plate removal should only be performed if a strong indication is evident. Possible benefits of the procedure should be considered carefully, taking the cost-benefit ratio into account.

Overtreatment of displaced midshaft clavicle fractures

Background and purpose - The best treatment for displaced clavicle fractures has been debated for decades. Operative treatment has become more common. However, several randomized trials comparing non-operative and operative treatment have not shown any compelling evidence in favor of surgery. We identified the preferred treatment of displaced midshaft clavicle fractures at public hospitals in 3 countries in Scandinavia. Patients and methods - A purpose-made multiple-choice questionnaire in English was sent to all public hospitals in Denmark, Sweden, and Finland. This was addressed to the orthopedic surgeon responsible for treatment of clavicle fractures, and completed questionnaires were obtained from 85 of 118 hospitals. Results - In the 3 countries, 69 of the 85 hospitals that responded would treat displaced clavicle fractures operatively. Clear criteria for treatment allocation were used at 58 of the hospitals, with the remaining 27 using individual assessment in collaboration with the patient. Precontoured locking plates were mostly used, placed either superiorly (64/85) or anteriorly (10/85). Interpretation - Displaced midshaft clavicle fractures are mainly treated operatively in Sweden, Denmark, and Finland. This treatment is not supported by compelling evidence.

Surgical Treatment of Displaced Midshaft Clavicle Fractures: Precontoured Plates Versus Noncontoured Plates

PURPOSE

To compare the outcomes and complications of open reduction and internal fixation using precontoured versus noncontoured plates for the treatment of midshaft clavicle fractures.

METHODS

Open reduction and internal fixation using was performed on 130 patients with a midshaft clavicle fracture. Precontoured plates were used in 69 cases (group A) and noncontoured plates in 61 cases (group B).

RESULTS

The average follow-up in both groups was approximately 21 months. There was a significant difference between the 2 groups in mean surgery duration and blood loss, although Disabilities of the Arm, Shoulder, and Hand and Constant-Murley Shoulder scores at final follow-up were similar. Plate removal was required in 44.9% (31 of 69) of the precontoured group and 65.6% (40 of 61) of the noncontoured group. The indication was prominence of the hardware in 27.5% (19 of 69) of the precontoured group and 54.1% (33 of 61) of the noncontoured. In both groups, body mass index was lower in patients requiring implant removal because of hardware prominence. A higher proportion of females in both groups required implant removal.

CONCLUSIONS

Precontoured plates are associated with a lower rate of hardware removal. Body mass index and gender may be factors that influence the rate of hardware removal.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Complications associated with operative fixation of acute midshaft clavicle fractures

INTRODUCTION

The aim of this study was to review the complication rate and profile associated with surgical fixation of acute midshaft clavicle fracture in a large cohort of patients treated in a level I trauma centre.

PATIENTS AND METHODS

We identified all patients who underwent surgical treatment of acute midshaft clavicle fracture between 2002 and 2010. The study group consisted of 138 fractures (134 patients) and included 107 men (78%) and 31 women (22%); the median age of 35 years (interquartile range (IQR) 24-45). The most common mechanism of injury was a road traffic accident (78%). Sixty percent (n=83) had an injury severity score of ≥15 indicating major trauma. The most common fracture type (75%) was simple or wedge comminuted (2B1) according to the Edinburgh classification. The median interval between the injury and operation was 3 days (IQR 1-6). Plate fixation was performed in 110 fractures (80%) and intramedullary fixation was performed in 28 fractures (20%). There were 85 men and 25 women in the plate fixation group with median age of 35 years (IQR 25-45) There were 22 men and six women in the intramedullary fixation group with median age of 31 years (IQR 24-42 years). Statistical analysis was performed using independent sample t test, Mann Whitney test, and Chi square test. Significant P-value was <0.05.

RESULTS

The overall incidence of complication was 14.5% (n=20). The overall nonunion rate was 6%. Postoperative wound infection occurred in 3.6% of cases. The incidence of complication associated with plate fixation was 10% (11 of 110 cases) compared to 32% associated with intramedullary fixation (nine of 28 cases; P=0.003). Thirty-five percent of complications were related to inadequate surgical technique and were potentially avoidable. Symptomatic hardware requiring removal occurred in 23% (n=31) of patients. Symptomatic metalware was more frequent after plate fixation compared to intramedullary fixation (26% vs 7%, P=0.03).

CONCLUSIONS

Intramedullary fixation of midshaft clavicle fracture is associated with a higher incidence of complications. Plate fixation is associated with a higher rate of symptomatic metalware requiring removal compared to intramedullary fixation. Approximately one in three complications may be avoided by attention to adequate surgical technique.

Locking versus non-locking neutralization plates for treatment of lateral malleolar fractures: a randomized controlled trial

PURPOSE

The reduction of periosteal compression through the use of a locking plate may minimize disturbances of bone blood supply and may improve the rate of bone union. A single-centre, assessor blinded randomized controlled trial was conducted to compare the clinical effectiveness of a locking plate and a non-locking plate.

METHODS

A total of 52 patients with AO/OTA 44B lateral malleolar fractures were included in this study. All patients underwent surgical fixation using a lag screw and neutralization plate. An identical treatment protocol was used in all patients, with exception of plate selection. The rate of radiographic bone union, defined as the complete disappearance of fracture lines confirmed through anteroposterior, lateral, and internal oblique views was compared at three, six, and 12 months following surgery. In addition, the Medical Outcomes 36-Item Short-Form Health Survey (SF-36) score, the time required for resolution of tenderness at the fracture site and the complication rate were evaluated.

RESULTS

Twenty-three patients were randomly assigned to undergo fixation using a locking plate, and 29 patients were assigned to undergo fixation using a non-locking plate. Intention-to-treat analysis showed no difference in the radiographic bone union rate of fibula, SF-36 score, the time for resolution of tenderness at the fracture site and complication rates.

CONCLUSION

No differences were observed in patients with AO/OTA 44B lateral malleolar fractures undergoing fixation with a locking versus non-locking neutralization plate.

Predictors associated with nonunion and symptomatic malunion following non-operative treatment of displaced midshaft clavicle fractures--a systematic review of the literature

PURPOSE

The aim of this study was to survey existing literature in order to identify all reported predictors associated with nonunion or symptomatic malunion in adult patients with displaced midshaft clavicle fractures treated non-operatively.

METHOD

A systematic literature search in Medline was carried out in order to identify publications in English, reporting on predictors for nonunion and malunion in adults with displaced midshaft clavicle fractures. After applying inclusion and exclusion criteria, eight publications were included in this systematic review.

RESULTS

A total of 2,117 midshaft clavicle fractures were included in the eight publications. All publications reported on predictors for nonunion but none were found to report on predictors for malunion. The studies were characterized by different definitions for nonunion and symptomatic malunion if at all present. A total of 13 potential factors associated with nonunion were identified, six of these (displacement, comminution, shortening, age, gender and smoking) were reported as predictors for nonunion. Outcome definitions varied among the studies.

CONCLUSION

The included publications varied greatly in design, sample size, and quality. Based on the present literature most of the predictors were found to be of limited evidence, however displacement seems to be the most likely factor that can be used to predict for nonunion. Treating all clavicle fractures with displacement surgically would inevitably lead to overtreatment, which is why future studies need to focus on predictive factors in order to differentiate between patients that would benefit from surgery and those who would not.

Locking versus non-locking neutralization plates for treatment of lateral malleolar fractures: a randomized controlled trial

PURPOSE

The reduction of periosteal compression through the use of a locking plate may minimize disturbances of bone blood supply and may improve the rate of bone union. A single-centre, assessor blinded randomized controlled trial was conducted to compare the clinical effectiveness of a locking plate and a non-locking plate.

METHODS

A total of 52 patients with AO/OTA 44B lateral malleolar fractures were included in this study. All patients underwent surgical fixation using a lag screw and neutralization plate. An identical treatment protocol was used in all patients, with exception of plate selection. The rate of radiographic bone union, defined as the complete disappearance of fracture lines confirmed through anteroposterior, lateral, and internal oblique views was compared at three, six, and 12 months following surgery. In addition, the Medical Outcomes 36-Item Short-Form Health Survey (SF-36) score, the time required for resolution of tenderness at the fracture site and the complication rate were evaluated.

RESULTS

Twenty-three patients were randomly assigned to undergo fixation using a locking plate, and 29 patients were assigned to undergo fixation using a non-locking plate. Intention-to-treat analysis showed no difference in the radiographic bone union rate of fibula, SF-36 score, the time for resolution of tenderness at the fracture site and complication rates.

CONCLUSION

No differences were observed in patients with AO/OTA 44B lateral malleolar fractures undergoing fixation with a locking versus non-locking neutralization plate.

Complications of operative treatment of clavicle fractures in a Level I Trauma Center

Traditionally, the belief is that the clavicle heals readily and with nonoperative treatment. Since evidence suggests that many clavicles benefit from operative care, the aim of this study was to find the incidence of complications after operative treatment of clavicle fractures. This retrospective study includes 56 patients (41 male and 15 female) who were treated operatively for clavicle fractures between 2010 and 2012. The indications were displacement more than 20 mm, comminution, tenting of the skin, floating shoulder, and open fractures. Seventy-five percent of the fractures occurred in the midshaft and 25 % in the lateral third of the clavicle. There were no fractures of the medial third. The midshaft fractures were either plated with 3.5 mm reconstruction plates or anatomical locking plates. For internal fixation of the lateral fractures, we used acromioclavicular hook plates. The mean follow-up period was 4.6 months (range 1.0-28.0). Three patients did not participate in the follow-up. There were 12 patients with complications (21 %). Five of them required reoperations. Two patients were reoperated due to clavicle nonunions, two patients due to traumatic refracture of the plated clavicle, and one because of pain caused by the plate. Four cases developed superficial infections, and there was one patient with a deep tissue infection. None of the patients showed signs of neurovascular impairment postoperatively. None of the patients complained about decreased range of motion or loss of muscle strength postoperatively. Plating of clavicle fractures is a procedure that results in lower rates of malunion, nonunion, and functional impairment compared with nonoperative treatment. Nonetheless, one case in ten has a complicated course. Attention to technique and careful follow-up may prevent these problems.