Treatment of midshaft clavicular delayed and non-unions with anteroinferior locking compression plating

Clavicle Shaft Non-Unions-Do We Even Need Bone Grafts?

Background: The surgical treatment of bony non-unions is traditionally performed with additional bone grafts when atrophic and/or stronger implants when hypertrophic. In the case of the clavicle shaft, however, in our experience, a more controversial method where no additional bone graft is needed leads to equally good consolidation rates, independent of the non-union morphology. This method requires the meticulous anatomical reconstruction of the initial fracture and fixation according to the AO principle of relative stability. Methods: A retrospective review following the STROBE guidelines was performed on a consecutive cohort of all patients who received surgical treatment of a midshaft clavicle non-union at the Medical Center of the University of Freiburg between January 2003 and December 2023. Patients were identified using a retrospective systematical query in the Hospital Information System (HIS) using the International Statistical Classification of Diseases and Related Health Problems Version 10 (ICD-10) codes of the German Diagnosis Related Groups (G-DRG). Two groups were formed to compare the consolidation rates of patients who received additional bone grafting from the iliac crest with those of patients who did not. A 3.5 mm reconstruction LCP plate was used in all patients. Consolidation rates were evaluated using follow-up radiographs and outcomes after material removal with a mean follow-up of 31.5 ± 44.3 months (range 0-196). Results: Final data included 50 patients, predominantly male (29:21); age: 46.0 ± 13.0 years, BMI 26.1 ± 3.7. Autologous bone grafts from the iliac crest were used in 38.0% (n = 19), while no bone addition was used in 62.0% (n = 30). Six patients were lost to follow-up. Radiological consolidation was documented after a mean of 15.1 ± 8.0 months for the remaining 44 patients. Consolidation rates were 94.4% (n = 17) in patients for whom additional bone grafting was used and 96.2% (n = 25) in patients for whom no graft was used. There was no relevant difference in the percentage of atrophic or hypertrophic non-unions between both groups (p = 0.2425). Differences between groups in the rate of consolidation were not significant (p = 0.7890). The complication rate was low, with 4.5% (n = 2). Conclusions: Independent of the non-union morphology, non-unions of the clavicle midshaft can be treated successfully with 3.5 mm locking reconstruction plates without the use of additional bone grafting in most cases.

Does plate position influence the outcome in midshaft clavicular fractures? A multicenter analysis

PURPOSE

To date, it remains unclear whether superior or anterior plating is the best option for treating midshaft clavicular fractures. The aim of this study was to compare both techniques with regard to the incidence of implant removal due to implant irritation, risk of complications, time to union, and function.

METHODS

In this retrospective cohort study, all midshaft clavicular fractures treated operatively between 2017 and 2020 in two hospitals in Switzerland were analyzed. The participating hospitals differed with regard to their standard practice; one offered superior plating only, while the other predominantly employed an anterior plate. The primary outcome was the incidence of implant removal for irritation. Secondary outcomes were time to union, complications, re-interventions, and range of motion during the follow-up period of at least 6 months.

RESULTS

In total, 168 patients were included in the study of which 81 (48%) received anterior plating and 87 (52%) superior plating. The overall mean age was 45 years (SD 16). There was no significant difference between anterior and superior plating with regard to implant removal (58.5% versus 57.1%, p = 0.887), infection (5.7% versus 1.8%, p = 0.071), and time to union (median 48 weeks versus 52 weeks, p = 0.643). Data on range of motion were available in 71 patients. There was no significant difference in anteflexion (median 180 degrees anterior versus 180 degrees superior) and abduction (median 180 degrees anterior versus 180 degrees superior) between the two groups.

CONCLUSION

This retrospective cohort study did not find sufficient evidence to recommend one implant position over the other for midshaft clavicular fractures with regard to removal due to irritation. Time to union was similar and Infections were equally rare in both groups. Notably, a considerable number of patients in both groups had their implants removed due to irritation. Larger prospective studies are needed to determine how much plate position contributes to the occurrence of irritation and whether other patient or implant-related factors might play a role. Until this is clarified, implant position should be based on surgeons preference and experience.

Malunion of a Clavicle Fracture in a Young Adult: A Case Report and Surgical Intervention

This case study examines the medical complexity of managing a neglected clavicle in a young patient, resulting in a complicated interstitial non-union. Despite initial therapeutic efforts, the fracture was not treated, resulting in significant pain as well as functional and aesthetic disabilities. This case outlines accurate clinical presentation and diagnostic methods. In addition, malunion clavicle fractures require multifaceted therapeutic approaches including surgical interventions, rehabilitation programs, and psychological support. Through comprehensive research and long-term follow-up, this report reveals the complexity of traumatic fractures, highlighting the importance of early recognition and intervention. To address the issue effectively, it is essential to follow a multidisciplinary approach that includes physical assessment, pharmacotherapy, and physiotherapy. This case report aims to highlight the critical role of comprehensive individual care in improving the patient's condition and emphasizes the importance of vigilant healthcare practices.

Complications and Outcomes After Surgical Intervention in Clavicular Nonunion: A Systematic Review

BACKGROUND

Surgical repair of clavicle fractures is being employed more frequently, although most fractures are still treated conservatively. Both can result in nonunion. Current treatments for clavicle nonunion include open reduction with internal fixation (ORIF) plating without bone graft, ORIF plating with bone graft, and intramedullary pin fixation.

METHODS

We performed a systematic review and meta-analysis of studies reporting outcome, complication, and reoperation rates following surgical treatment for clavicle nonunion. Subgroup analysis was undertaken for outcome and complication rates between single plating and intramedullary pin fixation, bone graft use, and nonunion time length definition.

RESULTS

Fifty-three studies met inclusion criteria (1,258 clavicle nonunions). Mean clinical follow-up was 2.6 years. Seventy-two percent of nonunions were of the middle third, 1% were proximal third, 12% were distal third, and 15% were not reported. Forty-eight percent of nonunions were atrophic or oligotrophic and 17% were hypertrophic (35% not reported). Mean time to union was 13.6 weeks. Ninety-five percent of patients achieved union after the primary nonunion surgery. Overall complication rate was 17%. Single-plating fixation had significantly faster union time (15.2 vs. 19.8 weeks), lower reoperation rate (23% vs. 37%), and hardware removal rate (20% vs. 34%) than intramedullary pin fixation. Bone graft had significantly lower rates of delayed union (0.6% vs. 3.6%) but higher complication (15% vs. 8%) and reoperation rates (29% vs. 14%) than the other groups. Studies that defined nonunion after 3 months had significantly faster union times than the 6-month studies (13 vs. 16 weeks). The 3-month group had a significantly lower overall complication rate (12% vs. 25%) and hardware/fixation failure rate (3% vs. 5.5%) than the 6-month group.

CONCLUSIONS

This systematic review is the largest report of complications, reoperations, and patient outcomes of clavicle nonunions after surgical intervention in the current literature. Plating showed faster time to union and lower reoperation rates than intramedullary pin fixation. Bone graft use showed lower rates of delayed union but substantially higher rates of complications and reoperations. Reports with a definition of nonunion at 3 months showed faster union times and lower complication rates compared to reports with a definition of nonunion that was 6 months or greater. Surgery could be considered at 3 months post-injury in cases of symptomatic non-united clavicle fracture, and plating results in reliable outcomes. Adjuvant bone grafting requires further study to determine its value and risk/benefit ratio.

LEVEL OF EVIDENCE

Level IV, Systematic Review. See Instructions for Authors for a complete description of levels of evidence.

Comparison of hook plate versus T-plate in the treatment of Neer type II distal clavicle fractures: a prospective matched comparative cohort study

Background

This study aimed to compare the clinical and radiological outcomes of distal clavicle fracture fixation with a hook plate versus the standard non-locking T-plate for unstable Neer type II fractures.

Methods

A prospective matched cohort study including two groups of hook plates and T-plates fixation was conducted in our two tertiary trauma centers. Patients with distal clavicle fractures Neer type II were assessed for union and the Constant-Murley score (CMS) at 1-, 3-, and 6-month follow-ups. Inadequate radiographic consolidation > 6 months after surgery was defined as non-union. Subscales of CMS_pain, CMS_{activities of daily living}, CMS_{range of motion (ROM)}, and CMS_strength were also compared between groups. According to recommendations, the implant was removed after union confirmation in the hook plate at a planned second surgery.

Results

Sixty consecutive patients were enrolled: 30 in the T-plate group and 30 in the hook plate group. CMS showed similar functional outcomes for T-plates and hook plates at all follow-ups (Month 6: 92.0 vs. 91.7, P = 0.45). However, on the month 1 follow-up, the T-plate group scored higher than the hook plate group for ROM and pain (CMS_pain = 13.0 vs. 12.3, P = 0.03; CMS_ROM = 35.2 vs. 33.2, P = 0.002). Despite this, Pain, ROM, and other CMS domains were comparable between groups (P > 0.05). The mean time to union was 2.5 + 1.4 months for the T-plate group and 2.3 + 1.6 months for the hook plate group (P = 0.44). There was one fixation failure in each group and one periprosthetic fracture in the hook plate group (two revisions for the hook plates and one for T-plates, P = 1.00). Non-union and other complications were not observed.

Conclusion

Both surgical approaches resulted in full recovery and good function. However, in the hook plate group ROM and pain scores were lower at 1 month. Standard non-locking T-plates are a viable alternative to hook plates with low cost and promising outcomes for treating displaced distal clavicle fractures.

Surgical Treatment of Clavicular Fractures, Refractures, Delayed and Non-Unions Using a Resorbable, Gentamicin-Eluting Calcium Sulphate/Hydroxyapatite Biocomposite

Objective

This study describes clinical and radiological outcomes following treatment of displaced primary fractures, refractures, delayed unions and non-unions of the clavicle with open reduction and internal fixation (ORIF) with a plate plus filling of the residual bone defect and/or implant augmentation with a gentamicin-loaded bone graft substitute (CERAMENT G, BONESUPPORT).

Patients and Methods

Patients who underwent surgical treatment either for displaced clavicle fractures, refractures, delayed unions or non-unions between June 2018 and May 2021 were enrolled in this retrospective study. Bony consolidation, complication rate, and functional outcomes, including overall health, were assessed.

Results

A total of 26 clavicles in 25 patients with a mean age of 50.7 (16–85) years, 16 male and 9 female, were enrolled in the study. The mean follow-up was 14.9 (6–31) months. There were 18 cases of displaced clavicle fractures, four refractures, two delayed unions and two non-unions. The majority of the clavicle lesions were located at the middle third (17/26, 65.4%), seven at the lateral third (26.9%) and two at the medial third (7.7%) of the clavicle. A mean Goldberg score of 7 indicated complete bony union and remodeling of the bone graft substitute in all cases. No complications occurred. The mean University of California at Los Angeles Shoulder Score and the mean Quick Disability of the Arm, Shoulder and Hand Score were 34.6±0.8 (32–35) points and 0.6±1.6 (0–5.4) points, respectively, and revealed excellent functional results. The mean 12-item Short-Form Survey physical component questionnaire was 57.7±1.7 (54.1–58.9) points, and no patient experienced any pain at the last follow-up.

Conclusion

Our initial experience suggests that ORIF using a plate plus bone defect filling and/or implant augmentation with a gentamicin-eluting bone graft substitute may be useful not only for complication management after clavicle fractures but also in the initial treatment of challenging clavicular fractures.

Treatment of a Recalcitrant Non-union of the Clavicle

Background

Plate fixation is the treatment of choice for a midshaft clavicle non-union. Those non-unions that require >1 surgical procedure to heal are termed recalcitrant non-union. Regardless of the number of previously failed procedures, our surgical strategy is aimed at achieving an optimal mechanical and biological environment to facilitate healing.

Materials and methods

We performed a retrospective analysis of 14 patients with a recalcitrant clavicle non-union treated with open reduction and plate fixation combined with graft augmentation when indicated. Healing rates after index surgery were analysed. All patients were observed for at least 12 months.

Results

All patients healed at a mean time of 193.2 days (range 90-390). Five of the 14 patients had at least one positive surprise culture, for which they received antibiotic treatment. At the latest follow-up, no patient reported pain or discomfort. Mean disability of the arm, shoulder and hand (DASH) score was 16.3 points (range 0-40), indicating only mild residual impairment. A possible link was found between the time between injury and definitive surgery and the time to healing [Pearson correlation 0.527, sig. (two-tailed) 0.000].

Conclusion

This study shows 100% bone healing and good functional outcomes after surgical revision for a recalcitrant clavicle non-union.

How to cite this article

Grewal S, Baltes TPA, Wiegerinck E, et al. Treatment of a Recalcitrant Non-union of the Clavicle. Strategies Trauma Limb Reconstr 2022;17(1):1-6.

Results of pre-contoured titanium anterior plating of midshaft clavicle fractures

BACKGROUND

Plating midshaft clavicle fractures anteriorly is gaining popularity because of low complication rates. Improvements in plate fixation constructs for midshaft clavicle fractures have unclear clinical significance. The purpose of this study was to present the early clinical and radiographic outcomes of pre-contoured titanium anterior plates for the treatment of midshaft clavicle fractures.

METHODS

Skeletally mature patients who underwent plate fixation of a midshaft clavicular fracture from 2008 to 2015 using pre-contoured titanium anterior plates were included in this retrospective investigation. The primary outcome measures were union rate and hardware removal rate. The secondary outcome measures included reoperation for all causes and mechanical implant failure.

RESULTS

A total of 26 patients were included. Complete healing occurred in 96% of patients without further surgical intervention, and all patients achieved union. Medical complications occurred in 2 patients (7.7%), consisting of cellulitis (n = 1) and chronic pain (n = 1). In 1 patient (3.8%), delayed union occurred and the use of a bone stimulator was required postoperatively to achieve union. Finally, 2 patients (7.7%) had symptomatic implants that required removal.

CONCLUSIONS

In the acute fracture setting, the anterior plating system used in this study led to a high rate of union with decreased rates of implant irritation. Only 7.7% of patients required hardware removal for symptomatic hardware, as opposed to the estimated 20%-60% reported in the literature in patients with symptomatic superior clavicle plates.

Treatment of forearm diaphyseal non-union: Autologous iliac corticocancellous bone graft and locking plate fixation

INTRODUCTION

Studies conducted on forearm bone diaphysis non-union are limited due to the rarity of this condition. The present study aimed to evaluate the outcome of our technique using autologous iliac corticocancellous bone graft fixed by locking plate system for the forearm bone diaphyseal non-union without infection.

PATIENTS AND METHODS

We treated eight patients with non-union of radial or ulnar shaft fracture (four men, four women) aged 38 years (range: 18-52 years) on average. The average follow-up period was 18 months (range: 12-24 months). In our technique, we applied the locking plate to the diaphyseal bone fragment, before grafting the bone block to the non-union site. After excision of sclerotic ununited bone, the autologous iliac corticocancellous bone was grafted to the defect and fixed with single locking screw. Pain, grip strength, and disabilities of the arm, shoulder, and hand (DASH) score were measured and compared before and 12 months after the surgery. Radiographs were taken at each follow-up, and the time of bony union was determined.

RESULTS

The mean time to radiological union was 4.2 months (range: 3-6 months), and bony union was achieved in all cases within 6 months. All measured values, visual analog scale, DASH score, and grip strength, were significantly improved at 12 months after surgery (p<0.05). No minor/major complications including infection, non-union, or malunion were reported.

CONCLUSIONS

Locking compression plate fixation and autologous iliac corticocancellous bone grafting with a holding locking screw appears to be a reliable primary procedure for non-union of the forearm diaphyseal fracture without infection.

LEVEL OF EVIDENCE

IV; therapeutic study.

Plate fixation versus titanium elastic nailing in midshaft clavicle fractures based on fracture classifications

BACKGROUND

The best strategy for implant selection in midshaft clavicular fractures (MCF) remains controversial. The present study aims to determine the optimal strategy for implant selection by comparing plate and Titanium Elastic Nail (TEN) with respect to outcomes and related complications and analyze the results based on fracture patterns.

METHODS

A total of 97 patients with MCF who underwent plate (48 patients) or TEN (49 patients) fixation were retrospectively reviewed. Both groups were divided into three subgroups by fracture type using the AO Foundation/Orthopaedic Trauma Association classification: simple fracture (type A), wedge fracture (type B), and multi-fragmentary fracture (type C). The observed outcome measures were bone union rate, related complications, functional scores, and patient satisfaction score. These outcomes were analyzed based on the fracture classification.

RESULTS

Both groups demonstrated excellent union rates (p = 0.495) and similar functional scores (p > 0.05). Visual analog scale (VAS) for satisfaction was better in TEN than plate fixation (p < 0.001). In type A and B subgroups, there were no significant difference in functional scores between plate and TEN fixation (p > 0.05). In type C subgroup, however, both VAS for pain and DASH score in TEN fixation were significantly worse than in plate fixation at 2 and 6 weeks postoperatively (p < 0.05). The incidences of clavicle shortening and skin irritation are higher especially in type C subgroup of TEN fixation (p < 0.05).

CONCLUSION

Patient satisfaction of TEN fixation was higher than that of plate fixation, but TEN fixation had a higher incidence of early postoperative pain and migration in type C fractures. Therefore, type A and B fractures can successfully be treated with plate or TEN fixation, but type C fractures should be treated with plate fixation.

Fracture nonunion in long bones: A literature review of risk factors and surgical management

Nonunion following a long bone fracture causes considerable morbidity when it occurs. Risk factors depend on specific fractures but there is a complex interplay of injury severity, comorbidities, patient medication and infection. The majority of nonunions occur after long bone fractures with the tibia, femur, forearm, humerus and clavicle predominating. Despite interest in the biological augmentation of fracture healing, the majority of nonunions can be effectively managed with conventional surgical techniques. In this review we present a review of risk factors for nonunion and the outcome following surgical management.

Clavicle nonunion: plate and graft type do not affect healing rates-a single surgeon experience with 71 cases

BACKGROUND

Clavicle nonunions often result after nonoperative treatment for the acute fracture. Those that require >1 surgical procedure in order for a nonunion to heal are termed recalcitrant. The aims of the present study were to (1) determine healing rates of clavicle nonunions after plate osteosynthesis using either a conventional or locked plate, (2) compare iliac crest bone graft vs. bone morphogenetic protein on nonunion healing, and (3) identify risk factors for the development of a recalcitrant nonunion.

METHODS

We performed a retrospective analysis of a prospectively collected database of 78 clavicle nonunions treated with open reduction and plate fixation with or without graft augmentation by a single surgeon over 25 years. Seventy-one patients over the age of 18 with at least 12 months of follow-up comprised the study group. We analyzed healing rates after the index clavicle nonunion surgery comparing plate type and graft technique as well as identifying risk factors for developing a recalcitrant nonunion.

RESULTS

A total of 62 patients (87.3%) healed after their index nonunion surgery at our institution. Three patients (4.2%) required additional surgery but healed, and 6 patients (8.5%) remain un-united; these 9 patients (12.7%) were defined as recalcitrant. There was no statistically significant difference in healing rates between plate type (P = .633) or type of bone graft (P = .157). There were no identifiable risk factors for the development of a recalcitrant nonunion.

CONCLUSIONS

Plate fixation of clavicle nonunions remains a successful method of treatment. The type of plate or the method of bone graft did not produce different results. There were no demographic, patient, or injury characteristics associated with the development of a recalcitrant nonunion.

Plate osteosynthesis for mid-shaft clavicle fractures: An update

INTRODUCTION

Over the last few years, treatment of mid-shaft clavicle fractures seems to have shifted from conservative to surgical. Our study reports the results of plate osteosynthesis of mid-shaft clavicle fractures and compares them with literature.

MATERIALS AND METHODS

A retrospective cohort study was conducted on 32 patients with mid-shaft clavicle fractures treated with plate and screws between January 2009 and December 2014. All the patients followed the same post-operative rehabilitation program with radiographic and clinical evaluation (DASH score and Constant score) at a minimum follow-up of 24 months.

RESULTS

All the patients healed clinically and radiographically, without deformities or non-unions, with complete and early functional recovery and return to their pre-injury sport activities. At one year follow-up the mean Constant Score was 93.8 (SD 4.8) and the mean DASH score was 42 (SD 5.0).

CONCLUSIONS

Osteosynthesis with plate and screws of mid-shaft clavicle fractures allows not only restoration of the anatomy, but also early recovery of shoulder function. For this reason, such surgical treatment should always be considered when facing this particular fracture group, also in accordance with recent literature.

Plating and cortical bone grafting of clavicular nonunions: clinical outcome and its relation to clavicular length restoration

Background

The goal of this study was to evaluate whether plating and cortical bone grafting of shortened clavicular nonunions would restore clavicular length and enable bone healing. The association between the clavicular length difference (CLD) between sides and long-term functional outcome was also explored.

Methods

For this retrospective 2-center study, patients who underwent plate fixation with cortical bone grafting of a clavicular nonunion were assessed after ≥2 years. The CLD and bone union were assessed using radiography and navigation ultrasound. The functional outcome was determined by the Constant score, Simple Shoulder Test score, and Subjective Shoulder Value, as well as local pain (0-10 numeric rating scale).

Results

Between 2 and 13 years after surgery, 25 patients (mean age, 53 years; 13 female patients) were examined. The median CLD was 0 mm (range, –17 to 13 mm) on ultrasound measurements and 2 mm (range, –32 to 9 mm) on radiographs. At follow-up, the median Constant score, Simple Shoulder Test score, Subjective Shoulder Value, and pain level were 82 points (range, 38-95 points), 12 points (range, 3-12 points), 95% (range, 60%-100%), and 0 (range, 0-8), respectively. There was no correlation between the CLD and all functional outcome scores. Bone union was achieved in all patients. After plate removal, 4 refractures occurred, 3 of which required revision.

Conclusions

Plate fixation with cortical bone grafting of clavicular nonunions is associated with restoration of clavicular length and a high rate of bone union. There is, however, a considerable risk of refracture following plate removal. There was no association between the CLD and clinical outcome.

Clavicular non-union treated with fixation using locking compression plate without bone graft

Background

The articles that have reported on the size at which a segmental defect of clavicular non-union requires bone grafting are scarce. This study evaluated the functional and radiologic results of fixation by locking compression plate (LCP) without bone graft when the defect size is less than 2 cm following bone sclerosis removal for the treatment of clavicular non-union.

Methods

The study included 17 patients with mid-shaft clavicular non-union. All patients underwent bone sclerosis resection and fixation using LCP without bone graft. The patients were evaluated preoperatively, and after a minimum of 24 months (mean, 44.47 months; range, 24 to 60 months) postoperatively in terms of the disabilities of the arm, shoulder and hand (DASH) score, the Constant-Murley score, and radiography.

Results

In this study, no patients were lost to follow-up. The mean DASH score improved from 38.76 ± 7.76 (31.00–46.52) points preoperatively to 19.88 ± 7.18 (12.70–27.06) points 2 years postoperatively (P < 0.01). The mean Constant-Murley score improved from 41.59 ± 8.81 (32.78–50.40) points preoperatively to 75.47 ± 13.50 (61.97–88.97) points 2 years postoperatively (P < 0.01). Radiographs revealed fracture union in all patients. No correlations between the defect size and the postoperative Constant-Murley score or between the defect size and the postoperative DASH score were found based on Pearson tests. No complications, particularly acromioclavicular joint complications and sternoclavicular joint complications, were observed.

Conclusions

In conclusion, we can suggest, from the findings of our study, that bone sclerosis resection and fixation using LCP without bone graft is effective for the treatment of clavicular non-union involving a gap of less than 2 cm and has a low rate of complications.

Clavicle aseptic nonunion: is there a place for cortical allogenic strut graft?

We investigated functional and radiological outcome in 57 cases of midshaft clavicle nonunion treated with open reduction and internal fixation with plate and screws over a 13 year-period. Intercalary bone graft was used in 42 patients; opposite autologous strut graft was used in 31 cases to provide mechanical support to the host bone. Patients were analysed using chart and radiological review and assessed with DASH questionnaire obtained at the latest follow-up. 37 patients were male while 20 were females, with a mean age of 35 years (63-17). All cases were of nonunion, 35 atrophic and 22 hypertrophic. The dominant side was injured in 32 cases and the non dominant in 25 cases. Primarily, 43 cases were treated conservatively with a figure of eight bandage. Time between fracture and our operative treatment was on average 44 months (13-72 months). Only those patients who were symptomatic were included in this study. We used straight reconstruction LCP and low profile precontoured plates. By reviewing patients charts all the cases but one of nonunion progressed to osseous healing at a mean time of 14 weeks (range 12-16). The patient with non-union refused further surgery. 49 patients were available for a final follow up. DASH score was 16.7 at an average of 42 months. Open surgery and internal fixation, using plate and screws in a compression construct is the treatment of choice for symptomatic clavicular non-unions. Intercalary autologous or allograft bone graft should be used especially in patient with significant bone loss; autologous cortical strut graft provides optimum mechanical stability, thus assuring optimal screw purchase and allowing immediate limb movement.

Anterior-Inferior Plating Results in Fewer Secondary Interventions Compared to Superior Plating for Acute Displaced Midshaft Clavicle Fractures

OBJECTIVES

To determine whether a difference in plate position for fixation of acute, displaced, midshaft clavicle fractures would affect the rate of secondary intervention.

DESIGN

Retrospective Comparative Study.

SETTING

Two academic Level 1 Regional Trauma Centers.

PATIENTS

Five hundred ten patients treated surgically for an acutely displaced midshaft clavicle fracture between 2000 and 2013 were identified and reviewed retrospectively at a minimum of 24 months follow-up (F/U). Fractures were divided into 2 cohorts, according to plate position: Anterior-Inferior (AI) or Superior (S). Exclusion criteria included age <16 years, incomplete data records, and loss to F/U. Group analysis included demographics (age, sex, body mass index), fracture characteristics (mechanism of injury, open or closed), hand dominance, ipsilateral injuries, time between injury to surgery, time to radiographic union, length of F/U, and frequency of secondary procedures.

INTERVENTION

Patients were treated either with AI or S clavicle plating at the treating surgeon's discretion.

MAIN OUTCOME MEASURES

Rate and reason for secondary intervention.

STATISTICAL ANALYSIS

Fisher exact test, t test. and odds ratio were used for statistical analysis.

RESULTS

Final analysis included 252 fractures/251 patients. One hundred eighteen (47%) were in group AI; 134 (53%) were in group S. No differences in demographics, fracture characteristics, time to surgery, time to union, or length of F/U existed between groups. Seven patients/7 fractures (5.9%) in Group AI underwent a secondary surgery whereas 30 patients/30 fractures (22.3%) in group S required a secondary surgery. An additional intervention secondary to superior plate placement was highly statistically significant (P < 0.001). Furthermore, because 80% of these subsequent interventions were a result of plate irritation with patient discomfort, the odds ratio for a second procedure was 5 times greater in those fractures treated with a superior plate.

CONCLUSIONS

This comparative analysis indicates that AI plating of midshaft clavicle fractures seems to lessen clinical irritation and results in significantly fewer secondary interventions. Considering patient satisfaction and a reduced financial burden to the health care system, we recommend routine AI plate application when open reduction internal fixation of the clavicle is indicated.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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

BACKGROUND

The treatment of displaced midshaft clavicle fractures remains controversial.

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Midshaft Clavicle Fractures: A Critical Review

The clavicle is the most commonly broken bone in the human body, accounting for up to 5% to 10% of all fractures seen in hospital emergency admissions. Fractures of the middle third, or midshaft, are the most common, accounting for up to 80% of all clavicle fractures. Traditional treatment of midshaft clavicle fractures is usually nonoperative management, using a sling or figure-of-eight bandage. The majority of adults treated nonoperatively for midshaft clavicle fractures will heal completely. However, newer studies have shown that malunion, pain, and deformity rates may be higher than previously reported with traditional management. Recent evidence demonstrates that operative treatment of midshaft clavicle fractures can result in better functional results and patient satisfaction than nonoperative treatment in patients meeting certain criteria. This article provides a review of relevant anatomy, classification systems, and injury mechanisms for midshaft clavicle fractures, as well as a comparison of various treatment options. [Orthopedics.2016; 39(5):e814-e821.].

Anteroinferior versus superior plating of clavicular fractures

BACKGROUND

Open reduction and plate fixation has gained recognition as an effective treatment for certain types of clavicular fractures. However, 88% of cases report some implant-related problems. To determine the optimal plate position, the aim of the present study was to compare implant-related irritation and proportion of plate removal in patients with clavicular fractures undergoing plate fixation by an anteroinferior or superior approach.

METHODS

Retrospectively collected data of 39 patients who underwent anteroinferior plating for displaced midshaft clavicular fractures were compared with prospectively collected data of 60 patients who were treated with superior plate fixation as part of a multicenter randomized controlled trial. Electronic medical records were reviewed for reports of complications, in particular, implant-related irritation and implant removal during follow-up. In addition, all patients were contacted in June 2014 to obtain additional information. The primary outcome parameter was implant-related irritation.

RESULTS

Univariate and multivariate regression analysis showed plate position was not significantly associated with implant-related irritation. Higher rates of asymptomatic patients with the plate still in place were observed in the anteroinferior group (46% vs 22%, P = .01). Almost an equal percentage of implant removals was seen in both groups because of implant irritation (36% vs 37%, P = .938).

CONCLUSIONS

The present study found the surgical approach of clavicular plating was not associated with implant-related irritation. Future studies are needed to determine whether there is an optimal approach for clavicle plating.

Risk profile of patients developing nonunion of the clavicle and outcome of treatment--analysis of fifty five nonunions in seven hundred and twenty nine consecutive fractures

PURPOSE

The most common complication following treatment of a clavicle fracture is nonunion. Most nonunions are symptomatic and treatment is mostly operative. The aim of this study was to describe risk profiles of patients developing nonunion and what outcome is observed following operative treatment of clavicle nonunions.

METHODS

In a consecutive series of 729 clavicle fractures we retrospectively identified 55 that developed nonunion (49 diaphysial and six lateral). All were treated operatively by reconstruction with (n = 28) or without (n = 27) autologous bone graft. Assessment of functionality and patient reported satisfaction and remission of symptoms was done a minimum of six months post-operatively by mail. Response rate was 60%.

RESULTS

The overall nonunion rate was 7.5%. Nine nonunions were initially treated operatively. Risk factors associated with nonunion of our series was anatomic site, fracture complexity, female gender, smoking habits and initial treatment. A total of eight post-operative complications were found. Remission of symptoms was reported by 29 of the 33. Outright satisfaction with current shoulder condition was reported by 24. The overall median DASH was 8 (range 0-61). Following revision of the eight complications a total of 53 united successfully.

CONCLUSION

Operative treatment of a clavicular nonunion seems to be effective as most patients unite and experience remission of symptoms. However, complications in close to 15% and lack of satisfaction of approximately 27% have to be acknowledged and thoroughly explained to the patient prior to treatment.

Use of the clavicular part of the pectoralis major in treatment of failed revision osteosynthesis of the clavicle

BACKGROUND

Symptomatic atrophic nonunion after multiple clavicle osteosynthesis can be difficult to treat. The aim of this study was to evaluate the results of a transfer of the clavicular part of the pectoralis major muscle as augmentation of osteosynthesis of these nonunions.

MATERIALS AND METHODS

A retrospective study included all patients who were treated between 2001 and 2010 (minimum 2-year follow-up). The indications for primary surgery, the number of operations, and the indication for a pectoralis major transfer were evaluated. Time of radiologic consolidation and postoperative complications were assessed. Clinical evaluation was performed with preoperative and postoperative satisfaction ratings and Constant-Murley scores.

RESULTS

The study included 11 patients. The indications for a primary osteosynthesis were acute displaced fractures (7), delayed union (2), nonunion (1), and malunion (1). On average, 3.7 procedures were performed (range, 2-6) before the tendon transfer. At revision, there were 2 patients with infection and 9 without infection. Of the 11 clavicles, 10 showed radiologic consolidation after a mean time of 10 weeks (6-20 weeks). The mean follow-up was 62 months (24-132 months). The mean Constant-Murley score increased from 37 (24-55) preoperatively to 59 (43-98), and the satisfaction rating increased from 2 (1-3) to 7 (2-10). Complications included nonunion (1), hardware removal (2), hardware irritation (4), and donor site pain (1).

CONCLUSION

The use of the clavicular part of the pectoralis major transfer as an augmentation in revision for symptomatic atrophic nonunion after multiple clavicle osteosynthesis showed good radiologic and acceptable clinical results.

Outcomes from surgical treatment of middle-third clavicle fractures non-union in adults: a series of 21 cases

INTRODUCTION

The aim of our study was to evaluate the results of surgical treatment of clavicle non-union after failure of conservative treatment. Our hypothesis was that stable fixation with bone graft derived from local bone stock (fracture site) or the iliac crest was essential to achieve bone union.

MATERIAL AND METHODS

Twenty-one patients with a symptomatic middle-third clavicle non-union after failure of initial conservative treatment were included in the study. Delay between the initial fracture and surgery for non-union was 27 months (6-144). In five cases, the non-union was hypertrophic and bone graft was obtained locally from the callus. In 16 patients, the non-union was atrophic. Bone was harvested from the iliac crest as cortico-cancellous graft (7 patients) and cancellous graft (8 patients). One patient refused bone grafting. A 3.5-mm plate with non-locking screws was placed anterior in 12 and superior in 9 patients.

RESULTS

At 41 months average follow-up (minimum of 12 months), 20 patients were available for review. Bone healing was obtained initially in 15 cases. Six complications required a revision procedure: 3 for infection and 3 for mechanical failure. At last follow-up, 19 patients were satisfied with the surgery. Average Constant score was 84±26 points (7-100), and Quick DASH score 17±22 points (0-91). Radiographic bone healing was obtained in 19 of the cases.

CONCLUSION

Treatment of middle-third clavicle non-union after initial failure of conservative treatment with stable fixation and bone graft is a reliable, well-suited and effective treatment. Our hypothesis was verified. Preoperative evaluation of appearance of the non-union X-rays can be used to determine the type of bone graft needed, but the final decision is often taken during surgery.

LEVEL OF EVIDENCE

Level IV.

Management of clavicle nonunion and malunion

BACKGROUND

Clavicle fractures are common injuries of the shoulder girdle and occasionally result in nonunion or symptomatic malunion. When present, these chronic injuries can result in considerable shoulder dysfunction. A number of surgical techniques have been described for the management of these injuries. Current literature suggests that supplemental bone grafting may not be necessary in all cases but should be considered in the setting of atrophic nonunion. However, optimal treatment is controversial, as discussed in the literature. This article highlights the current treatment options based on the existing literature and describes our preferred techniques.

METHODS

We carried out a comprehensive review of the PubMed and Medline databases using multiple keywords (eg, clavicle fracture, clavicle nonunion, and clavicle malunion) to identify the relevant literature regarding this topic. Reference lists of the relevant articles were reviewed for additional important articles.

CONCLUSION

Nonunion and malunion of the clavicle remain challenging problems. Reliable bony union and improved shoulder function can be expected with thoughtful surgical planning, appropriate implant choice, and meticulous surgical technique.

Minimally invasive plate osteosynthesis using anterior-inferior plating of clavicular midshaft fractures

INTRODUCTION

This study evaluated the clinical and radiological outcomes of acute displaced clavicular midshaft fractures treated with minimally invasive plate osteosynthesis (MIPO).

MATERIALS AND METHODS

Fifteen patients with acute displaced clavicular midshaft fractures underwent MIPO. A locking reconstruction plate was applied on the anterior aspect of the clavicle through two small incisions. Functional outcomes were assessed using range of shoulder motion and University of California Los Angeles (UCLA) shoulder score. Radiological evaluation included time to union, fracture healing, and clavicular length difference measured as proportional length difference with the unaffected side.

RESULTS

All fractures healed within a mean of 15.1 weeks postoperatively. The mean proportional length difference was 0.66 ± 2.2% compared with the unaffected arm. Shoulder motion recovered to pre-injury activity level in all patients. The UCLA shoulder scores showed excellent results in 13 patients and good results in two patients. Nonunion and implant failures were not found in any patients. One patient complained of temporary hypoesthesia around the lateral clavicle area.

CONCLUSIONS

MIPO using anterior-inferior plating for acute displaced clavicular midshaft fractures provided satisfactory clinical outcomes without serious complications and could be an effective alternative option to conventional operative treatments.

Function plateaus by one year in patients with surgically treated displaced midshaft clavicle fractures

BACKGROUND

Based on short-term (1 year or less) followup, primary fixation of displaced midshaft clavicle fractures reportedly results in better function compared with that reported for nonoperative methods. Whether better function persists beyond 1 year is unclear.

QUESTIONS/PURPOSES

For displaced midshaft clavicle fractures, do the better mean Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley Shoulder (CSS) scores for operative versus nonoperative treatment at 1 year change between 1- and 2-year followup?

PATIENTS AND METHODS

We previously reported 132 patients in a randomized prospective trial at 1 year, and here we report a further followup of 95 of the 132 patients (72%) at 2 years after injury. We evaluated all patients with the DASH and CSS scores.

RESULTS

The mean DASH and CSS scores were similar at 2 years compared with 1 year postinjury for both the nonoperated and operated patients. The mean scores for the operated patients remained higher than those in the nonoperative group (DASH operative 4.1 ± 7.0 versus DASH nonoperative 11.4 ± 19.7, CSS operative 97.1 ± 4.5 versus CSS nonoperative 91.6 ± 14.1) at 2 years postinjury.

CONCLUSIONS

The improvement in DASH and CSS scores seen with primary fixation of displaced clavicle fractures persists at 2 years but does not differ from values seen after 1 year of followup, suggesting a clinical steady state has been reached whereby outcome is unlikely to change with time.

LEVEL OF EVIDENCE

Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Conservative management versus open reduction and internal fixation for mid-shaft clavicle fractures in adults--the Clavicle Trial: study protocol for a multicentre randomized controlled trial

Background

Clavicle fractures account for around 4% of all fractures and up to 44% of fractures of the shoulder girdle. Fractures of the middle third (or mid-shaft) account for approximately 80% of all clavicle fractures. Management of this group of fractures is often challenging and the outcome can be unsatisfactory. In particular it is not clear whether surgery produces better outcomes than non-surgical management. Currently there is much variation in the use of surgery and a lack of good quality evidence to inform our decision.

Methods/Design

We aim to undertake a multicentre randomised controlled trial evaluating the effectiveness and safety of conservative management versus open reduction and internal fixation for displaced mid-shaft clavicle fractures in adults. Surgical treatment will be performed using the Acumed clavicle fixation system. Conservative management will consist of immobilisation in a sling at the side in internal rotation for 6 weeks or until clinical or radiological union. We aim to recruit 300 patients. These patients will be followed-up for at least 9 months. The primary endpoint will be the rate of non-union at 3 months following treatment. Secondary endpoints will be limb function measured using the Constant-Murley Score and the Disabilities of the Arm, Shoulder and Hand (DASH) Score at 3 and 9 months post-operatively.

Discussion

This article presents the protocol for a multicentre randomised controlled trial. It gives extensive details of, and the basis for, the chosen methods, and describes the key measures taken to avoid bias and to ensure validity.

Trial Registration

United Kingdom Clinical Research Network ID: 8665. The date of registration of the trial is 07/09/2006. The date the first patient was recruited is 18/12/2007.