Which lateral clavicle fractures can be treated by an arthroscopic-assisted endobutton procedure? An analysis of risk factors

Comparison of Interobserver Agreement of Four Classification Systems for Lateral Clavicle Fractures between Two Groups of Surgeons: A Multicenter Study

OBJECTIVE

Distal clavicle fracture classification directly affects the treatment decisions. It is unclear whether the classification systems implemented differ depending on surgeons' backgrounds. This study aimed to compare the interobserver agreement of four classification systems used for lateral clavicle fractures by shoulder specialists and general trauma surgeons.

METHODS

Radiographs of 20 lateral clavicle fractures representing a full spectrum of adult fracture patterns were analyzed by eight experienced shoulder specialists and eight general trauma surgeons from 10 different hospitals. All cases were graded according to the Orthopedic Trauma Association (OTA), Neer, Jäger/Breitner, and Gongji classification systems. To measure observer agreement, Fleiss' kappa coefficient (κ) was applied and assessed.

RESULTS

When only X-ray films were presented, both groups achieved fair agreement. However, when the 3D-CT scan images were provided, improved interobserver agreement was found in the specialist group when the OTA, Jäger/Breitner, and Gongji classification systems were used. In the generalist groups, improved agreement was found when using the Gongji classification system. In terms of interobserver reliability, the OTA, Neer, and Jäger/Breitner classification systems showed better agreement among shoulder specialists, while a slightly lower level of agreement was found using the Gongji classification system. For the OTA classification system, interobserver agreement had a mean kappa value of 0.418, ranging from 0.446 (specialist group) to 0.402 (generalist group). For the Neer classification system, interobserver agreement had a mean kappa value of 0.368, ranging from 0.402 (specialist group) to 0.390 (generalist group). For the Jäger/Breitner classification system, the inter-observer agreement had a mean kappa value of 0.380, ranging from 0.413 (specialist group) to 0.404 (generalist group). For the Gongji classification system, interobserver agreement had a mean kappa value of 0.455, ranging from 0.480 (specialist group) to 0.485 (generalist group).

CONCLUSION

Generally speaking, 3D-CT scans provide a richer experience that can lead to better results in most classification systems of lateral clavicle fractures, highlighting the value of digitization and specialization in diagnosis and treatment. Competitive interobserver agreement was exhibited in the generalist group using the Gongji classification system, suggesting that the Gongji classification is suitable for general trauma surgeons who are not highly experienced in the shoulder field.

Outcomes, Union Rate, and Complications After Operative and Nonoperative Treatments of Neer Type II Distal Clavicle Fractures: A Systematic Review and Meta-analysis of 2284 Patients

BACKGROUND

As nonoperative treatment of Neer type II distal clavicle fractures is associated with nonunion rates up to 33%, operative treatment is frequently advocated. However, evidence is lacking regarding which operative treatment to perform and whether this is superior to nonoperative treatment in terms of functional outcome and complication rate.

PURPOSE

(1) To evaluate which surgical technique in the treatment of Neer type II distal clavicle fractures is optimal with regard to patient-reported outcomes and union and complication rates. (2) To review nonoperatively treated patients.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the literature and meta-analysis were performed on January 27, 2021, in PubMed, Embase, CENTRAL, CINAHL/EBSCO, Web of Science/Clarivate Analytics, and SPORTDiscus/EBSCO. The search included all studies regarding nonoperative and operative treatment of Neer type II distal clavicle fractures with a minimum of 20 patients and follow-up of 12 months. The primary and secondary outcomes were patient-reported outcome measures at 12 months and union, complication, and revision rates.

RESULTS

A total of 59 articles were included involving 2284 patients. Coracoclavicular fixation, hook plate, transacromial pins, alternative plate, tension band wire/K-wire, a combination of surgical techniques, and a nonoperative group were described. Hook plates showed lower Constant-Murley scores as compared with coracoclavicular fixation (standard mean difference, -0.77; 95% CI, -1.26 to -0.28; P = .002). However, no significant difference was seen when the hook plate was compared with the locking plate and tension band wire/K-wire groups, and no significant difference in union rate was seen among all operative treatment groups. Operatively treated patients had significantly higher union rates than patients treated nonoperatively (standard mean difference: 0.05; 95% CI, 0.01 to 0.37; P = .004).

CONCLUSION

Patients treated with hook plates showed significantly lower Constant-Murley scores and higher complication and revision rates as compared with those treated with coracoclavicular fixation, without differences in union rate. Higher Constant-Murley scores were seen in those patients with supplemental coracoclavicular fixation when using locking. Nonoperatively treated patients showed good functional outcome despite the 31% nonunion rate, although future studies are necessary to substantiate this conclusion. When using a locking plate, additional craniocaudal fixation showed significant better functional outcome.

Complications following arthroscopic-assisted coracoclavicular stabilization in patients with unstable lateral clavicle fractures

PURPOSE

Lateral clavicle fractures are unstable and prone to nonunions, which is why they are often treated surgically rather than conservatively. Despite the variety of surgical techniques found in the literature, the best method for treating this rare fracture type has not yet been determined. Our case series aimed to describe a coracoclavicular (CC) reconstruction technique and to assess complications and patient outcomes 1 year postoperatively.

METHODS

Nineteen patients who underwent surgery for an unstable lateral clavicle fracture (IIB, IIC, IID) with a suture button device (Dog Bone, Arthrex, Inc., Naples, FL, USA) were available for clinical and radiological follow-up. The assessments included the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (ASES) score, the Constant Score (CS), the Subjective Shoulder Value (SSV), as well as the ipsilateral and contralateral coracoclavicular distance.

RESULTS

The median age was 50 years (IQR 28-59), 13 (68.4%) were male and the delay to surgery was 5 days (IQR 2-9). The median clinical scores were 100 (ASES), 91 (CS), and 95 (SSV). The CC distance improved postoperatively (p = 0.003). However, nonunion occurred in 3 (15.8%) patients, 5 (26.3%) had other complications, and 5 (26.3%) needed revision surgery (4 plate removals and 1 pseudoarthrosis). The overall complication rate was 36.8%.

CONCLUSION

Restoring the CC ligaments alone could not reliably achieve fracture stability, with more than one-third of cases in this series experiencing major complications. Given the high revision and nonunion rates, we do not recommend this type of surgical technique.

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.

Clinical Impact of Malunion After All-Arthroscopic Coracoclavicular Stabilization for Displaced and Unstable Lateral Clavicle Fractures

OBJECTIVE

To evaluate the clinical outcome of lateral clavicle malunion treated with all-arthroscopic coracoclavicular (CC) stabilization.

DESIGN

Retrospective, case series.

SETTING

Department of hand and upper extremity surgery, university hospital center.

PATIENTS

Forty-five patients with unstable and displaced lateral clavicle fracture treated between January 2015 and August 2019 were included in the study.

INTERVENTION

Closed reduction and arthroscopic CC stabilization using cortical buttons.

MAIN OUTCOME MEASUREMENTS

Shoulder pain and active motion. Patient-reported outcome measures included the Constant score, the Subjective Shoulder Value, the AcromioClavicular Joint Instability score, and the Specific AcromioClavicular Score. Radiographic evaluation assessed bony union and malunion.

RESULTS

Mean duration of follow-up was 25 months (12-60 months). Five patients (11%) had lateral clavicle nonunion and 7 (16%) had lateral clavicle malunion (5 in the coronal plane and 2 in the axial plane). Lateral clavicle malunion did not significantly affect clinical or functional outcomes (P > 0.05). Mean active shoulder motion was forward flexion 163 degrees (SD 28), abduction 162 degrees (SD 26), and external rotation 63 degrees (SD 21). On average, the patients scored 88.3 (SD 17.7) in the Constant score, 90% (SD 12) in the Subjective Shoulder Value, 88.8 (SD 9.4) in the AcromioClavicular Joint Instability score, and 11.4 (SD 8.5) for SACS. The overall complication rate was 38% (including 7 malunions, 5 nonunions, 2 adhesive capsulitis, and 3 button malpositions).

CONCLUSIONS

Closed reduction and internal fixation of lateral clavicle fracture with all-arthroscopic CC stabilization using cortical button potentiates bony union but may generate lateral clavicle malunion, which does not affect the clinical or functional outcome. This result can be attributed to CC ligament healing and acromioclavicular joint congruence. All-arthroscopic CC stabilization is a minimally invasive but demanding surgical alternative for managing unstable and displaced lateral clavicle fracture.

LEVEL OF EVIDENCE

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

Additional coracoclavicular augmentation reduces revision rates in the treatment of lateral clavicle fractures as compared to angle-stable plate osteosynthesis alone

INTRODUCTION

There is no uniform approach to the management of lateral clavicle fractures. Recent studies have investigated additive coracoclavicular (CC) augmentation as a treatment option; however, it is unclear whether it is superior to conventional locking plate osteosynthesis.

METHODS

We carried out a retrospective analysis of 40 patients with lateral clavicle fracture (Neer type IIb) who were treated between 2014 and 2017 with either a hybrid locking plate osteosynthesis/additive arthroscopy-assisted CC augmentation (HP) procedure or a locking plate osteosynthesis only (PO) approach to determine which strategy was more effective. At follow-up, subjective shoulder value, age- and sex-adjusted Constant-Murley score, Taft (TF) score, American Shoulder and Elbow score, Nottingham clavicle score, and Visual Analogue Scale score were compared between patient groups. A radiologic evaluation was also conducted.

RESULTS

A total of 14/17 patients (83%; 9 male/5 female, mean age: 43 ± 15 years) were followed up in the PO group. The mean follow-up time was 29 ± 12.4 months. In the HP group, 17/23 patients (74%; 9 male/8 female, mean age: 43 ± 17 years) were followed up, with a mean follow-up time of 18 ± 7.1 months. There were no significant differences in clinical parameters between the HP and PO groups; notably, the shoulder girdle-specific TF score was comparable in the 2 groups (HP: 11.3 ± 1.1 points and PO: 10.9 ± 0.9 points). In the HP group, additional pathologies were identified and arthroscopically treated in 35% of cases. Radiologic examination revealed a significant difference between pre- and postoperative CC distance in the HP group (P = 0.001).

CONCLUSION

Additive CC augmentation in combination with locking plate osteosynthesis seems to improve the vertical stability and reduces the revision rate in patients with a lateral clavicle fracture. Furthermore, an arthroscopy-assisted procedure allows for an intraoperative detection and single-step treatment of accompanying intraarticular pathologies.

Arthroscopically Assisted Coraco-Clavicular Ligament Reconstruction in Treatment of Acute Displaced Distal Clavicle Fractures Provides Good to Excellent Shoulder Function Despite Low Union Rates and High Complication Rates: A Systematic Review

PURPOSE

The aim of this systematic review was to assess the clinical outcome of arthroscopically assisted coraco-clavicular ligament (AACCL) reconstruction for treatment of displaced distal clavicle fractures in terms of union rate, complications, and shoulder function.

METHODS

A review of the online databases Medline and Embase was conducted on January 1, 2021, according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies reporting union rate, complications, and shoulder function were included. The studies were appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool.

RESULTS

The search strategy identified 14 studies eligible for inclusion, 12 retrospective case series and 2 nonrandomized retrospective comparative studies. All studies reported on shoulder function, union rate, and complications. The overall shoulder function was good to excellent according to Constant-Murley score, with mean scores ranging from 81.8 to 96.2 [I² (inconsistency) = 0% (95% confidence interval [CI] = 0% to 61%)]. The mean union rate ranged from 70% to 100% [I² = 32.6% (95% CI = 0% to 63.4%)], and the mean complication rate ranged from 0 to 28.6% [I² = 43.4% (95% CI = 0% to 68.4%)]. The most common complications were hardware related (3.1%), wound related (2.7%), and postoperative shoulder stiffness (2.2%).

CONCLUSION

This systematic review analyzed clinical studies that evaluated the outcome of AACCL reconstruction in displaced distal clavicle fractures. The overall findings of this systematic review are that the union rate can be as low as 70% with this technique and the complication rate as high as 28.6%. Overall shoulder function was good to excellent according to Constant-Murley score. As the literature surrounding this topic is heterogeneous, further comparative clinical studies are required to assess superiority compared with other traditional techniques.

LEVEL OF EVIDENCE

V: systematic review of level III and IV studies.

Concomitant glenohumeral injuries in patients with distal clavicle fractures undergoing arthroscopic-assisted surgery: a systematic review

Background

To determine the incidence of concomitant intra-articular glenohumeral injuries in patients undergoing surgical management from distal clavicle fractures (DCF) with shoulder arthroscopy and their impact on outcome.

Methods

This systematic review was conducted following the PRISMA guidelines. PubMed, EMBASE, and Virtual Health Library databases were accessed in October 2021. All the clinical studies evaluating the surgical management of DCF and using concomitant intra-operatory shoulder arthroscopy were included. Studies that did not specify the concomitant injury type were not eligible. Data from the incidence of intra-articular glenohumeral injuries, injury type, length of the follow-up, and clinical outcomes were retrieved. The quantitative content assessment was performed using the STROBE statement checklist. Evaluation of the publication bias of the included studies was performed using the risk of bias assessment tool for systematic reviews.

Results

Data from five retrospective and five prospective cohort studies were analyzed. Eight of the included studies were conducted on patient cohorts with Neer type II injuries. Data pooling revealed a mean of 17.70% of concomitant glenohumeral injuries, whereas 84.21% of them required additional surgical management (Table 1). Rotator cuff injuries, labral tears, and biceps pulley lesions were the most common concomitant injuries.

Conclusion

Preoperative MRI or diagnostic arthroscopy to evaluate glenohumeral associated injuries to DCF should be recommended.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcomes of Arthroscopic Fixation of Unstable Distal Clavicle Fractures: A Systematic Review

Background:

Surgical management of unstable distal clavicle fractures (DCFs) remains controversial. Traditional open techniques result in acceptable union rates but are fraught with complications. In response to these limitations, arthroscopic techniques have been developed; however, clinical outcome data are limited.

Purpose:

The primary purpose was to systematically evaluate the clinical and radiographic outcomes of arthroscopic fixation of unstable DCFs. The secondary purpose was to characterize the overall complication rate, focusing on major complications and subsequent reoperations.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic review of the literature was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and included a search of the PubMed, Web of Science, Cochrane Register of Controlled Trials, EMBASE, and Scopus databases. English-language studies between 2008 and 2019 that reported on outcomes of patients with DCFs who underwent operative fixation using an arthroscopic or arthroscopically assisted surgical technique were included. Data consisted of patient characteristics, fracture type, surgical technique, concomitant injuries, union rates, functional outcomes, and complications.

Results:

A total of 15 studies consisting of 226 DCFs treated using an arthroscopically based technique were included in the systematic review. The majority of fractures were classified as Neer type II. Most (97%) of the fractures underwent arthroscopic fixation using a cortical button coracoclavicular stabilization surgical technique. Bony union was reported in 94.1% of the fractures. Good to excellent outcomes were recorded in most patients at the final follow-up. The Constant-Murley score was the most widely used functional outcome score; the pooled mean Constant score was 93.06 (95% CI, 91.48-94.64). Complications were reported in 14 of the 15 studies, and the overall complication rate was 27.4%. However, only 12% of these were considered major complications, and only 6% required a reoperation for hardware-related complications.

Conclusion:

Arthroscopic fixation of DCFs resulted in good functional outcomes with union rates comparable to those of traditional open techniques. While the overall complication profile was similar to that of other described techniques, there was a much lower incidence of major complications, including hardware-related complications and reoperations.

Inter- and intraobserver agreement of three classification systems for lateral clavicle fractures - reliability comparison between two specialist groups

BACKGROUND

Although of great value in the management of lateral clavicle fractures, substantial variation in their classification exists. We performed a retrospective study to address the inter- and intraobserver reliability of three different classification systems for lateral clavicle fractures.

METHODS

Radiographs of 20 lateral clavicle fractures that represented a full spectrum of adult fracture patterns were graded by five experienced radiologists and five experienced trauma surgeons according to the Orthopaedic Trauma Association (OTA), the Neer, and the Jäger/Breitner classification systems. This evaluation was performed at two different time points separated by 3 months. To measure the observer agreement, the Fleiss kappa coefficient (κ) was applied and assessed according to the grading of Landis and Koch.

RESULTS

The overall interobserver reliability showed a fair agreement in all three classification systems. For the OTA classification system, the interobserver agreement showed a mean kappa value of 0.338 ranging from 0.350 (radiologists) to 0.374 (trauma surgeons). Kappa values of the interobserver agreement for the Neer classification system ranged from 0.238 (trauma surgeons) to 0.276 (radiologists) with a mean κ of 0.278. The Jäger/Breitner classification system demonstrated a mean kappa value of 0.330 ranging from 0.306 (trauma surgeons) to 0.382 (radiologists).The overall intraobserver reliability was moderate for the OTA and the Jäger/Breitner classification systems, while the overall intraobserver reliability for the Neer classification system was fair.The kappa values of the intraobserver agreements showed, in all classification systems, a wide range with the OTA classification system ranging from 0.086 to 0.634, the Neer classification system ranging from 0.137 to 0.448, and a range from 0.154 to 0.625 of the Jäger/Breitner classification system.

CONCLUSIONS

The low inter- and intraobserver agreement levels exhibited in all three classification systems by both specialist groups suggest that the tested lateral clavicle fracture classification systems are unreliable and, therefore, of limited value. We should recognize there is considerable inconsistency in how physicians classify lateral clavicle fractures and therefore any conclusions based on these classifications should be recognized as being somewhat subjective.

Clavicle fractures in adults; current concepts

BACKGROUND

For decades, clavicle fractures have been treated conservatively. In the last 20 years, however, non-union rates after conservative treatment appear higher than previously reported and more evidence regarding operative treatment has become available. This has led to a paradigm shift towards an increase in operative treatment. The aim of this review is to present the current concepts and available evidence regarding clavicle fracture treatment.

METHODS

Conservative and operative treatment options together with their indications for medial, shaft and lateral clavicle fractures are discussed. For all three anatomical locations, a treatment algorithm is proposed.

CONCLUSION

In general, non-displaced fractures are treated conservatively. Operative treatment has to be discussed with patients with displaced clavicle fractures, especially in the young and active patient.