Minimally invasive plate osteosynthesis for midshaft clavicular fractures using superior anatomic plating

Complications and clinical outcomes with minimally invasive plate osteosynthesis (MIPO) technique for midshaft clavicle fractures: a systematic review and meta-analysis

Background

Clavicle fractures are among the most common upper limb fractures in adults, with the midshaft region being the most frequently affected site. Minimally invasive plate osteosynthesis (MIPO) has emerged as an alternative to the traditional open reduction and internal fixation (ORIF) technique, offering potential advantages. The purpose of this study was to conduct a systematic review to explore the results of this technique in the existing literature, with emphasis on the occurrence of surgical complications and functional outcomes and also to provide a comprehensive comparison of MIPO and ORIF in the management of midshaft clavicle fractures.

Methods

We conducted a systematic review to evaluate the complication incidence and clinical outcomes of MIPO for midshaft clavicle fractures. We searched PubMed/Medical Literature Analysis and Retrieval System Online (MEDLINE), Scopus, the Cochrane Database of Controlled Trials, and the Cochrane Database of Systematic Reviews databases without language or date restrictions. Studies focusing on midshaft clavicle fractures treated with MIPO were included, while other clavicle fractures and nonclinical studies were excluded. The risk of bias was assessed using the Methodological Index for Nonrandomized Studies criteria and the Risk of Bias Tool 2 Cochrane tool. Data synthesis included qualitative analysis, and if applicable, quantitative analysis and meta-analysis. Adherence to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines ensured reporting quality.

Results

A total of 107 studies were initially identified, after applying inclusion and exclusion criteria, 22 studies were included for data extraction. These studies involved the evaluation of 714 clavicles treated with the MIPO technique. Of the 714 MIPO cases, 11 cases of implant failure, 5 nonunions, 2 infections, and 28 cases with neurological impairment were observed. Quantitative analysis comparing MIPO with ORIF revealed that MIPO had significantly shorter surgery time (mean difference -12.95, 95% confidence interval [-25.27 to -0.63], P = .04) and lower occurrence of numbness (odds ratio 0.29, 95% CI [0.15-0.56], P = .0002) compared to ORIF. Time to bone union, functional outcomes, and other complications were similar between MIPO and ORIF at the final follow-up. An overall moderate risk of bias was found across the studies.

Conclusion

The MIPO technique yields good and comparable results to ORIF for midshaft clavicle fractures. Additionally, the MIPO technique may offer advantages such as reduced surgical time and lower chances of neurological impairment.

Precontoured dynamic compression plate using patient-specific 3D-printed models in minimally invasive surgical technique for midshaft clavicle fractures

INTRODUCTION

This study introduced a novel approach for the treatment of midshaft clavicle fractures, utilizing patient-specific 3D-printed models for accurate preoperative contouring of dynamic compression plates (DCPs) and an alternative minimally invasive plate osteosynthesis (MIPO) technique with precontoured DCPs through small vertical separated incisions.

PATIENT AND METHODS

Mirror image 3D clavicular models were reproduced from 40 patients with acute displaced midshaft clavicle fractures who underwent MIPO using precontoured DCPs inserted through small, vertical separated incisions. Exclusion criteria included patients with open fractures, pathological fractures, ipsilateral limb injury, skeletal immature patients, and those who had previous clavicle fractures or surgery. Postoperative evaluation was conducted using clinical and radiographic review. The Constant-Murley and American Shoulder and Elbow Surgeons Shoulder Scores were used for clinical evaluations, and the Patient and Observer Scar Assessment Scale was used to assess surgical scars.

RESULTS

The average time to union of all fractures was 12.88 weeks (range, 8-15) without loss of reduction. The patient-specific precontoured DCPs fitted well in all cases, with fracture consolidation and minimal three cortical sides connecting the fracture fragment. No hardware prominence and skin complications occurred, and clinical evaluation showed no existing difference compared with the contralateral sides. The average Constant-Murley and American Shoulder and Elbow Surgeons Shoulder Scores were 96.33 ± 3.66 and 93.26 ± 5.15, respectively. Two patients requested their implant removal, and scar qualities were satisfactory.

CONCLUSIONS

Our study demonstrated that the use of a patient-specific precontoured DCP, in combination with 3D printing technology, provides accurate preoperative planning, effective fracture reduction, and improved postoperative outcomes in displaced midshaft clavicle fractures. The MIPO with a patient-specific precontoured DCP through separated vertical incisions along the Langer's lines appears to be a promising option, regarding appearance, avoiding associated complications, and obviating the need for reoperation. These results suggest that this technique has merit and can be a viable option for the treatment of midshaft clavicle fractures.

Dual- Versus Single-Plate Fixation of Clavicle Fractures: Understanding the Rationale Behind both Approaches

Clavicle fractures are a common injury resulting from a high-energy force, such as a fall onto the shoulder, motor vehicle accident, or sporting activity. Although some clavicle fractures may be treated nonoperatively, operative treatment results in higher union rates and faster return to activity. Here we discuss the operative treatment options for plating of clavicle fractures; specifically, a single plate placed either superiorly or anteriorly or two plates placed orthogonally. Because both techniques provide adequate stability, fracture and patient characteristics should guide the surgical decision making regarding single versus dual plating of clavicle fractures.

Technique, Indications and Limitations of a Minimally Invasive Approach to Treat Distal Radius Fractures and Malunions

The minimally invasive flexor carpi radialis approach can be used for volar locking plate fixation of distal radius fractures. It offers the advantage of preserving ligamentotaxis, which facilitates the reduction and the small size of the scar improves the esthetic result of the procedure. It is indicated for extra-articular fractures of the distal radius. In the case of an intra-articular fracture, an arthroscopy may be associated. In the case of a proximal diaphyseal extension of the fracture, a second proximal approach can be added in order to use a longer plate. Relative contraindications are comminuted articular fractures in elderly osteoporotic patients. Functional and radiological results are comparable to those obtained with the extented flexor carpi radialis approach. A conversion of the procedure for a larger incision is always possible in the case of a difficult reduction.

Comparative Study Between the Mini-Open (≤2.5 Cm) Approach and Conventional Open Lateral Approach in the Surgical Treatment of Radial Head Fractures

Purpose

The conventional lateral approach is widely used to treat radial head fractures with screws. However, the traditional incision may have shortcomings, including excessive exposure and significant scarring. We propose an innovative method – a mini-open lateral approach of less than 2.5 cm for surgical treatment of radial head fractures with screws.

Methods

From Jan 2017 to Dec 2020, 34 patients diagnosed with closed radial head fracture were treated with open reduction and internal fixation (ORIF) in this study. The novel group (mini-open group) included 15 patients, and the other 19 patients were in the traditional group. The time of operation and the blood loss during operation were recorded. Postoperative clinical outcomes and radiographic results were recorded and compared between the two groups. The range of motion (ROM) in the elbow, the Visual Analogue Scale (VAS), the Mayo Elbow Performance Score (MEPS), Rating Scale of the American Shoulder and Elbow Surgeons (ASES), and the Shortened Disabilities of the Arm, Shoulder and Hand Questionnaire (Q-DASH) score and complications, such as wound infection, vascular and nerve damage, and fragment redisplacement were observed in the two groups.

Results

In the comparison between the two groups, there was no significant difference in age, sex, cause of radial head fracture, or other basic information. The operation time, intraoperative blood loss, and VAS score at 3 days postoperation were significantly reduced in the novel group (p < 0.05). The follow-up results showed that there was no significant difference in MEPS, ASES, or Q-DASH scores between the two groups.

Conclusion

The mini-open approach reduced intraoperative blood loss, shortened operation time, relieved patient pain, and achieved a satisfactory postoperative clinical result, which demonstrates that the novel approach is a safe and effective option for treating radial head fractures.

Osteossíntese minimamente invasiva com placa para fraturas de clavícula

Objective  To analyze the radiological, clinical, and functional outcomes of clavicle fractures treated with the minimally-invasive plate osteosynthesis (MIPO) technique.

Methods  From June 2018 to July 2019, 17 cases of clavicular fractures were managed using the MIPO technique under C-arm fluoroscopy. The functional outcomes were assessed using the Constant-Murley score and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The clinical results of union, the complications, the operative time, the hospital stay, as well as infection, were analyzed.

Results  The mean follow-up time was of 10.41 ± 1.75 months (range: 8 to 14 months). There were 11 male and 6 female patients, with a mean age of 39.05 ± 10.76 years (range: 22 to 57 years). All fractures united on the mean time of 15.35 ± 3.08 weeks (range: 12 to 20 weeks). The mean operative time was of 98.11 ± 13.83 minutes (range: 70 to 130 minutes), and the mean length of the hospital stay was of 4.7 ± 1.12 days (range: 3 to 7 days). The mean Constant-Murley score was of 74.82 ± 6.36 in 4 ^th postoperstive month, and of 92.35 ± 5.48 in the 8 ^th postoperative month, which was statistically significant. The mean DASH score was of 9.94 ± 1.55 in the 4 ^th postoperative month, and of 5.29 ± 1.85 in the 8 ^th postoperative month, which was also statistically significant. One patient had superficial skin infection at the site of the incision.

Conclusions  The MIPO technique is an alternative method for the fixation of clavicle fractures, but it is technically more demanding, and requires well-equipped operating room facilities.

Combination of mini locking plate and nitinol arched shape-memory connector for purely lateral malleolus fractures: technique and clinical results

Background

Lateral malleolus fractures occur frequently. The common techniques for fixing purely lateral malleolus fractures are often challenging, owing to the extent of soft tissue damage and fracture non-union. Herein, we report a new treatment that entails minimally invasive insertion and continuous compression of the broken ends as a novel technique, and evaluate its clinical results.

Methods

This study enrolled 21 patients (13 males and 8 females; mean age 32.06±3.45 years, range 23–69 years) with purely lateral malleolus fractures. Each patient underwent open reduction treatment with a mini locking plate for internal fixation and compression of the fracture end with an Arched Shape-Memory Connector (ASC). The clinical assessments were made using the American Orthopedic Foot and Ankle Society (AOFAS) scores, which were recorded at the final follow-up visit.

Results

The patients were followed for an average of 14.7±1.2 months (range, 12–18 months). None of the patients showed surgical failure, and all of the purely lateral malleolus fractures healed in an average of 12.6±1.5 weeks (range, 10–16 weeks). The mean AOFAS score was 88.94 (range, 83–90).

Conclusions

The new treatment had beneficial outcomes for purely lateral malleolus fractures. Mini locking plates are minimally invasive for surgical intervention, and combined with continuous concentrated compression with an ASC to accelerate osseous healing, they aid in restoration of function and enable early rehabilitation with a low incidence of postoperative complications.

Minimally invasive anterior plate osteosynthesis of the distal radius: A 710 case-series

INTRODUCTION

Since the 2000s, internal fixation of distal radius fracture by volar locking plate on an extended flexor carpi radialis (FCR) approach has become the gold standard.

OBJECTIVE

The present study aimed to assess medium-term results of minimally invasive plate osteosynthesis (MIPO) in distal radius fracture.

MATERIAL AND METHODS

The series comprised of 710 cases (512 female; mean age, 58 years). The 15mm approach was on the lateral edge of the FCR. The plate was slipped under the pronator quadratus. Closure used intradermal running suture without drain or orthosis.

RESULTS

At a mean 7 months' follow-up, mean scar length was 17mm (range, 10-40mm), pain 1.13/10 (0-8), Quick-DASH 13.28 (0-86.36), and patient-rated wrist evaluation (PRWE) 11.48 (0-91). Compared to contralateral values, mean flexion was 87.23%, extension 88.52%, pronation 96.17%, supination 93.41%, and grip strength 79.68%. Hardware was removed in 45.92% of cases. There were 16 cases of secondary displacement, with 4 revision procedures, one of sepsis at 6 months, 10 of complex regional pain syndrome, and 14 of median nerve paresthesia, with 4 carpal tunnel release procedures.

DISCUSSION

The minimally invasive FCR approach can be used for volar plate fixation of distal radial fracture. It has the advantage of conserving ligamentotaxis, facilitating reduction and improving scar esthetics. The incision can be extended if need be.

LEVEL OF EVIDENCE

III; single-centre retrospective study.

Optimal plate position in minimally invasive plate osteosynthesis for mid-shaft clavicle fractures: simulation using 3D-printed models of actual clinical cases

INTRODUCTION

This study evaluated the optimal anatomical locking plate position using three-dimensional printed models of the clavicle.

MATERIALS AND METHODS

Three-dimensional models of the fractured clavicle were reproduced from seventeen patients who underwent minimally invasive plate osteosynthesis (MIPO) procedures. The fracture location-the percentage of the distal fragment length compared to the entire clavicle-ranged from 30-44%. We evaluated four commercially available plate systems for position and fitting with the bone. After reducing the fracture on each three-dimensional model, we determined the optimal plate and its position.

RESULTS

The anatomical plate fitted well when positioned in the middle of the clavicle for a fracture location ranging from 40 to 60%. When the fracture location was 30-40%, the anatomical plate fit well onto the bone model only in 36% of clavicles; otherwise, the reversed position of the anatomical plate or the lateral plate fit well. The anatomical plate was found to be unsuitable when the fracture location was less than 30%; in this case, the lateral plate was the best fit.

CONCLUSION

Fitting the anatomical plate in MIPO for clavicle fractures depends on the fracture location. This can help surgeons determine the optimal plate for clavicle MIPO.

Comparison between Minimally Invasive Plate Osteosynthesis and Conventional Open Plating for Midshaft Clavicle Fractures: A Systematic Review and Meta-Analysis

Objective

The aim of this study was to compare the functional outcome and complications in midshaft clavicle fractures receiving minimally invasive plate osteosynthesis and conventional open plating.

Methods

Relevant studies were searched in the databases of Medline, EMBASE, Cochrane Library, Ovid, and Web of Science from inception to March 1, 2019. Pooled data were analyzed with Cochrane Collaboration's Review Manager 5.3.

Results

A total of 7 studies were included, of which 2 were randomized controlled trials, 3 were retrospective cohort studies, and 2 were prospective cohort studies including 316 patients. No statistical differences in functional outcome (weighted mean difference [WMD] = 0.99, P = 0.12), operation time (WMD = −10.44, P = 0.07) and time to bone union (WMD = −0.23, P = 0.70) were observed between the two groups. However, minimally invasive plate osteosynthesis reduced rates of skin numbness (odds ratio (OR) = 0.25, 95% CI : 0.13 to 0.48; P < 0.0001) and complications (OR = 0.33, 95% CI : 0.16 to 0.71; P = 0.005) compared with conventional open plating.

Conclusion

This systematic review and meta-analysis found no differences in terms of functional outcomes, operation time, and fracture healing time between minimally invasive plate osteosynthesis and conventional open plating. However, minimally invasive plate osteosynthesis had apparent advantages in rates of skin numbness and complications.

Minimally invasive plate osteosynthesis (MIPO) in AO/OTA type B displaced clavicle fractures

INTRODUCTION

Open reduction and plate fixation is known to reduce chances of malunion and symptomatic nonunion in displaced middle-third clavicle fractures. However, this treatment modality is also associated with several complications, such as hardware irritation, numbness around the surgical scar, infection, nonunion and implant failure. The minimally invasive plate osteosynthesis (MIPO) technique may reduce these complications.

OBJECTIVE

To study clinical, radiological and functional outcomes of MIPO in AO/OTA type B displaced clavicle fractures and report any complications.

MATERIALS AND METHODS

A total of 22 patients underwent internal fixation of acute displaced AO/OTA type B clavicle fractures from Jan 2014 to Dec 2015 by MIPO using locking compression plates. Patients were followed up at a regular interval and assessed clinically and radiologically. The clavicle length difference was measured. Functional assessment was done at the end of 2 year using constant shoulder score (CSS) and disability of the arm, shoulder and hand score (Quick DASH) and complications if any were noted.

RESULTS

All fractures united at a mean of 12.5 weeks. One (4.5%) patient had numbness around the surgical scar. None of the patients had wound-related complications. In four patients, hardware irritation was noted. The difference in clavicle length was not significant. All patients had excellent CSS and Quick DASH score at the final follow-up.

CONCLUSION

Internal fixation of displaced AO/OTA type B clavicle fractures by MIPO showed high fracture union rates and good functional outcomes.

Does candidate for plate fixation selection improve the functional outcome after midshaft clavicle fracture? A systematic review of 1348 patients

INTRODUCTION

The hypothesis of this study was that patient selection for midshaft clavicle fracture (open reduction internal fixation with plate versus conservative) would give better functional outcome than random treatment allocation.

METHODS

We performed a systematic literature search for primary studies providing functional score and non-union rate after conservative or surgical management of midshaft clavicle fractures. Six randomized controlled trial and 19 non-randomized controlled trial studies encompassing a total of 1348 patients were included.

RESULTS

Patients treated with surgical management were found to have statistically superior Constant scores in non-randomized controlled trials than in randomized controlled trials (94.76 ± 6.4 versus 92.49 ± 6.2; p < 0.0001). For conservative treatment, randomized controlled trials were found to have significantly better functional outcome. The prevalence of non-union (6.1%) did not show significant statistical difference between non-randomized controlled trial and randomized controlled trial studies. The functional outcome after surgical management was significantly higher than after conservative management in both randomized controlled trial and non-randomized controlled trial groups. The non-union rate after surgery (1.1% for both non-randomized controlled trial and randomized controlled trial) was significantly lower than following conservative treatment (9.9% non-randomized controlled trial versus 15.1% randomized controlled trial).

DISCUSSION

This review shows that patient selection for surgery may influence functional outcome after midshaft clavicle fracture. Our results also confirm that plate fixation provides better functional outcome and lower non-union rate.

A Comparison of Clinical and Radiological Outcomes of Minimally Invasive and Conventional Plate Osteosynthesis for Midshaft Clavicle Fractures

Thirty patients with displaced midshaft clavicle fractures were prospectively enrolled in this study. Fifteen were randomly assigned to the minimally invasive plate osteosynthesis group and 15 to the conventional plate osteosynthesis group. Constant score, visual analog scale satisfaction score, operative time, scar length, and complications, including hypoesthesia, were evaluated at least 1 year postoperatively to determine functional outcomes and time to bone union as a radiological outcome. Factors related to bone union, including the gap interval between fracture fragments and the number of fracture fragments, were also evaluated. The Constant score and the visual analog scale satisfaction score were higher in the minimally invasive plate osteosynthesis group than in the conventional plate osteosynthesis group; however, there was no significant difference between the groups in these scores or in the time to bone union (all P>.05). Hypoesthesia was the only complication, and its incidence was not different between the groups (P=.249). However, operative time (52.33±13.87 vs 110.33±25.39 minutes, P<.001) and scar length (64.95±3.19 vs 99.39±15.98 mm, P<.001) were significantly shorter in the minimally invasive plate osteosynthesis group than in the conventional plate osteosynthesis group, respectively. In the minimally invasive plate osteosynthesis group, time to bone union was significantly correlated with the gap interval (P=.004) and the number of fracture fragments (P=.002). Minimally invasive plate osteosynthesis showed some superiority over conventional plate fixation for midshaft clavicle fractures, having a shorter operative time and scar length. The time to bone union was influenced by the reduction status and the number of fracture fragments in the minimally invasive plate osteosynthesis group. [Orthopedics. 2018; 41(5):e649-e654.].

Long Volar Plating for Metadiaphyseal Fractures of Distal Radius: Study Comparing Minimally Invasive Plate Osteosynthesis versus Conventional Approach

Background  Minimally invasive plate osteosynthesis (MIPO) has been used in wrist surgery for several years. The purpose of this retrospective study was to compare clinical and radiologic outcomes of MIPO technique with those of a conventional approach in the treatment of metadiaphyseal distal radius fracture by long volar plating. Materials and Methods  Our series consisted of 32 fractures in 31 patients, mean age 63.9 years, including 16 men and 15 women. MIPO technique was used in 15 wrists (group 1) and conventional approach (> 60 mm of skin incision) in 17 wrists (group 2). In group 1, a long volar plate was inserted under pronator quadratus through a 15- to 30-mm distal incision then fixed to the epiphysis of the distal radius. Then, through a 15- to 30-mm proximal incision, the plate was fixed to the diaphysis of the radius, thus reducing the fracture. Results  In group 1, mean distal incision size was 23.5 and 16.9 mm for proximal one. Mean total scar size (sum of both distal and proximal incisions) was 40.0 mm in group 1 and 84.1 mm in group 2. Mean tourniquet time was 58.4 minutes in group 1 and 68.9 minutes in group 2. At latest follow-up, no significant difference was noted in both the groups concerning pain, quick-DASH score, grip strength, ROM, and radiologic data. One extensor pollicis longus rupture treated by tendon transfer was done in group 1. Conclusion  The MIPO technique for metadiaphyseal fractures of the distal radius by long volar plating has cosmetic and economic advantages compared with the conventional approach. Conversion to conventional approach is possible at any time in case of technical difficulties. Level of Evidence  III.

Comparative Results of External Fixation, Plating, or Nonoperative Management for Diaphyseal Clavicle Fractures

OBJECTIVE

The aim of this study was to compare the treatment outcomes of mid-diaphyseal clavicular fractures between an external fixator and more widely selected treatment options such as plate osteosynthesis or conservative methods.

MATERIALS AND METHODS

The medical records of 64 patients who were treated for mid-diaphyseal clavicular fracture in our clinic from 2009 to 2013 were reviewed. The inclusion criterion was mid-diaphyseal closed clavicular fractures with shortening of more than 2 cm. The Constant and DASH (disabilities of the arm, shoulder, and hand) scores at the final follow-up, initial displacement, nonunion, and complication rates were compared. Statistical differences between groups were assessed with the Kruskal-Wallis test, and pairwise comparison analysis was used to evaluate the differences within the groups.

RESULTS

Of the 64 patients, 24 (37.5%) were treated with plate osteosynthesis (group 1), 11 (17.2%) with an external fixator (group 2), and 29 (45.3%) conservatively with a figure-of-eight bandage (group 3). The mean follow-up periods were as follows: group 1: 37 ± 10.4 months, group 2: 33 ± 7 months, and group 3: 35 ± 9.4 months. The initial amount of displacement and DASH score were: group 1: 89.1 ± 7.8, group 2: 89.1 ± 7.8, and group 3: 6.1 ± 6.6) (p = 0.079). The Constant score of group 2 (93 ± 6.1) was significantly higher than that of group 3 (85 ± 8.4) (p = 0.013). No statistical difference was found in the distribution of nonunions (p = 0.387). However, in group 3, the number of malunions (11/29, 37.9%) was significantly higher compared to the other 2 groups (group 1: 1/24, 4.2%; group 2: 2/11, 18.2%) (p = 0.006).

CONCLUSIONS

This study revealed that the treatment of acute clavicular fractures with an external fixator was a good alternative to plate osteosynthesis or conservative treatment.