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Jubel A, Knopf M, Jubel JM, Herbst H, Antonie M. [Clavicle nonunion]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024:10.1007/s00113-024-01465-7. [PMID: 39058394 DOI: 10.1007/s00113-024-01465-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/26/2024] [Indexed: 07/28/2024]
Abstract
After conservative treatment nonunion (pseudarthrosis) of the clavicle can be observed approximately 10 times more frequently (15-24%) than after surgical treatment (1.4%). Risk factors include the fracture location, displacement, fracture type, sex, the severity of the accident and refractures. The diagnosis of pseudarthrosis of the clavicle can be made by a thorough medical history, clinical examination and imaging procedures. The main symptom is pain, often accompanied by malalignment, instability, neurological symptoms and restricted mobility of the affected shoulder. The diagnosis is confirmed by X‑ray images and, if necessary, a computed tomography (CT) scan. Pseudoarthrosis is classified according to the morphological appearance in X‑ray images and the cause. A differentiation is made between vital and nonvital pseudarthroses. Only symptomatic pseudarthrosis requires treatment. Nonoperative methods, such as magnetic field therapy or ultrasound are minimally effective. Surgical interventions are indicated for pain, movement restrictions or neurovascular problems. The goals of surgical treatment are to restore the vitality, bone length and stability through angular stable osteosynthesis. In cases of surgical pretreatment the anteroinferior plate position offers a good alternative to the superior plate position. In some cases double plating osteosynthesis can be indicated. Autogenous bone material, allogeneic substitute material and vascularized grafts are used for bony defects. Surgical treatment shows high rates of healing but also carries an increased risk of infection.
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Affiliation(s)
- Axel Jubel
- Klinik für Unfall- und Wiederherstellungschirurgie, Eduardus-Krankenhaus Köln, Custodisstr. 3-17, 50679, Köln, Deutschland.
- Department Medizin, Danube Private University, Krems, Österreich.
| | - Maximilian Knopf
- Department Medizin, Danube Private University, Krems, Österreich
| | - Jil Marie Jubel
- Klinik und Poliklinik für Dermatologie und Allergologie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Hannah Herbst
- Department Medizin, Danube Private University, Krems, Österreich
| | - Moritz Antonie
- Department Medizin, Danube Private University, Krems, Österreich
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Gagnon D, Mouallem M, Leduc S, Rouleau DM, Chapleau J. A systematic scoping review of the latest data on orthobiologics in the surgical treatment of non-union. Orthop Traumatol Surg Res 2024:103896. [PMID: 38663743 DOI: 10.1016/j.otsr.2024.103896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 04/02/2024] [Accepted: 04/18/2024] [Indexed: 05/03/2024]
Abstract
INTRODUCTION Recent studies have shown a growing concern regarding the cost-effectiveness and the lack of supporting data for the biologic agents that are being increasingly used in the orthopedic field. Our aim was to conduct a systematic scoping review of recent publications (last five years) on the use of orthobiologics to treat fracture non-union and summarize the latest available data. PATIENTS AND METHODS The inclusion criteria for this review were articles published in English, from 2016 to 2022, and focusing on the use of orthobiologics for the surgical treatment of non-union. Searches were conducted in March 2023 using Pubmed/MEDLINE and Embase. Studies on spinal fusion or gene therapy were excluded. Reviews, case reports with five cases or less, conference proceedings, preliminary reports, pediatric or non-human studies were excluded as well. RESULTS The search found 1807 articles, 15 were eligible after PRISMA checklist and exclusions. The evidence was heterogenous and there was only one level II RCT. Recent data suggests that bone morphogenic protein (BMP-2) products could be effective for septic and aseptic tibial non-unions. However, the evidence was not conclusive regarding BMP-7, plasma rich platelets (PRP), stem cells or demineralized bone matrix (DBM). DISCUSSION Every non-union case is different in terms of bone defect, biology, mechanical stability, surgical technique and host factors, which contributes to the conflicting reports on the efficacy of orthobiologics in the literature. We might never see a level 1, high powered and robust study defining the efficacy, safety profile and cost-effectiveness of such products. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- David Gagnon
- Faculty of Medicine, Université de Montréal, 2900 boulevard Edouard-Montpetit, Montreal, QC. H3T 1J4, Canada
| | - Maya Mouallem
- Faculty of Medicine, Université de Montréal, 2900 boulevard Edouard-Montpetit, Montreal, QC. H3T 1J4, Canada
| | - Stéphane Leduc
- Faculty of Medicine, Université de Montréal, 2900 boulevard Edouard-Montpetit, Montreal, QC. H3T 1J4, Canada; Department of orthopedic surgery, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, C2095-5400 Boul. Gouin O., Montreal, QC. H4J 1C5, Canada
| | - Dominique M Rouleau
- Faculty of Medicine, Université de Montréal, 2900 boulevard Edouard-Montpetit, Montreal, QC. H3T 1J4, Canada; Department of orthopedic surgery, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, C2095-5400 Boul. Gouin O., Montreal, QC. H4J 1C5, Canada
| | - Julien Chapleau
- Faculty of Medicine, Université de Montréal, 2900 boulevard Edouard-Montpetit, Montreal, QC. H3T 1J4, Canada; Department of orthopedic surgery, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, C2095-5400 Boul. Gouin O., Montreal, QC. H4J 1C5, Canada.
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Yokoyama Y, Furuhata R, Tanji A, Fujita S. Osteosynthesis using scorpion plate for nonunion of distal clavicle fracture with small distal bone fragment: A case report. Trauma Case Rep 2023; 48:100953. [PMID: 37876980 PMCID: PMC10590729 DOI: 10.1016/j.tcr.2023.100953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 10/26/2023] Open
Abstract
Distal clavicle nonunion is a relatively common complication of unstable, displaced distal clavicle fractures; however, its standard surgical procedure has not been fully established. We describe a case of symptomatic nonunion of a distal clavicle fracture with a very small distal bone fragment that was treated with a scorpion plate. A 63-year-old man presented with left shoulder pain after a bicycle fall 5 months earlier. Plain radiographs and computed tomography revealed atrophic nonunion of the distal clavicle with a small distal bone fragment measuring 12 mm in length. Shoulder pain interfered with his work and daily life; therefore, we scheduled surgery. After releasing the nonunion site, cancellous bone was grafted from the iliac crest. We placed a scorpion plate with two grasping arms that fixed the distal clavicular fragment without straddling the acromioclavicular joint. One year postoperatively, his pain subsided, and bone union was confirmed. Our case presents a surgical procedure for treating the nonunion of distal clavicle fractures using a scorpion plate and an autologous bone graft. This procedure is especially beneficial for cases with small distal bone fragments, because the grasping arms of the scorpion plate allow secure fixation of the distal bone fragment and bone graft without further fragmentation.
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Affiliation(s)
- Yuya Yokoyama
- Department of Orthopaedic Surgery, Ashikaga Red Cross Hospital, Ashikaga-shi, Tochigi, Japan
| | - Ryogo Furuhata
- Department of Orthopaedic Surgery, Ashikaga Red Cross Hospital, Ashikaga-shi, Tochigi, Japan
| | - Atsuhi Tanji
- Department of Orthopaedic Surgery, Ashikaga Red Cross Hospital, Ashikaga-shi, Tochigi, Japan
| | - Shota Fujita
- Department of Orthopaedic Surgery, Ashikaga Red Cross Hospital, Ashikaga-shi, Tochigi, Japan
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Hochreiter B, Saager LV, Zindel C, Calek AK, Stern C, Wieser K, Gerber C. Computer-assisted planning vs. conventional surgery for the correction of symptomatic mid-shaft clavicular nonunion and malunion. JSES Int 2023; 7:2321-2329. [PMID: 37969529 PMCID: PMC10638583 DOI: 10.1016/j.jseint.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
Background The aim of this study was to compare the clinical and radiographic outcomes of treatment of symptomatic mal- and/or nonunion of midshaft clavicle fractures using radiographically based free-hand open reduction and internal fixation (ORIF) or computer-assisted 3D-planned, personalized corrective osteotomies performed using patient-specific instrumentation (PSI) and ORIF. The hypotheses were that (1) patients treated with computer-assisted planning and PSI would have a better clinical outcome, and (2) computer-assisted surgical planning would achieve a more accurate restoration of anatomy compared to the free-hand technique. Methods Between 1998 and 2020, 13 patients underwent PSI, and 34 patients underwent free-hand ORIF and/or corrective osteotomy. After application of exclusion criteria, 12/13 and 11/34 patients were included in the study. The clinical examination included measurement of the active range of motion and assessment of the absolute and relative Constant-Murley Scores and the subjective shoulder value. Subjective satisfaction with the cosmetic result was assessed on a Likert scale from 0 to 100 (subjective aesthetic value). 11/13 and 6/11 patients underwent postoperative computed tomography evaluation of both clavicles. Computed tomography scans were segmented to generate 3D surface models. After projection onto the mirrored contralateral side, displacement analysis was performed. Finally, bony union was documented. The average follow-up time was 43 months in the PSI and 50 months in the free-hand cohort. Results The clinical outcomes of both groups did not differ significantly. Median subjective shoulder value was 97.5% (70; 100) in the PSI group vs. 90% (0; 100) in the free-hand group; subjective aesthetic value was 86.4% (±10.7) vs. 75% (±18.7); aCS was 82.3 (±10.3) points vs. 74.9 (±26) points; and rCS was 86.7 (±11.3) points vs. 81.9 (±28.1) points. In the free-hand group, 2/11 patients had a postoperative neurological complication. In the PSI cohort, the 3D angle deviation was significantly smaller (PSI/planned vs. free-hand/contralateral: 10.8° (3.1; 23.8) vs. 17.4° (11.6; 42.4); P = .020)). There was also a trend toward a smaller 3D shift, which was not statistically significant (PSI/planned vs. free-hand/contralateral: 6 mm (3.4; 18.3) vs. 9.3 mm (5.1; 18.1); P = .342). There were no other significant differences. A bony union was achieved in all cases. Conclusion Surgical treatment of nonunion and malunions of the clavicle was associated with very good clinical results and a 100% union rate. This study, albeit in a relatively small cohort with a follow-up of 4 years, could not document any clinically relevant advantage of 3D planning and personalized operative templating over conventional radiographic planning and free-hand surgical fixation performed by experienced surgeons.
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Affiliation(s)
- Bettina Hochreiter
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Laura Victoria Saager
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christoph Zindel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Anna-Katharina Calek
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christoph Stern
- Department of Radiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Karl Wieser
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Christian Gerber
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Balgrist Campus, Orthopaedic Research Center, Zürich, Switzerland
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deMeireles AJ, Czerwonka N, Levine WN. Clavicle Nonunion and Malunion: Surgical Interventions for Functional Improvement. Clin Sports Med 2023; 42:663-675. [PMID: 37716729 DOI: 10.1016/j.csm.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Clavicle nonunion and malunion are relatively uncommon but, when symptomatic, can result in pain and dysfunction that requires surgical intervention. Various reconstructive and grafting techniques are available to achieve stable fixation and union. In the setting of persistent nonunion, vascularized bone grafting may be necessary. A thorough understanding of the patient's type of nonunion and potential for healing is crucial for achieving satisfactory results because is thoughtful preoperative planning and surgical fixation.
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Affiliation(s)
- Alirio J deMeireles
- Department of Orthopedic Surgery, Columbia University Irving Medical Center-NewYork Presbyterian Hospital, New York, NY, USA
| | - Natalia Czerwonka
- Department of Orthopedic Surgery, Columbia University Irving Medical Center-NewYork Presbyterian Hospital, New York, NY, USA
| | - William N Levine
- Department of Orthopedic Surgery, Columbia University Irving Medical Center-NewYork Presbyterian Hospital, New York, NY, USA.
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Sliepen J, Hoekstra H, Onsea J, Bessems L, Depypere M, Noppe N, Herteleer M, Sermon A, Nijs S, Vranckx JJ, Metsemakers WJ. Treatment and outcome of fracture-related infection of the clavicle. Injury 2023; 54:110910. [PMID: 37421837 DOI: 10.1016/j.injury.2023.110910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/16/2023] [Accepted: 06/18/2023] [Indexed: 07/10/2023]
Abstract
INTRODUCTION The number of operatively treated clavicle fractures has increased over the past decades. Consequently, this has led to an increase in secondary procedures required to treat complications such as fracture-related infection (FRI). The primary objective of this study was to assess the clinical and functional outcome of patients treated for FRI of the clavicle. The secondary objectives were to evaluate the healthcare costs and propose a standardized protocol for the surgical management of this complication. METHODS All patients with a clavicle fracture who underwent open reduction and internal fixation (ORIF) between 1 January 2015 and 1 March 2022 were retrospectively evaluated. This study included patients with an FRI who were diagnosed and treated according to the recommendations of a multidisciplinary team at the University Hospitals Leuven, Belgium. RESULTS We evaluated 626 patients with 630 clavicle fractures who underwent ORIF. In total, 28 patients were diagnosed with an FRI. Of these, eight (29%) underwent definitive implant removal, five (18%) underwent debridement, antimicrobial treatment and implant retention, and fourteen patients (50%) had their implant exchanged in either a single-stage procedure, a two-stage procedure or after multiple revisions. One patient (3.6%) underwent resection of the clavicle. Twelve patients (43%) underwent autologous bone grafting (tricortical iliac crest bone graft (n = 6), free vascularized fibular graft (n = 5), cancellous bone graft (n = 1)) to reconstruct the bone defect. The median follow-up was 32.3 (P25-P75: 23.9-51.1) months. Two patients (7.1%) experienced a recurrence of infection. The functional outcome was satisfactory, with 26 out of 28 patients (93%) having full range of motion. The median healthcare cost was € 11.506 (P25-P75: € 7.953-23.798) per patient. CONCLUSION FRI is a serious complication that can occur after the surgical treatment of clavicle fractures. In our opinion, when treated adequately using a multidisciplinary patient-specific approach, the outcome of patients with an FRI of the clavicle is good. The median healthcare costs of these patients are up to 3.5 times higher compared to non-infected operatively treated clavicle fractures. Although not studied individually, we consider factors such as the size of the bone defect, condition of the soft tissue, and patient demand important when it comes to guiding our surgical decision making in cases of osseous defects.
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Affiliation(s)
- Jonathan Sliepen
- University Medical Center Groningen, Department of Trauma Surgery, University of Groningen, 9713 GZ Groningen, The Netherlands; University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium
| | - Harm Hoekstra
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Jolien Onsea
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Laura Bessems
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Melissa Depypere
- University Hospitals Leuven, Department of Laboratory Medicine, 3000 Leuven, Belgium
| | - Nathalie Noppe
- University Hospitals Leuven, Department of Radiology, 3000 Leuven, Belgium
| | - Michiel Herteleer
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - An Sermon
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium
| | - Stefaan Nijs
- University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Jan J Vranckx
- University Hospitals Leuven, Department of Plastic and Reconstructive Surgery, 3000 Leuven, Belgium
| | - Willem-Jan Metsemakers
- University Hospitals Leuven, Department of Trauma Surgery, 3000 Leuven, Belgium; KU Leuven, University of Leuven, Department of Development and Regeneration, 3000 Leuven, Belgium.
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van der Burg FA, Baltes TP, Kloen P. Large segmental defects in midshaft clavicle nonunion treated with autologous tricortical iliac crest bone graft. Shoulder Elbow 2023; 15:45-53. [PMID: 36895606 PMCID: PMC9990112 DOI: 10.1177/17585732211064815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/05/2021] [Accepted: 11/07/2021] [Indexed: 11/16/2022]
Abstract
Background To evaluate the use of intercalary iliac crest bone graft in the treatment of clavicle nonunion with a large segmental bone defect (3-6 cm). Methods This retrospective study evaluated patients with large segmental bone defects (3-6 cm) after clavicle nonunion, treated with open reposition internal fixation and iliac crest bone graft between February 2003 and March 2021. At follow-up the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was administered. A literature search was performed to provide an overview of commonly used graft types per defect size. Results We included five patients treated with open reposition internal fixation and iliac crest bone graft for clavicle nonunion with a median defect size of 3.3 cm (range 3-6 cm). Union was achieved in all five, and all pre-operative symptoms resolved. The median DASH score was 23 out of 100 (IQR 8-24). An extensive literature search revealed that there are no studies describing the use of an used iliac crest graft for defects larger than 3 cm. Instead, a vascularized graft was typically used to treat defects sizes between 2.5 and 8 cm. Discussion An autologous non-vascularized iliac crest bone graft can be safely used and is reproducible to treat a midshaft clavicle non-union with a bone defect between 3 and 6 cm.
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Affiliation(s)
- Fleur Ae van der Burg
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, The Netherlands
| | - Thomas Pa Baltes
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, The Netherlands
| | - Peter Kloen
- Department of Orthopaedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, The Netherlands
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Yetter T, Harper J, Weatherby PJ, Somerson JS. Complications and Outcomes After Surgical Intervention in Clavicular Nonunion: A Systematic Review. JBJS Rev 2023; 11:01874474-202301000-00012. [PMID: 36722838 DOI: 10.2106/jbjs.rvw.22.00171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Thomas Yetter
- John Sealy School of Medicine, The University of Texas Medical Branch, Galveston, Texas
| | - Jacob Harper
- John Sealy School of Medicine, The University of Texas Medical Branch, Galveston, Texas
| | - Paul J Weatherby
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
| | - Jeremy S Somerson
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
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Fox B, Clement ND, MacDonald DJ, Robinson M, Nicholson JA. Plate fixation of midshaft clavicle fractures for delayed union and non-union is a cost-effective intervention but functional deficits persist at long-term follow-up. Shoulder Elbow 2022; 14:360-367. [PMID: 35846398 PMCID: PMC9284296 DOI: 10.1177/1758573221990367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/27/2020] [Accepted: 12/31/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The primary aim of this study was to compare the long-term functional outcome of midshaft clavicle fracture fixation for delayed (≥3 month) and non-union (≥6 month) compared to a matched cohort of patients that achieved union with non-operative management. The secondary aim was to assess cost-effectiveness of fixation. METHODS A consecutive series of patients over 10-years were retrospectively reviewed using the QuickDASH, Oxford Shoulder Score and EuroQol five-dimension summary index (EQ-5D). These patients were compared to a matched cohort that achieved union after non-operative management using propensity score matching. RESULTS Sixty patients (follow-up 79%, n = 60/76) at 4.1 years post-operative (1.1-10.0 years) had a QuickDASH of 16.5 (95% CI 11.6-21.5), Oxford Shoulder Score 41.5 (39.0-44.1) and EQ-5D 0.7621 (0.6822-0.8421). One in five patients were dissatisfied with their final outcome (n = 13/60). Functional outcome was inferior following fixation when compared to patients that united with non-operative management (QuickDASH 16.5 vs. 5.5, p < 0.001 and EQ-5D 0.7621 vs. 0.9073, p = 0.001). However, significant improvements were found when compared to pre-operative scores (QuickDASH p < 0.001 and EQ-5D p < 0.001). The cost per QALY for fixation was £5624.62 for the study cohort. CONCLUSIONS Clavicle fixation for delayed and non-union is a cost-effective intervention but outcomes are worse compared to patients that unite with non-operative management.
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Affiliation(s)
- Ben Fox
- Jamie A Nicholson, Department of Trauma and
Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.
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Safe and Effective Treatment of Compromised Clavicle Fracture of the Medial and Lateral Third Using Focused Shockwaves. J Clin Med 2022; 11:jcm11071988. [PMID: 35407594 PMCID: PMC8999686 DOI: 10.3390/jcm11071988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 03/27/2022] [Accepted: 03/31/2022] [Indexed: 11/17/2022] Open
Abstract
A delay or failure to heal is the most common possible complication in clavicle fractures, especially in cases primarily treated conservatively. As the current standard therapy, surgical revision achieves good healing results, but is associated with potential surgery-related complications. Shockwave therapy as a non-invasive therapy shows similar reasonable consolidation rates in the non-union of different localizations, but avoids complications. Compromised clavicle fractures in the middle and lateral third treated with focused high-energy shockwave therapy were compared with those treated with surgical revision (ORIF). In addition, a three-dimensional computer simulation for evaluating the pressure distribution during shockwave application accompanied the clinical study. A comparable healing rate in bony consolidation was achieved in both groups. Significantly fewer complications, however, occurred in the shockwave group. The simulations showed safe application in this instance, particularly in avoiding lung tissue affection. When applied correctly, shockwaves represent a safe and promising therapy option for compromised clavicle fractures in the middle and lateral third.
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