Intrinsic and extrinsic risk factors for nonunion after nonoperative treatment of midshaft clavicle fractures

Multicenter, Prospective, Observational Study of Nonoperative Versus Operative Treatment for High-Energy Midshaft Clavicle Fractures

OBJECTIVES

Evaluate if nonoperative or operative treatment of displaced clavicle fractures delivers reduced rates of nonunion and improved Disability of the Arm, Shoulder, and Hand (DASH) scores.

METHODS

DESIGN

Multicenter, prospective, observational.

SETTING

Seven Level 1 Trauma Centers in the United States.

PATIENT SELECTION CRITERIA

Adults with closed, displaced (100% displacement/shortened >1.5 cm) midshaft clavicle fractures (Orthopaedic Trauma Association 15.2) were treated nonoperatively, with plates and screw fixation, or with intramedullary fixation from 2003 to 2018.

OUTCOME MEASURES AND COMPARISONS

DASH scores (2, 6 weeks, 3, 6, 12, and 24 months), reoperation, and nonunion were compared between the nonoperative, plate fixation, and intramedullary fixation groups.

RESULTS

Four hundred twelve patients were enrolled, with 203 undergoing plate fixation, 26 receiving intramedullary fixation, and 183 treated nonoperatively. The average age of the nonoperative group was 40.1 (range 18-79) years versus 35.8 (range 18-74) in the plate group and 39.3 (range 19-56) in the intramedullary fixation group (P = 0.06). One hundred forty (76.5%) patients in the nonoperative group were male compared with 154 (75.9%) in the plate group and 18 (69.2%) in the intramedullary fixation group (P = 0.69). All groups showed similar DASH scores at 2 weeks, 12 months, and 24 months (P > 0.05). Plate fixation demonstrated better DASH scores (median = 20.8) than nonoperative (median = 28.3) at 6 weeks (P = 0.04). Intramedullary fixation had poorer DASH scores at 6 weeks, 3 months, and 6 months than plate fixation and worse DASH scores than nonoperative at 6 months (P < 0.05). The nonunion rate for nonoperative treatment (14.6%) was significantly higher than the plate group (0%) (P < 0.001).

CONCLUSIONS

Operative treatment of displaced clavicle fractures provided lower rates of nonunion than nonoperative treatment. Except at 6 weeks, no difference was observed in DASH scores between plate fixation and nonoperative treatment. Intramedullary fixation resulted in worse DASH scores than plate fixation at 6 weeks, 3 months, and 6 months and worse DASH scores than nonoperative at 6 months. Implant removal was the leading reason for reoperation in the plate and intramedullary fixation groups, whereas surgery for nonunion was the primary reason for surgery in the nonoperative group.

LEVEL OF EVIDENCE

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

Dual Versus Single Plate Fixation of Displaced Midshaft Clavicle Fractures: A Cost-Effectiveness Analysis

BACKGROUND

Prior studies have highlighted lower rates of reoperation if fixation of a displaced midshaft clavicle fracture is performed with dual plating (DP) compared with single plating (SP). Despite higher initial costs associated with the DP construct, the observed reduction in secondary surgeries compared with the SP construct may make it a more cost-effective treatment option. The objective of this study was to assess the cost-effectiveness of DP compared with SP in patients with operatively indicated displaced midshaft clavicle fractures.

METHODS

We developed a decision tree to model the occurrence of postoperative complications (acute hardware complications, wound healing issues, deep infection, nonunion, and symptomatic hardware) associated with secondary surgeries. Complication-specific risk estimates were pooled for both plating techniques using the available literature. The time horizon was 2 years, and the analysis was conducted from the health-care payer's perspective. The costs were estimated using direct medical costs, and the benefits were measured in quality-adjusted life-years (QALYs). We assumed that DP would be $300 more expensive than SP initially. We conducted probabilistic and 1-way sensitivity analyses.

RESULTS

The model predicted reoperation in 6% of patients in the DP arm compared with 14% of patients in the SP arm. In the base case analysis, DP increased QALYs by 0.005 and costs by $71 per patient, yielding an incremental cost-effectiveness ratio (ICER) of $13,242 per QALY gained. The sensitivity analysis demonstrated that the cost-effectiveness of DP was driven by the cost of the index surgery, risk of symptomatic hardware, and nonunion complications with SP and DP. At a willingness-to-pay threshold of $100,000 per QALY gained, 95% of simulations suggested that DP was cost-effective compared with SP.

CONCLUSIONS

When indicated, operative management of displaced midshaft clavicle fractures using DP was found to be cost-effective compared with SP. Despite its higher initial hardware costs, DP fixation appears to offset its added costs with greater health utility via lower rates of reoperation and improved patient quality of life.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level II . See Instructions for Authors for a complete description of levels of evidence.

Less than 1.5cm shortening in clavicle midshaft fracture has long-term functional impact

INTRODUCTION

Mediolateral shortening is a risk in treatment of clavicle shaft fracture, and can lead to scapular dyskinesis and shoulder dysfunction. Many studies advocated surgical treatment if shortening exceeds 15mm.

HYPOTHESIS

Clavicle shaft shortening of less than 15mm has negative impact on shoulder function at more than 1 year's follow-up.

MATERIALS AND METHODS

A retrospective case-control comparative study was performed, with assessment by an independent observer. Clavicle length was measured on frontal radiographs showing both clavicles, and the ratio between the healthy and affected sides was calculated. Functional impact was assessed on Quick-DASH. Scapular dyskinesis was analyzed by global antepulsion on Kibler's classification. In total, 217 files were retrieved for a 6-year period. Clinical assessment was performed for 20 patients managed non-operatively and 20 patients managed by locking plate fixation, at a mean 37.5months' follow-up (range: 12-69months).

RESULTS

Mean Quick-DASH score was significantly higher in the non-operated group: 11.363 [0-50] versus 2.045 [0-11.36] (p=0.0092). Pearson ρ correlation between percentage shortening and Quick-DASH score was -0.3956 [95% CI: -0.6295; -0.0959] (p=0.012). Clavicle length ratio differed significantly between groups: operated group, +2.2% [-5.1%; +17%] for 0.34cm; non-operated group, -8.28% [-17.3%; -0.7%] for 1.38cm (p<0.0001). Shoulder dyskinesis was significantly more frequent non-operated patients: 10 versus 3 (p=0.018). A threshold of 1.3cm shortening was found for functional impact.

CONCLUSION

Restoring scapuloclavicular triangle length is an important aim in management of clavicular fracture. Surgery by locking plate fixation is therefore to be recommended in case of>8% radiological shortening (1.3cm) to avoid medium- and long-term complications in shoulder function.

LEVEL OF EVIDENCE

III; case-control study.

Influence of smoking on the healing of conservatively treated displaced midshaft clavicle fractures

Aims

Tobacco, in addition to being one of the greatest public health threats facing our world, is believed to have deleterious effects on bone metabolism and especially on bone healing. It has been described in the literature that patients who smoke are approximately twice as likely to develop a nonunion following a non-specific bone fracture. For clavicle fractures, this risk is unclear, as is the impact that such a complication might have on the initial management of these fractures.

Methods

A systematic review and meta-analysis were performed for conservatively treated displaced midshaft clavicle fractures. Embase, PubMed, and Cochrane Central Register of Controlled Trials (via Cochrane Library) were searched from inception to 12 May 2022, with supplementary searches in Open Grey, ClinicalTrials.gov, ProQuest Dissertations & Theses, and Google Scholar. The searches were performed without limits for publication date or languages.

Results

The meta-analysis included eight studies, 2,285 observations, and 304 events (nonunion). The random effects model predicted a pooled risk ratio (RR) of 3.68 (95% confidence interval 1.87 to 7.23), which can be considered significant (p = 0.003). It indicates that smoking more than triples the risk of nonunion when a fracture is treated conservatively.

Conclusion

Smoking confers a RR of 3.68 for developing a nonunion in patients with a displaced middle third clavicle fracture treated conservatively. We know that most patients with pseudarthrosis will have pain and a poor functional outcome. Therefore, patients should be informed of the significantly higher risks of nonunion and offered smoking cessation efforts and counselling. Moreover, surgery should be considered for any patient who smokes with this type of fracture.

An Institutional Standardised Protocol for the Treatment of Acute Displaced Midshaft Clavicle Fractures (ADMCFs): Conservative or Surgical Management for Active Patients?

BACKGROUND AND OBJECTIVES

The treatment of acute displaced midshaft clavicle fractures (ADMCFs) is still under debate. The aim of this study was to verify the effectiveness of our institutional protocol by comparing the clinical and radiographic outcomes of two groups of patients with ADMCFs treated operatively and non-operatively.

MATERIALS AND METHODS

active patients with a traumatic, isolated non-pathological ADMCF with at least 1-year clinical and radiographic follow up were included. Surgical treatment was performed in the cases where the residual displacement was higher than 140% after the application of a figure-of-eight bandage (F8-B). All other cases were treated conservatively with a F8-B. A total of 134 patients were enrolled and divided into two groups: surgical and conservative groups, with 59 and 75 patients, respectively. Radiological and clinical parameters were evaluated.

RESULTS

Good clinical (Constant-Murley Score, the Quick Disability of the Arm, Shoulder and Hand score, and VAS satisfaction) and radiographic outcomes (initial and residual shortening, initial and residual displacement) were obtained for ADMCFs in both groups. Multivariate analysis showed that patients treated conservatively had better clinical outcomes compared to surgically treated patients (p < 0.001). Return to sports was longer in those treated with surgery. Initial shortening was found to impact clinical outcomes as well as initial displacement. None of the patients showed signs of non-union in both groups.

CONCLUSIONS

Very good mid-term clinical results can be obtained in adult patients with ADMCFs, conservatively or operatively managed, by applying our institutional treatment protocol based on objective radiographic parameters evaluated in the ER.

The human clavicle's nutrient foramen's prevalence, number, location, and direction: A systematic review and meta-analysis

INTRODUCTION

The clavicle's nutrient foramen is a surrogate marker for its nutrient artery. Knowing its location may be useful for interpreting fractures and to avoid iatrogenic lesions. The aim of this review was to determine the prevalence, number, location, and direction of the nutrient foramen.

METHODS

Embase, Medline, PubMed, Scopus, and Web of Science were searched and supplemented by Google Scholar, hand-searching major anatomical journals, and the reference list of included studies (updated March 08, 2022). Titles and abstracts were screened for eligibility, and observational studies with quantitative data were included based on full text evaluation. Internal validity was assessed using the anatomical quality assessment tool. Pooled prevalence proportions were derived using a random effects DerSimonian-Laird model using the Freeman-Tukey double arcsine transformation with Miller's inverse back-transformation.

RESULTS

From 18,889 unique reports, 33 studies with 3760 clavicles and 3358 foramina were included. All studies suffered from untransparent reporting. The prevalence of the nutrient foramen was 97.75%, 95% confidence interval 94.70%-99.60%. It was mainly found as a single foramen on the middle third segment's posterior surface with acromial (lateral) obliquity. Results were stable over time, robust to sensitivity analyses, albeit limited by unexplained heterogeneity and asymmetry.

CONCLUSION

This review may aid in interpreting fractures passing through a high-risk area (mean foraminal index range 36.31-61.03%) for lesions to the nutrient artery. Practical implications are a need to update current inaccurate textbook descriptions and further advocate evidence-based anatomy to improve conduct and reporting of anatomical research.

Risk factors for complications and reoperation following operative management of displaced midshaft clavicle fractures

BACKGROUND

Optimal management of a displaced midshaft clavicle fracture remains controversial. This study assessed demographic factors, fracture pattern, and surgical technique as potential predictors of surgical complications. Smoking, diabetes, obesity, polytrauma, high-energy mechanism, inpatient status, transverse or comminuted fractures, and single-plating technique were hypothesized to be associated with an increased risk of complications following clavicle fracture open reduction internal fixation (ORIF).

METHODS

Consecutive patients with minimum 12-week follow-up from the trauma and sports medicine divisions at a single tertiary institution who presented with a midshaft clavicle fracture and underwent ORIF between 2007 and 2020 were retrospectively identified. Patient demographics, fracture pattern, plating technique, and postoperative complications were recorded. Postoperative complications were classified into major (reoperation) and minor (no reoperation) complications. Chi-squared statistics, Fisher's exact test, analysis of variance, Kruskal-Wallis test, and multivariate logistic regression modeling were utilized with a significance level set to P < .05.

RESULTS

One hundred ninety-eight patients (average = 39.5 ± 14.6 years) were identified with an average follow-up of 9.1 ± 10.7 months. The cohort consisted of 155 males (78.3%), 62 smokers (31.3%), and 12 diabetics (6.1%). Injury characteristics revealed 80 transverse fractures (40.4%), 87 oblique fractures (43.9%), and 31 Z-type fractures (15.7%). Seventy-nine patients (39.9%) underwent superior plating, 72 (36.4%) underwent anterior plating, and 47 (23.7%) underwent dual plating. Overall, postoperative complications occurred in 47 patients (23.7%), 29 minor (14.6%) and 18 major (9.1%). Major complications requiring reoperation were symptomatic hardware, nonunion, deep infection, wound dehiscence, and broken hardware. Minor complications consisted of sensory deficit or paresthesia beyond peri-incisional numbness, superficial infections, postoperative pain and/or stiffness, and delayed union. Smoking status (P = .008), obesity (P = .009), and transverse or Z-type fractures (P = .002) were significant prognostic factors for overall complication risk. Only manual labor was predictive of minor complications (P = .019). Transverse or Z-type fractures and single plating were predictive of major complications (P = .004 and P = .008, respectively). No reoperations occurred in patients who underwent dual plating. Smokers (P = .027) with transverse/Z-type fractures (P = .022) were at the highest risk of reoperation with single plating.

CONCLUSION

The overall rate of complications following ORIF of displaced midshaft clavicle fracture was 27.3%, with 9.1% requiring reoperation. Given relatively high complication rates, in instances when nonoperative vs. operative management is equivocal, nonoperative management should be strongly considered in obese patients, smokers, and patients who present with transverse or Z-type fracture. If operative management is indicated, use of dual plating may decrease reoperation rates.

Management of Displaced Midshaft Clavicle Fractures with Figure-of-Eight Bandage: The Impact of Residual Shortening on Shoulder Function

The treatment of displaced midshaft clavicle fractures (MCFs) is still controversial. The aims of our study were to evaluate clinical and radiological outcomes and complications of patients with displaced MCFs managed nonoperatively and to identify potential predictive factors of worse clinical outcomes. Seventy-five patients with displaced MCFs were enrolled and treated nonoperatively with a figure-of-eight bandage (F8-B). Initial shortening (IS) and displacement (ID) of fragments were radiographically evaluated at the time of diagnosis and immediately after F8-B application by residual shortening (RS) and displacement (RD). The clavicle shortening ratio was evaluated clinically at last follow-up. Functional outcomes were assessed using Constant (CS), q-DASH, DASH work and DASH sport scores. Cosmetic outcomes and rate of complications were evaluated. Good to very good mid-term clinical results were achieved by using the institutional treatment protocol. Multiple regression identified RS as an independent predictor of shoulder function, while RD affects fracture healing. These findings support the efficacy of our institutional protocol and thus could be useful for orthopedic surgeons during the decision-making process.

Fracture, nonunion and postoperative infection risk in the smoking orthopaedic patient: a systematic review and meta-analysis

This systematic review and meta-analysis aimed to analyse negative effects of smoking in orthopaedic and trauma patients.

A PubMed search was carried out for studies published until July 2020 regarding effects of smoking on fracture risk, nonunion, infection after orthopaedic surgery, and persisting nonunion after scaphoid nonunion surgery. Random effects models calculated for outcome parameters, and relative risks (RR) with 95% confidence intervals are provided. No adjustments for covariates were made. Heterogeneity was assessed with Higgins’ I2, publication bias with Harbord’s p (Hp), sensitivity analysis performed on funnel plots and quality of studies was analysed using the Newcastle-Ottawa Scale.

Of 3362 retrieved entries, 69 were included in the final analysis. Unadjusted RR for smokers to develop vertebral (six studies, seven entries; RR: 1.61; p = 0.008; I2 = 89.4%), hip (11 studies, 15 entries; RR: 1.28; p = 0.007; I2 = 84.1%), and other fractures (eight studies, 10 entries; RR: 1.75; p = 0.019; I2 = 89.3%) was significantly higher. Postoperative infection risk was generally higher for smokers (21 studies; RR: 2.20; p < 0.001; I2 = 58.9%), and remained upon subgroup analysis for elective spinal (two studies; RR: 4.38; p < 0.001; I2 = 0.0%) and fracture surgery (19 studies; RR: 2.10; p < 0.001; I2 = 58.5%). Nonunion risk after orthopaedic (eight studies; RR: 2.15; p < 0.001; I2 = 35.9%) and fracture surgery (11 studies; RR: 1.85; p < 0.001; I2 = 39.9%) was significantly higher for smokers, as was persisting nonunion risk after surgery for scaphoid nonunion (five studies; RR: 3.52; p < 0.001; I2 = 0.0%). Sensitivity analysis for each model reduced heterogeneity whilst maintaining significance (all I2 < 20.0%).

Smoking has a deleterious impact on fracture incidence, and (subsequent) development of nonunions and postoperative infections.

Cite this article: EFORT Open Rev 2021;6:1006-1019. DOI: 10.1302/2058-5241.6.210058

Factors Associated With Surgical Treatment of Isolated, Displaced Midshaft Clavicle Fractures

Given the current available evidence, surgical treatment of isolated, displaced midshaft clavicle fractures is discretionary. The aim of this study was to determine whether there are identifiable factors associated with the surgical treatment of isolated, displaced midshaft clavicle fractures. A retrospective cohort study of 150 patients who underwent nonoperative treatment and 290 patients who underwent surgical treatment of isolated, displaced midshaft clavicle fractures from January 2010 to March 2019 at 2 level I trauma centers was performed. Multivariable regression analysis demonstrated that younger age (odds ratio [OR], 0.97; 95% CI, 0.95-0.99), absence of diabetes mellitus (OR, 0.045; 95% CI, 0.003-0.79), nonsmoking status (OR, 0.31; 95% CI, 0.13-0.75), higher American Society of Anesthesiologists classification (OR, 5.0; 95% CI, 2.7-9.2), fracture comminution (OR, 2.3; 95% CI, 1.3-3.9), and fracture displacement (OR, 1.1; 95% CI, 1.0-1.1) were associated with surgical treatment of an isolated, displaced midshaft clavicle fracture. Furthermore, lower social deprivation (OR, 0.99; 95% CI, 0.97-0.99) and private insurance compared with Medicare (OR, 6.6; 95% CI, 1.6-27) were associated with surgical treatment. The authors conclude that surgical treatment of discretionary midshaft clavicle fractures is influenced by patient factors, fracture characteristics, and socioeconomic factors. Further study is needed to understand the etiology of social disparities in clavicle surgery and rectify unintended trends in treatment. [Orthopedics. 2021;44(4):e515-e520.].

Surgical Treatment of Comminuted Midshaft Clavicle Fracture by Minimally Invasive Technique: Description and Preliminary Results

Objective  The present paper aimed to evaluate functional and radiographic outcomes from a group of patients with comminuted midshaft clavicle fracture who were surgically treated using a minimally invasive technique and followed-up for a minimum period of 12 months. Methods  Longitudinal, observational study with 32 consecutive patients (31 males; mean age, 41 years old) with comminuted midshaft clavicle fracture who were surgically treated using the minimally invasive osteosynthesis technique with a 3.5-mm reconstruction plate in the upper position. Patients were clinically and radiologically evaluated for a minimum follow-up period of 12 months. Results  In 30 patients (93.72%), fracture consolidation occurred in an average time of 17 weeks (range, 12 to 24 weeks). The mean follow-up time was 21 months (range, 12 to 45 months). No implant break or pseudoarthrosis were recorded. There was no complaint of paresthesia around the surgical incisions. The surgically-treated shoulder presented lower passive elevation and longer clavicle length ( p  < 0.05) compared with the contralateral shoulder. Functional evaluation revealed an average Disability of Arm, Shoulder and Hand (DASH) score of 1.75, which is considered satisfactory. Age > 60 years old had a negative correlation with DASH score (p <0.05). Conclusion  The minimally invasive osteosynthesis technique was satisfactory for the treatment of comminuted midshaft clavicle fracture, with a high consolidation rate and a low complication rate.

Acute plate fixation of displaced midshaft clavicular fractures is not associated with earlier return of normal shoulder function when union is achieved

Aims

It is unclear whether acute plate fixation facilitates earlier return of normal shoulder function following a displaced mid-shaft clavicular fracture compared with nonoperative management when union occurs. The primary aim of this study was to establish whether acute plate fixation was associated with a greater return of normal shoulder function when compared with nonoperative management in patients who unite their fractures. The secondary aim was to investigate whether there were identifiable predictors associated with return of normal shoulder function in patients who achieve union with nonoperative management.

Methods

Patient data from a randomized controlled trial were used to compare acute plate fixation with nonoperative management of united fractures. Return of shoulder function was based on the age- and sex-matched Disabilities of the Arm, Shoulder and Hand (DASH) scores for the cohort. Independent predictors of an early recovery of normal shoulder function were investigated using a separate prospective series of consecutive nonoperative displaced mid-shaft clavicular fractures recruited over a two-year period (aged ≥ 16 years). Patient demographics and functional recovery were assessed over the six months post-injury using a standardized protocol.

Results

Data from the randomized controlled trial consisted of 86 patients who underwent operative fixation compared with 76 patients that united with nonoperative treatment. The recovery of normal shoulder function, as defined by a DASH score within the predicted 95% confidence interval for each respective patient, was similar between each group at six weeks (operative 26.7% vs nonoperative 25.0%, p = 0.800), three months (52.3% vs 44.2%, p = 0.768), and six months post-injury (86.0% vs 90.8%, p = 0.349). The mean DASH score and return to work were also comparable at each timepoint. In the prospective cohort, 86.5% (n = 173/200) achieved union by six months post-injury (follow-up rate 88.5%, n = 200/226). Regression analysis found that no specific patient, injury, or fracture predictor was associated with an early return of function at six or 12 weeks.

Conclusion

Return of normal shoulder function was comparable between acute plate fixation and nonoperative management when union was achieved. One in two patients will have recovery of normal shoulder function at three months, increasing to nine out of ten patients at six months following injury when union occurs, irrespective of initial treatment.

Cite this article: Bone Jt Open 2021;2(7):522–529.

The emergency medicine management of clavicle fractures

BACKGROUND

Clavicle fractures are common. An emergency physician needs to understand the diagnostic classifications of clavicle fractures, have a plan for immobilization, identify associated injuries, understand the difference between treating pediatric and adult patients, and have an approach to multimodal pain control. It is also important to understand when expert orthopedic consultation or referral is indicated.

OBJECTIVE OF THE REVIEW

To provide an evidence-based review of clavicle fracture management in the emergency department.

DISCUSSION

Clavicle fractures account for up to 4% of all fractures evaluated in the emergency department. They can be separated into midshaft, distal, and proximal fractures. They are also classified in terms of their degree of displacement, comminution and shortening. Emergent referral is indicated for open fractures, posteriorly displaced proximal fractures, and those with emergent associated injuries. Urgent referral is warranted for fractures with greater than 100% displacement, fractures with >2 cm of shortening, comminuted fractures, unstable distal fractures, and floating shoulder. Nondisplaced or minimally displaced fractures with no instability or associated neurovascular injury are managed non-operatively with a sling. Pediatric fractures are generally managed conservatively, with adolescents older than 9 years-old for girls and 12 years-old for boys being treated using algorithms that are similar to adults.

CONCLUSIONS

When encountering a patient with a clavicle fracture in the emergency department the fracture pattern will help determine whether emergent consultation or urgent referral is indicated. Most patients can be discharged safely with sling immobilization and appropriate outpatient follow-up.

Displaced midshaft clavicle fractures in adults - is non-operative management enough?

INTRODUCTION

Displaced fractures of middle third of clavicle are traditionally managed non-operatively. Recently, the trend is towards surgical management considering functional deficits in some of the non-operatively managed patients. The purpose of the study was to examine the functional outcome of non-operative treatment in these injuries, while identifying the factors responsible for less than ideal outcome and determine the guidelines for patient counselling.

PATIENTS AND METHODS

One hundred patients with displaced fractures of middle third of clavicle were prospectively evaluated clinico-radiologically for one year from injury. Risk factors for non-union were determined using Fisher's exact test. Logistic regression was used to identify factors contributing to functional outcome. Threshold values for the radiological displacements were estimated with the smooth threshold regression using the logistic transition function.

RESULTS

Ninety-four out of 100 fractures united. The factors associated with non-union were: smoking, diabetes and poor soft tissue condition over the fracture. Ninety-two out of 94 patients who had their fractures united achieved "good" (Constant Score above 70) or "very good" (Constant Score above 85) functional outcome at one year, out of which only 49 belonged to "very good" category. The most important factors influencing functional outcome were fracture angulation and clavicular shortening. From the model, it was estimated that with one unit increase in degree of angulation or 1 mm increase in shortening, the odds of scoring above 85 reduces by around 14%. Based on this, an equation and a probability calculator were developed from which the probability of achieving a Constant Score above 85 can be calculated. Threshold analysis yielded 22.8° for angulation and 16.8 mm for shortening at which the probability of achieving "very good" function is only 0.23.

CONCLUSION

Displaced midshaft clavicular fractures with the intent of achieving "good" outcome must be managed non-operatively. If the patient expectation is not to accept even minor functional deficits, the treatment objective must be raised to achieve a minimum Constant score of 86. Substituting the radiological displacements in the equation, the probability of the patient achieving this objective can be calculated. Non-operative management is offered if this probability figure is acceptable to the patient, otherwise counselled for surgery. Non-operatively managed patients with coexisting diabetes, smoking or poor soft tissue condition must be watched for the possibility of going for non-union.

Sonographic bridging callus at six weeks following displaced midshaft clavicle fracture can accurately predict healing

AIMS

To evaluate if union of clavicle fractures can be predicted at six weeks post-injury by the presence of bridging callus on ultrasound.

METHODS

Adult patients managed nonoperatively with a displaced mid-shaft clavicle were recruited prospectively. Ultrasound evaluation of the fracture was undertaken to determine if sonographic bridging callus was present. Clinical risk factors at six weeks were used to stratify patients at high risk of nonunion with a combination of Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) ≥ 40, fracture movement on examination, or absence of callus on radiograph.

RESULTS

A total of 112 patients completed follow-up at six months with a nonunion incidence of 16.7% (n = 18/112). Sonographic bridging callus was detected in 62.5% (n = 70/112) of the cohort at six weeks post-injury. If present, union occurred in 98.6% of the fractures (n = 69/70). If absent, nonunion developed in 40.5% of cases (n = 17/42). The sensitivity to predict union with sonographic bridging callus at six weeks was 73.4% and the specificity was 94.4%. Regression analysis found that failure to detect sonographic bridging callus at six weeks was associated with older age, female sex, simple fracture pattern, smoking, and greater fracture displacement (Nagelkerke R2 = 0.48). Of the cohort, 30.4% (n = 34/112) had absent sonographic bridging callus in addition to one or more of the clinical risk factors at six weeks that predispose to nonunion. If one was present the nonunion rate was 35%, 60% with two, and 100% when combined with all three.

CONCLUSION

Ultrasound combined with clinical risk factors can accurately predict fracture healing at six weeks following a displaced midshaft clavicle fracture. Cite this article: Bone Joint Res 2021;10(2):113-121.

Factors Affecting Patient Decision-Making Regarding Midshaft Clavicle Fracture Treatment

Introduction Midshaft clavicle fractures are a common problem encountered by orthopedic surgeons. There remains debate between non-surgical and surgical treatment options for certain midshaft clavicle fractures. Due to the lack of a clear treatment strategy, this presents an opportunity for shared decision-making, which has been shown to be important to patients. Methods A 19-question survey was created encompassing basic demographic information, then taking respondents through a simulation of a midshaft clavicle fracture patient encounter. Subjects were subsequently asked their preferred treatment choice as well as shared decision-making preferences for the simulated encounter. A pilot study was performed with medical students from our home institution to assess study sample size. The survey was then distributed through an online software platform (Amazon Mechanical Turk). Statistical analysis was performed using STATA, Microsoft Excel, and Qualtrics. Results 253 subjects responded to the online survey. Over 70% of respondents had no to minimal knowledge of clavicle fractures and potential medical interventions/treatments. 67.6% of respondents preferred shared decision-making, over autonomous or paternalistic models. 45.5% of respondents wanted additional time outside the physician-patient consultation before making a treatment decision. A majority of the respondents who selected surgery (44.3%; 43/97) and no surgery (69.9%; 109/156), based their decisions on outcomes data provided in the simulation alone. There was no statistically significant relationship between income, race/ethnicity, education level, work status, sex, or type of visual fracture representation (i.e., radiograph vs. cartoon image) and treatment decision (p>0.05). Younger age (p=0.007) and being married (p=0.001) were associated with increased likelihood to select surgery as the treatment decision.  Conclusion Most respondents had no-to-minimal knowledge about clavicle fractures, placed a high value in shared decision-making for midshaft clavicle fractures, and prioritized outcomes data in making treatment decisions. Younger age and marital status may increase the likelihood of a patient selecting to proceed with surgery over non-operative treatment.

Posttraumatic Pseudoarthrosis of a Clavicle Fracture in an 11-Year-Old Girl: A Case Report and Analysis

Clavicular fractures are some of the most common bone injuries in the paediatric population, yet the rates of nonunion are very low under 18 years. To the best of our knowledge, posttraumatic nonunion of the clavicle in a paediatric population is rarely reported. We report the case of an 11-year-old girl who presented with a nondislocated fracture of the midshaft to the proximal third of the right clavicle. Initial conservative treatment by sling immobilization demonstrated radiologically confirmed healing at 3 months. However, at 1-year follow-up, she presented with painful nonunion. Diagnostic MRI and CT exams confirmed a pseudoarthrosis, requiring elective open reduction and internal fixation with the aid of an ipsilateral iliac crest bone graft.

Displaced Midshaft Clavicle Fracture Union Can Be Accurately Predicted with a Delayed Assessment at 6 Weeks Following Injury: A Prospective Cohort Study

BACKGROUND

It is unclear if clinical recovery following a midshaft clavicle fracture can accurately predict fracture-healing. The additional information that can be assessed at 6 weeks after injury may have superior predictive value compared with information available at the time of the injury.

METHODS

A prospective study of all patients (≥16 years of age) who sustained a fully displaced midshaft clavicle fracture was performed. We assessed patient demographic characteristics, injury factors, functional scores, and radiographic predictors with a standardized protocol at 6 weeks. Conditional stepwise regression modeling was used to assess which factors independently predicted nonunion at 6 months after the injury as determined by computed tomography (CT). The nonunion predictor 6-week model was compared with a previously validated model based on factors available at the time of the injury, which included smoking, comminution, and fracture displacement.

RESULTS

At 6 months, 200 patients completed follow-up. The CT-defined nonunion rate was 14% (27 of 200). Of the functional scores, the QuickDASH (the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire) had the highest accuracy on receiver operator characteristic (ROC) curve analysis with a 39.8-point threshold, above which was associated with nonunion (area under curve [AUC], 76.8%; p < 0.001). Sixty-nine percent of the cohort had a QuickDASH score of <40 points at 6 weeks, and 95% (131 of 138) of these patients had fracture union. On regression modeling, a QuickDASH score of ≥40 points (p = 0.001), no callus on radiographs (p = 0.004), and fracture movement on examination (p = 0.001) were significant predictors of nonunion. If none were present, the predicted nonunion risk was 3%, found in 40% (80 of 200) of the cohort. Conversely, if ≥2 of the predictors were present, found in 23.5% of the cohort, the predicted nonunion risk was 60%. The nonunion predictor model at 6 weeks appeared to have superior accuracy (AUC, 87.3%) when compared with the nonunion predictor model at the time of injury (AUC, 64.8%) for fracture-healing on ROC curve analysis.

CONCLUSIONS

Delayed assessment at 6 weeks following displaced midshaft clavicle fracture enables an accurate prediction of patients who are likely to have union with nonoperative management. One in 4 patients are at an increased risk of nonunion and may benefit from operative intervention.

LEVEL OF EVIDENCE

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

Clinical Evaluation of the Surgical Treatment of Midshaft Clavicle Fractures at a Hospital in the South of Santa Catarina

Objective  To evaluate the results of the surgical treatment of fractures of the middle third of the clavicle. Methods  A retrospective cross-sectional study, in which 36 patients who suffered fractures of the middle third of the clavicle and who were surgically treated from January 2012 to February 2017 were evaluated. They were evaluated for types of fracture, age, smoking, osteosynthesis material, and Constant-Murley and Modified-University of California at Los Angeles Shoulder Rating Scale (UCLA-M) scores. Results  The mean Constant-Murley and UCLA-M scores were 91.59 and 31.29 respectively. The mean age was 37.62 years, and it was statistically related to the type of osteosynthesis ( p  < 0.05), but the osteosynthesis material did not show significance with the improvement in the rates of the functional scores. Conclusion  The surgical treatment provides good functional results after diaphyseal fractures of the clavicle, regardless of the line of the fracture, with a low rate of pseudarthrosis.

Midshaft Clavicle Fractures: Surgery Provides Better Results as Compared With Nonoperative Treatment: A Meta-analysis

BACKGROUND

There is no agreement on the best treatment for displaced midshaft clavicle fractures (MCFs), which are currently addressed by nonoperative or surgical approaches.

PURPOSE

To compare fracture healing and functional outcome after surgical versus nonsurgical treatment of MCFs, to help specialists in deciding between these different strategies by providing a synthesis of the best literature evidence.

STUDY DESIGN

Meta-analysis.

METHODS

A systematic research of the literature was performed in different online databases: PubMed, Web of Science, Cochrane library, and grey literature. PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines were used. The risk of bias was evaluated with the Cochrane Collaboration's "risk of bias" tool, and the quality of evidence was graded according to Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. Randomized controlled trials investigating differences between surgery and nonoperative treatment for displaced MCFs were included. The primary outcome was the nonunion rate. Other outcomes analyzed were time to union and to return to activities, Constant score, and Disabilities of the Arm, Shoulder and Hand (DASH) index. Patients' satisfaction, secondary operations, and complications were also recorded.

RESULTS

Out of 832 records found, 14 randomized controlled trials with 1546 patients were included. A significantly lower risk ratio was found for nonunion (10%; 95% CI, 6%-18%, P < .001) favoring surgery. Time to union was 5.1 weeks shorter with surgery (P = .007). The complication rate (including the number of reinterventions) was higher in the surgical group (31.3% vs 20.5%, P < .001). Shoulder function at short-term follow-up was significantly better in the surgical group (DASH index mean difference = 4.0 points), while no statistical difference was found in the Constant score and in the DASH index at midterm follow-up (P = .41 and .80, respectively). At long-term follow-up, both shoulder functional scores were significantly better in the surgery group: the overall Constant score mean difference was 5.3 points (95% CI, 2.3-8.4 points; P < .001), and the DASH index mean difference was 4.3 points (95% CI, 0.2-8.4 points; P = .04).

CONCLUSION

Surgical treatment of MCFs significantly reduces the nonunion rate and shortens the time to union as compared with the nonoperative approach and, despite a slightly higher incidence of complications, leads to better shoulder functional scores at short- and long-term follow-up. Further studies should address the clinical significance of the documented improvement.

Intramedullary Nailing and Minimally Invasive Percutaneous Plate Osteosynthesis in Treatment of Displaced Clavicular Mid-shaft Fractures: A Prospective Study

OBJECTIVE

To compare the difference between MIPO and IMN methods in the treatment of displaced clavicular mid-shaft fractures.

METHODS

A total 163 patients were consecutively enrolled and randomly divided into the MIPO group or the IMN group. Clinical characteristics and outcomes including age, gender, causes of fractures, and AO/OTA type as well as hospitalization time, healing time, and postoperative complications were analyzed. Constant-Murley scores and DASH scores were used for assessment of shoulder joint and upper extremity function, respectively.

RESULTS

In this study, 82 cases received MIPO and 81 cases received IMN. The mean operation time, mean bleeding volume, mean hospitalization time, and mean healing time showed no significant difference between the MIPO and IMN groups. At 3 months after surgery, Constant-Murley scores were significantly higher and DASH scores were significantly lower in the MIPO group than the IMN group. No significant difference was observed for both indexes at 6 months. The fracture nonunion rate was significantly lower in the MIPO group. No significant difference was found in other complications.

CONCLUSION

Both methods were effective for the treatment of displaced clavicular mid-shaft fractures. However, the MIPO method might be better for recovery of shoulder and upper extremity function in the short term and might have a lower nonunion rate.

Open reduction and internal fixation of clavicular fractures after a delay of three months is associated with an increased risk of complications and revision surgery

AIMS

The primary aim of this study was to determine if delayed clavicular fixation results in a greater risk of operative complications and revision surgery.

PATIENTS AND METHODS

A retrospective case series was undertaken of all displaced clavicular fractures that underwent plate fixation over a ten-year period (2007 to 2017). Patient demographics, time to surgery, complications, and mode of failure were collected. Logistic regression was used to identify independent risk factors contributing towards operative complications. Receiver operating characteristic (ROC) curve analysis was used to determine if a potential 'safe window' exists from injury to delayed surgery. Propensity score matching was used to construct a case control study for comparison of risk.

RESULTS

A total of 259 patients were included in the analysis. Postoperative infection occurred in 3.9% of all patients (n = 10); the only variable associated was a greater time interval from injury to fixation (p = 0.001). Failed primary surgery requiring revision fixation was required in 7.7% of the cohort (n = 20), with smoking (p < 0.001), presence of a postoperative infection (p < 0.001), increasing age (p = 0.018), and greater time delay from injury to surgery (p = 0.015) identified as significant independent predictors on regression analysis. ROC analysis revealed that surgery beyond 96 days from injury increased the rate of major complications and revision surgery. Using a matched case cohort of cases before (n = 67) and after (n = 77) the 'safe window', the risk of postoperative infection increased (odds ratio (OR) 7.7, 95% confidence interval (CI) 1.9 to 62.9; p = 0.028), fixation failure (OR 3.8, 95% CI 1.2 to 12.1; p = 0.017) and revision surgery (OR 4.8, 95% CI 1.5 to 15.0; p = 0.004).

CONCLUSION

A delay to primary fixation of up to three months following injury may be acceptable, beyond which there is an increased risk of major operative complications and revision surgery. Cite this article: Bone Joint J 2019;101-B:1385-1391.

Early clinical and radiographic outcomes of a mini-fragment, low profile plating system in tibial plafond fractures

OBJECTIVE

The Smith and Nephew mini-EVOS plating system is a mini-fragment, low profile, variable-angled plating system designed to obtain anatomic reduction while also minimizing soft tissue handling. However, literature has been limited in reporting the clinical and surgical outcomes of these specific plates. The goal of our study is to evaluate the safety and efficacy of the Smith and Nephew mini-EVOS plate in pilon fracture management, where significant high energy forces can result in severe fracture patterns and soft tissue injury.

METHODS

Patients 18-65 years of age who underwent plate fixation of their tibial plafond fractures (OTA/AO) using the Smith and Nephew mini-EVOS plating system at our urban university-based level-1 trauma center were included in this retrospective investigation. A total of 37 patients (37 fractures) from January 2015 to March 2018 were included in this study. Primary outcome measure was mechanical hardware failure. Secondary outcome measures included nonunion, malunion, medical and surgical complications.

RESULTS

The fractures were classified according to the OTA/AO classification as 43C1 (n = 15), 42C2 (n = 6), and 43C3 (n = 16). A mechanical failure was observed in three patients (8.1%). Six additional patients needed a re-operation of the surgical site including two nonunion repairs, one malunion repair, one symptomatic hardware removal, and two soft tissue debridements. The mean follow-up was 298.9 days (range: 96-936).

CONCLUSIONS

Early results of operative fixation of tibial plafond fractures using the Smith-Nephew mini-EVOS demonstrated low hardware failure and complication rates. This plating system is a safe and effective implant.

LEVEL OF EVIDENCE

Therapeutic Level IV.

[Clavicular fractures : Diagnostics, management and treatment]

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

Surgical treatment of mid-shaft clavicle fractures by minimally invasive internal fixation facilitated by intra-operative external fixation: A preliminary study

BACKGROUND

Mid-shaft clavicle fractures are common and may require surgery. The objective of this study in adults with high-risk mid-shaft clavicle fractures was to evaluate the clinical and radiological outcomes of a minimally invasive surgical technique involving a minimally invasive approach, fracture reduction, temporary intra-operative external fixation, and locking plate internal fixation.

HYPOTHESIS

This minimally invasive surgical technique for mid-shaft clavicle fractures ensures satisfactory radiographic fracture healing and medium-term functional outcomes, with a short immobilisation, rapid return to sports, and low complication rate.

MATERIAL AND METHOD

A retrospective review was performed of patients managed using our minimally invasive surgical technique between 1 January 2012 and 31 December 2016. The primary outcome measure was the 3-month radiographic healing rate. The secondary outcome measures were duration of post-operative immobilisation, 3- and 6-month QuickDASH scores, and post-operative complications.

RESULT

A total of 19 patients were included, 18 males and 1 female with a mean age of 37 years. Radiographic healing was consistently achieved within 3 months. Immobilisation duration was 3 weeks. The mean QuickDASH score was 23.75 after 3 months and 7.5 after 6 months. Return to sports occurred after 3 months. The only complication was transient paraesthesia in the distribution of the C8 nerve root in 1 patient.

DISCUSSION

The management of mid-shaft clavicle fractures remains controversial. The high complication rates associated with conventional surgical techniques make treatment decisions difficult. A surgical technique characterised by temporary intra-operative external fixation to facilitate minimally invasive internal fixation may have a lower complication rate and shorter immobilisation requirements compared to conventional surgery.

LEVEL OF EVIDENCE

IV, retrospective observational study.

Routine fixation of displaced midshaft clavicle fractures is not cost-effective: a cost analysis from a randomized controlled trial

AIMS

The primary aim of this study was to establish the cost-effectiveness of the early fixation of displaced midshaft clavicle fractures.

PATIENTS AND METHODS

A cost analysis was conducted within a randomized controlled trial comparing conservative management (n = 92) versus early plate fixation (n = 86) of displaced midshaft clavicular fractures. The incremental cost-effectiveness ratio (ICER) was used to express the cost per quality-adjusted life-year (QALY). The Six-Dimension Short-Form Health Survey (SF-6D) score was used as the preference-based health index to calculate the cost per QALY at 12 months after the injury.

RESULTS

The mean 12-month SF-6D was 0.9522 (95% confidence interval (CI) 0.9355 to 0.9689) following conservative management and 0.9607 (95% CI 0.9447 to 0.9767) following fixation, giving an advantage for fixation of 0.0085, which was not statistically significant (p = 0.46). The mean cost per patient was £1322.69 for conservative management and £5405.32 for early fixation. This gave an ICER of £480 309.41 per QALY. For a threshold of £20 000 per QALY, the benefit of fixation would need to be present for 24 years to be cost-effective compared with conservative treatment. Linear regression analysis identified nonunion as the only factor to adversely influence the SF-6D at 12 months (p < 0.001).

CONCLUSION

Routine plate fixation of displaced midshaft clavicular fractures is not cost-effective. Nonunion following conservative management has an increased morbidity with comparable expense to early fixation. This may suggest that a targeted approach of fixation in patients who are at higher risk of nonunion would be more cost-effective than the routine fixation of all displaced fractures. Cite this article: Bone Joint J 2019;101-B:995-1001.

Surgery for the fractured clavicle: factors predicting nonunion

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clavicle fracture nonunion in the paediatric population: a systematic review of the literature

AIMS

Clavicle fracture nonunions are extremely rare in children. The aim of this systematic review was to assess what factors may predispose children to form clavicle fracture nonunions and evaluate the treatment methods and outcomes.

METHODS

We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, aiming to find papers reporting clavicle fracture nonunion in children under the age of 18 years. Data was collected on patient demographics, fracture type, mechanism of injury (MOI), surgical intervention and reported outcome. Two independent reviewers evaluated all the data.

RESULTS

A total of 13 articles reporting 21 cases of clavicle fracture nonunion were identified. The mean age at time of injury was 11.4 years (4 to 17). Falls were the most common MOI. The majority of nonunions occurred after displaced fractures on the right side. Six were refractures. Mean time of presentation following injury was 13.5 months (4 to 60). In all, 16 were treated surgically. Radiographic union was eventually achieved in 12 cases, with functional outcome satisfactory in all cases.

CONCLUSION

Clavicle nonunion is an extremely rare but possible complication in children. The majority occur after displaced right-sided fractures or refractures and present around one year after injury. Surgical fixation provides good radiographic healing and functional outcomes.

LEVEL OF EVIDENCE

IV.

Fixation of comminuted midshaft clavicle fractures with bone fragments separated by soft tissue using a novel double ligature technique: A case report

RATIONALE

Clavicle fractures are common, and mostly occur in the midshaft. Methods for operative treatment of midshaft clavicle fractures are evolving, as they improve clinical outcomes compared with traditional conservative management. However, fixation of comminuted midshaft clavicle fractures with bone fragments separated by soft tissue remains a challenge.

PATIENT CONCERNS

Here, we present a case of comminuted midshaft clavicle fracture with a bone fragment separated from the main fracture by soft tissue.

DIAGNOSIS

Left comminuted midshaft clavicle fracture.

INTERVENTIONS

We treated this patient with a novel double ligature technique using absorbable suturing.

OUTCOMES

In the past 7 years, we have treated >50 patients with this technique. We have achieved good clinical outcomes with no complications.

LESSONS

We recommend widespread use of our novel double ligature technique for treating comminuted midshaft clavicle fractures with bone fragments separated by soft tissue.

Nonunion After Clavicle Osteosynthesis: High Incidence of Propionibacterium acnes

OBJECTIVE

The objective of this study was to review the etiology of clavicle nonunions after osteosynthesis and investigate the outcomes of a treatment with a single-stage revision.

DESIGN

Retrospective case series.

SETTING

Orthopaedic specialty hospital.

PATIENTS

Twenty cases of nonunion after osteosynthesis of the clavicle were identified. The average age was 44 years (±13 years). In 9 cases, there was catastrophic implant failure that prompted the revision surgery. In the 18 cases in which cultures were taken, 15 of the 18 (83%) were treated as infections with a course of antibiotics. In 14 cases, the cultures were positive for Propionibacterium acnes.

RESULTS

Fifteen patients were treated with a prolonged course of antibiotics. Eighteen patients had follow-up, and the average time to radiographic union was 22 weeks. There were no cases of nonunion after revision surgery.

CONCLUSIONS

There is a high rate of positive cultures in cases of nonunion after osteosynthesis of the clavicle. This suggests the etiology of midshaft clavicle nonunions may result from a combination of suboptimal mechanical fixation and latent infection. Our treatment protocol of superior and anterior plating, interfragmentary fixation, bone grafting, and appropriate antimicrobial treatment of latent infections has resulted in 100% union rate.

LEVEL OF EVIDENCE

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

Clavicle fractures

Management of clavicle fracture has progressed over the last decade, notably with wider use of surgery in midshaft fracture, and new techniques for lateral fracture. Midshaft clavicle fracture treatment needs to be personalized and adapted to the patient's activity level. Whichever the segment involved, treatment for non-displaced fracture is functional; elbow-to-body sling immobilization seems the best tolerated. Apart from regular surgical indications (shoulder impaction, floating shoulder, open fracture or fracture with neurovascular complications), surgery is recommended in case of bone shortening exceeding 1.5cm in young active patients. The technique needs to take account of clavicle anatomy: notably periosteal vascularization in midshaft fracture and acromioclavicular ligament integrity and location in case of lateral fracture. Plate osteosynthesis should take account of bone diameter and 3D curvature; intramedullary fixation should take account of intramedullary canal morphology. Although iatrogenic vascular complications are rare, vessel relations and variants need to be known, especially in the medial end of the clavicle and midshaft. Lateral segment fractures are a particular entity. Large-scale randomized studies are needed to assess indications and results for the various possible internal fixation techniques: isolated or associated to ligament reconstruction, rigid or flexible, and open or arthroscopic.

Do smokers have greater risk of delayed and non-union after fracture, osteotomy and arthrodesis? A systematic review with meta-analysis

OBJECTIVES

Systematic review and meta-analysis of published observational cohort studies. To quantify the increased risk smokers have of experiencing a delayed and/or non-union in fractures, spinal fusion, osteotomy, arthrodesis or established non-unions.

SETTING

Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (EMBASE), Allied and Complementary Medicine Database (AMED) and Web of Science Core Collection from 1966 to 2015.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Observational cohort studies that reported adult smokers and non-smokers with delayed and/or non-union or time to union of the fracture, spinal fusion, osteotomy, arthrodesis or established non-union were eligible.

DATA EXTRACTION AND OUTCOME MEASURES

2 authors screen titles, abstracts and full papers. Data were extracted by 1 author and checked independently by a second. The relative risk ratios of smoking versus non-smoking and the mean difference in time to union patients developing a delayed and/or non-union were calculated.

RESULTS

The search identified 3013 articles; of which, 40 studies were included. The meta-analysis of 7516 procedures revealed that smoking is linked to an increased risk of delayed and/or non-union. When considered collectively, smokers have 2.2 (1.9 to 2.6) times the risk of experiencing delayed and/or non-union. In all the subgroups, the increased risk was always ≥1.6 times that of non-smokers. In the patients where union did occur, it was a longer process in the smokers. The data from 923 procedures were included and revealed an increase in time to union of 27.7 days (14.2 to 41.3).

CONCLUSIONS

Smokers have twice the risk of experiencing a non-union after fracture, spinal fusion, osteotomy, arthrodesis or treatment of non-union. Time to union following fracture, osteotomy, arthrodesis or treatment of an established non-union is longer in smokers. Smokers should be encouraged to abstain from smoking to improve the outcome of these orthopaedic treatments.

Do smokers have greater risk of delayed and non-union after fracture, osteotomy and arthrodesis? A systematic review with meta-analysis

OBJECTIVES

Systematic review and meta-analysis of published observational cohort studies. To quantify the increased risk smokers have of experiencing a delayed and/or non-union in fractures, spinal fusion, osteotomy, arthrodesis or established non-unions.

SETTING

Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (EMBASE), Allied and Complementary Medicine Database (AMED) and Web of Science Core Collection from 1966 to 2015.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Observational cohort studies that reported adult smokers and non-smokers with delayed and/or non-union or time to union of the fracture, spinal fusion, osteotomy, arthrodesis or established non-union were eligible.

DATA EXTRACTION AND OUTCOME MEASURES

2 authors screen titles, abstracts and full papers. Data were extracted by 1 author and checked independently by a second. The relative risk ratios of smoking versus non-smoking and the mean difference in time to union patients developing a delayed and/or non-union were calculated.

RESULTS

The search identified 3013 articles; of which, 40 studies were included. The meta-analysis of 7516 procedures revealed that smoking is linked to an increased risk of delayed and/or non-union. When considered collectively, smokers have 2.2 (1.9 to 2.6) times the risk of experiencing delayed and/or non-union. In all the subgroups, the increased risk was always ≥1.6 times that of non-smokers. In the patients where union did occur, it was a longer process in the smokers. The data from 923 procedures were included and revealed an increase in time to union of 27.7 days (14.2 to 41.3).

CONCLUSIONS

Smokers have twice the risk of experiencing a non-union after fracture, spinal fusion, osteotomy, arthrodesis or treatment of non-union. Time to union following fracture, osteotomy, arthrodesis or treatment of an established non-union is longer in smokers. Smokers should be encouraged to abstain from smoking to improve the outcome of these orthopaedic treatments.