Infection After Surgical Reconstruction of a Clavicle Fracture Using a Reconstruction Plate: A Report of Seven Cases

Surgical treatment, complications, reoperations, and healthcare costs among patients with clavicle fracture in England

INTRODUCTION

The clinical and economic burden of clavicle fractures in England is not well documented. This study evaluated rates of surgical treatment, post-surgical complications, reoperations and costs in patients with clavicle fractures using the Clinical Practice Research Datalink (CPRD) database.

METHODS

CPRD data were linked to National Health Service Hospital Episode Statistics data. Patients with a diagnosis of clavicle fracture between 2010-2018 were selected in CPRD (date of fracture = index date). Of those, patients with surgical intervention within 180 days from index fracture were identified. Rates of post-surgical complications (i.e., infection, non-union, and mal-union), reoperations (for device removal or for postoperative complications), post-operative costs and median time to reoperations were evaluated up to 2 years after surgery.

RESULTS

21,340 patients with clavicle fractures were identified (mean age 35.0 years(standard deviation (SD): 26.5), 66.7% male). Surgery was performed on 672 patients (3.2% of total cohort) at an average 17.1 (SD: 25.2) days post-fracture. Complications (i.e., infection, non-union, or malunion) affected 8.1% of surgically treated clavicle fracture patients; the rate of infection was 3.5% (95% CI, 1.7%- 5.2%), non-union 4.4% (95% CI, 2.4%-6.5%), and mal-union 0.3% (95% CI, 0%-0.7%). Adjusting for age, gender, comorbidities and time to surgery, the all-cause reoperation rate was 20.2% (13.2%-30.0%) and the adjusted rate of reoperation for implant removal was 17.0% (10.7%-25.9%)-84% of all-cause reoperations were thus performed for implant removal. Median time to implant removal was 254 days. The mean cost of reoperations for all causes was £5,000. The most expensive reoperations were for cases that involved infection (mean £6,156).

CONCLUSIONS

Complication rates following surgical clavicle fracture care averaged 8.1%. However, reoperation rates exceed 20%, the vast majority of reoperations being performed for device removal. Technologies to alleviate secondary device removal surgeries would address a significant clinical unmet need.

Intramedullary headless compression screw fixation for midshaft fractures of the clavicle: A case report study

Historically, displaced midshaft clavicle fractures have been managed conservatively. However, recent literature has supported operative management of displaced and shortened clavicle fractures. Several options exist for surgical fixation, including plating and intramedullary (IM) fixation. IM fixation has the potential advantages of a smaller incision and decreased dissection and soft-tissue exposure and less prominent hardware.

Rockwood and Hagie pins represented the most popular form of IM fixation during the last two decades,but concerns exist regarding stability and complications. The use of alternative IM implants, such as Kirschner wires, titanium elastic nails, and cannulated screws, also has been described in limited case series. However, concerns persist regarding the complications associated with the use of these implants, including implant failure, migration, skin complications, prominent screw head and construct stability. Our technique describes intramedullary fixation of midshaft clavicle fractures using a single headless compression screw (HCS) 4.5–6.5-mm. which is simple, affordable, and allows intramedullary compression, stability, load sharing, little periosteal stripping, very limited skin incision and rapid recovery after surgery.

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Recent literature has supported operative management of displaced and shortened clavicle fractures.

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Intramedullary fixation has the potential advantages of a smaller incision and decreased dissection and exposure and less prominent hardware.

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Intramedullary fixation using a single headless compression screw overcome many complications reported with other intramedullary devices.

Infection after fracture osteosynthesis - Part I

Bone and surgical site infections after osteosynthesis are notoriously difficult to manage and pose a tremendous burden in fracture management. In this article, we use the term osteosynthesis-associated infection (OAI) to refer to this clinical entity. While relatively few surgically treated fractures become infected, it is challenging to perform a rapid diagnosis. Optimal management strategies are complex and highly customized to each scenario and take into consideration the status of fracture union, the presence of hardware and the degree of mechanical stability. At present, a high level of relevant evidence is unavailable; most findings presented in the literature are based on laboratory work and non-randomized clinical studies. We present this overview of OAI in two parts: an examination of recent literature concerning OAI pathogenesis, diagnosis and classification and a review of treatment options.

[Postoperative implant-associated osteomyelitis of the shoulder: Hardware-retaining revision concept using temporary drainage]

BACKGROUND

Posttraumatic and postoperative osteomyelitis (PPO) is a subgroup of bone infections with increasing importance. However, to date no standardized reoperation concept exists particularly for patients with PPO of the shoulder region. Therefore the purpose of this study was to evaluate a revision concept including débridement, irrigation, and insertion of temporary drainage with hardware retention until healing.

PATIENTS AND METHODS

A total of 31 patients with PPO were included with a proximal humerus fracture (n = 14), clavicle fracture (n = 10), or AC-joint separation (n = 7). In all, 27 of these patients could be followed for > 1 year.

RESULTS

Hardware retention until fracture or ligament healing could be achieved in > 83%. Six patients required follow-up débridement due to recurrent infections, but then were unremarkable. Clinical outcome showed excellent Constant scores (91.6 ± 2.8).

CONCLUSION

A cost-efficient, simple, and successful revision concept for patients with PPO of the shoulder region is described.

Clinical comparison of two different plating methods in minimally invasive plate osteosynthesis for clavicular midshaft fractures: A randomized controlled trial

AIM

The aim of this study was to compare the clinical and radiographic outcomes between two different plating methods (superior vs. anteroinferior) in minimally invasive plate osteosynthesis (MIPO) for acute displaced clavicular shaft fractures.

MATERIALS AND METHODS

A prospective, randomized controlled trial was performed in a single centre. Nineteen patients were treated with superior plating and 18 with anteroinferior plating using the MIPO technique. A 3.5-mm locking reconstruction plate was bent preoperatively and applied to either the anteroinferior or superior aspect of the clavicle through two separate incisions. The operating time, time to union, the proportional length difference, complications, and functional outcome of the shoulder joint were evaluated using the Constant score and the University of California Los Angeles (UCLA) score.

RESULTS

There was no statistically significant difference in the Constant score and UCLA score. The mean time to union was 16.8 weeks for superior plating and 17.1 weeks for anteroinferior plating (p=0.866). The average operation time was 77.2min in superior plating and 79.4min in anteroinferior plating (p=0.491). One patient in the superior plating group showed plate failure. Despite no significant difference, one patient had nonunion in the superior plating group (p>0.999).

CONCLUSIONS

From a clinical perspective, although MIPO with anteroinferior plating provides better outcomes especially in complications without statistically significant difference, both plating methods provided satisfactory clinical and radiographic outcomes.

LEVEL OF EVIDENCE

Level I, a single-centre, prospective, randomized controlled trial.

Titanium Elastic Nail versus plate fixation of displaced midshaft clavicle fractures: A retrospective comparison study

This study has two purposes: (1) to compare the clinical results between the Titanium Elastic Nail (TEN) and plate fixation of the displaced midshaft clavicle fracture; and (2) to demonstrate the relationship between length shortening and functional outcome after TEN fixation, especially in the comminuted fracture pattern. A retrospective, case-controlled study was conducted and 55 patients were included in our study: 25 in the TEN fixation group (TEN group) and 30 in the plate fixation group (plate group). All patients were classified into four subgroups: simple fracture in the TEN group (ST; n = 13), simple fracture in the plate group (SP; n = 15), comminuted fracture in the TEN group (CT; n = 12), and comminuted fracture in the plate group (CP; n = 15). Wound size was significantly smaller in the TEN group (p < 0.001). The injured clavicular length after fracture healing was significantly shorter in the TEN group (p = 0.036). There was no significant difference in the mean Constant and DASH scores. Injured clavicle shortening was significantly larger in the CT subgroup (p = 0.018). However, there was no statistically significant difference in Constant score and DASH score while comparing the CT subgroup to other subgroups. Although TEN fixation may lead to a higher degree of length shortening after bony union especially in cases of comminuted fracture pattern, no statistically significant difference was observed in objective functional results as compared to other subgroups. Therefore, TEN can be used to fix a displaced midshaft clavicle fracture even in cases of comminuted fracture pattern, which overall is an effective and less surgically invasive procedure.

Comparison between open plating versus minimally invasive plate osteosynthesis for acute displaced clavicular shaft fractures

BACKGROUND

Current literatures describe good clinical outcomes of acute displaced fracture of clavicle treated with minimally invasive plate osteosynthesis (MIPO). But, there are little comparative data of the outcomes between open plating and MIPO techniques. We compared the outcomes of open plating and MIPO for treatment of acute displaced clavicular shaft fractures.

MATERIALS AND METHODS

The author performed a retrospective review on a consecutive series of patients with clavicular shaft fracture who underwent open plating or MIPO. Fourteen patients were treated with open plating with interfragmentary screw fixation, and 19 were treated with the MIPO technique without exposing a fracture site itself. A superior plating method was applied to both groups. Patient demographics, clinical outcomes using Constant score and University of California Los Angeles (UCLA) shoulder score, operation time, union rate, complications, and radiographic evaluation were evaluated.

RESULTS

There were no statistically significant differences in the demographic data, including patient's variables (age, gender, involved side, smoking, alcohol, and diabetic status) and fracture characteristics (trauma mechanism, distribution of fracture type, presence of polytrauma, and time from trauma to surgery) between the two groups. Mean operation time was 87.5 min in open plating and 77.2 min in MIPO (p=0.129). The mean time to union was 15.7 weeks in patients who underwent open plating and 16.8 weeks in patients who underwent MIPO (p=0.427). Although there was no significant difference, nonunion developed 1 case in MIPO while none was in open plating. Four patients in open plating had skin numbness (none in MIPO, p=0.024). There was no significant difference in the Constant score and UCLA score of the two surgical methods.

CONCLUSION

This study showed that both open plating with interfragmentary screw fixation (Open plating) and minimally invasive plate osteosynthesis (MIPO) are equally effective and safe treatment methods for acute displaced clavicle shaft fracture.

Complications and technical pitfalls of titanium elastic nail fixation for midclavicular fractures

Intramedullary titanium elastic nails have been reported to fix displaced midclavicular fractures with excellent functional outcomes and minor complications. This study reports and analyzes the complications and technical pitfalls associated with titanium elastic nail fixation of displaced midclavicular fractures and describes how to prevent these problems. The authors operated on 27 patients (17 men, 10 women; mean age, 45.8 years; range, 16.5-66.9 years) with marked displaced midclavicular fractures using intramedullary titanium elastic nail fixation. The mean Constant score and Disability of the Arm, Shoulder, and Hand score were 93.58 (range, 66.5-100) and 6.22 (range, 0-35), respectively. The mean length difference compared with the contralateral clavicle was a shortening of 0.3 cm (range, -1.5 to 1 cm). Eight patients (30%) had different levels of difficulty at the medial entry point. Clavicular length shortening of more than 1 cm occurred in 5 patients (19%), and all of these patients experienced medial nail tip prominence/protrusion. One patient had 1-cm lengthening of the injured clavicle caused by distraction of the fracture site during titanium elastic nail insertion. Iatrogenic perforation of the posterolateral cortex occurred in 3 patients. Initial misplaced nail insertion occurred in 1 woman who underwent revision with the mini-open method. In 2 patients it was impossible to remove the full nail under general anesthesia. In conclusion, high patient satisfaction and functional outcomes were achieved after titanium elastic nail fixation of displaced midclavicular fractures. However, some complications and technical pitfalls must be considered before titanium elastic nails are used to fix displaced midclavicular fractures.

Displaced mid-shaft clavicular fractures: surgical treatment with intramedullary screw fixation

INTRODUCTION

Clavicle fractures account for around 4 % of all fractures and up to 44 % of fractures of the shoulder girdle. Fractures of the middle third account for approximately 80 % of all clavicle fractures. Management of mid-shaft clavicular fractures is often challenging and the outcome can be unsatisfactory.

MATERIALS AND METHODS

We prospectively evaluated 20 patients (16 males and 4 females) with an average age of 31 years (range 18-50 years) presented with fresh mid-shaft clavicular fractures who underwent open intramedullary fixation using a 6.5 partially threaded cancellous screw. The screw was inserted from the lateral fragment after retrograde drilling of that fragment. Average follow-up period was 16 months (range 10-24).

RESULTS

All cases united within 7-9 weeks (mean 8.2). Superficial infection was observed in one patient, three experienced decreased sensation over the site of incision, and four had symptoms of frozen shoulder.

DISCUSSION AND CONCLUSION

The technique is safe, simple, reliable method for fixation of displaced mid-shaft clavicle fractures with minimal complications and excellent functional outcomes. No complaints or indications for hardware removal after fractures healing.

A surgical technique for minimally invasive plate osteosynthesis of clavicular midshaft fractures

This study describes a minimally invasive plate osteosynthesis technique to treat acute displaced clavicular midshaft fractures using anterior-inferior plating. The technique assesses the fracture via a medial window and a lateral window without opening the fracture area itself. A 3.5-mm locking reconstruction plate is applied to fix the clavicle fracture, and reduction is achieved with a joystick technique using 2 threaded k-wires. The clinical outcomes of 19 patients with clavicle midshaft fractures treated using this technique are also described.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Systematic review of the complications of plate fixation of clavicle fractures

BACKGROUND

The number of displaced midshaft clavicle fractures treated surgically is increasing and plate fixation is often the treatment modality of choice. The study quality and scientific levels of evidence at which possible complications of this treatment are presented vary greatly in literature.

PURPOSES

The purpose of this systematic review is to assess the prevalence of complications concerning plate fixation of dislocated midshaft clavicle fractures.

METHODS

A computer-based search was carried out using EMBASE and PUBMED/MEDLINE. Studies included for review reported complications after plate fixation alone or in comparison to either treatment with intramedullary pin fixation and/or nonoperative treatment. Two quality assessment tools were used to assess the methodological quality of the studies. Included studies were ranked according to their levels of evidence.

RESULTS

After study selection and reading of the full texts, 11 studies were eligible for final quality assessment. Nonunion and malunion rates were less than 10% in all analysed studies but one. The vast majority of complications seem to be implant related, with irritation or failure of the plate being consistently reported on in almost every study, on average ranging from 9 to 64%.

CONCLUSION

The quantity of relevant high evidence studies is low. With low nonunion and malunion rates, plate fixation can be a safe treatment option for acute dislocated midshaft clavicle fractures, but complications related to the implant material requiring a second operation are frequent. Future prospective trials are needed to analyse the influence of various plate types and plate position on implant-related complications.

Minimally invasive fixation of displaced midclavicular fractures with titanium elastic nails

OBJECTIVES

Clavicular fractures account for 2.6% of all fractures, and more than 80% involve the middle third of the clavicle. Plate fixation has been the most common method of fixation reported but has been associated with complications such as infection, wound breakdown, nonunion, implant failures, poor cosmetic outcome, and local skin numbness. We report on a series of cases receiving minimally invasive insertion of titanium elastic nails (TEN) to fix the displaced midclavicular fractures.

DESIGN

Prospective, clinical study.

SETTING

Regional referral center.

PATIENTS/PARTICIPANTS

From November 2006 to October 2007, we operated on 23 patients (16 men) with displaced (no cortical contact between the proximal and distal fragments radiographically and/or greater than 2 cm of shortening) midclavicular fractures fixed with TEN. The mean age of the patients was 41.57 years.

INTERVENTION

All patients with displaced midclavicular fractures were treated with TEN. The nails were inserted from the medial entry point on the sternal end and passed through the fracture site under fluoroscopy monitoring.

MAIN OUTCOME MEASUREMENTS

Complications, clavicular shortening after TEN fixation, Constant shoulder score, and Disability of the Arm, Shoulder, and Hand score for functional outcome measurement.

RESULTS

Closed reduction was successful in 16 patients, and seven patients needed open reduction. There was no nonunion, infection, nail breakage, or refracture after nail removal in our series. The mean operative wound length was 2.2 cm, and mean clavicular length shortening was 0.32 cm. Iatrogenic perforation of the lateral cortex occurred in two patients, and nail misplacement occurred in one patient requiring revision. All patients followed up greater than 12 months. The mean Disability of the Arm, Shoulder, and Hand score was 6 (range, 0-35; standard deviation, 10.47) and mean Constant score was 96 (range, 78-100; standard deviation, 6.34).

CONCLUSIONS

Minimally invasive fixation with TEN is a safe method and can be performed with minor complications. This method of fixation of displaced midclaviclular fractures should result in a good cosmetic appearance and satisfactory stabilization of displaced midclavicular fractures without comminution.

Intramedullary screw fixation for midshaft fractures of the clavicle

Open intramedullary fixation of 37 fresh midshaft clavicular fractures in 35 patients was performed using a 6.5 partially threaded cancellous screw. Mean age was 38 years (range 18-65). The screw was inserted from the medial fragment after retrograde drilling of that fragment. Average follow-up period was 21 months (range 9-36). Radiological evidence of union was apparent in all cases within six to eight weeks after surgery (mean 7.8). Two cases had intraoperative failure of fixation, nine complained of subcutaneous prominence of the screw head, five experienced decreased sensation over the site of incision, and three had symptoms of frozen shoulder. In conclusion, the technique is simple, affordable and it does not require special instrumentation or implants. It allows intramedullary compression, stability, stress sharing, minimal periosteal stripping, and early recovery after surgery.

Management of clavicle fractures

Fractures of the clavicle are relatively common injuries that can occur in patients of all ages. The history and physical examination remain the primary means of diagnosing this injury. Plain radiographs are helpful to confirm the diagnosis and to provide information regarding fracture classification, prognosis, and treatment options. The emphasis of this article is on the management of these injuries. Historically, only unstable distal clavicle fractures were treated operatively. However, recent well-conducted studies demonstrate that plate fixation of displaced midshaft clavicle fractures may result in improved functional outcome and a lower rate of malunion and non-union, compared with non-operative treatment. For clavicle fractures managed non-operatively, the sling-and-swathe or figure-of-eight splints remain appropriate options. Multiple factors should be considered when counseling an athlete on the appropriate time to return to sports participation after a clavicle fracture.