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

[Surgical access route and choice of implant in the region of the clavicle shaft]

BACKGROUND

Clavicle fractures are among the most frequent injuries of the shoulder girdle. Nondisplaced fractures are generally treated conservatively, whereas dislocated fractures require surgical reduction and stabilization. A variety of implants and surgical techniques with reliable results are available. While all techniques provide similar healing rates, they share a common disadvantage with the high incidence of implant irritation and correspondingly high rates of second interventions for material removal.

OBJECTIVE

The various surgical techniques for clavicle shaft fractures with their specific areas of application as well as advantages and disadvantages are presented. This review also provides an aid for deciding which surgical technique is most appropriate based on the fracture morphology. Furthermore, an overview of current research activities is presented, with a specific focus on new implants which could help to reduce implant irritation.

RESULTS AND CONCLUSION

Open superior and anteroinferior plate osteosyntheses each show similar reliable results. The minimally invasive plate osteosynthesis (MIPO) technique offers an alternative for multifragmented fractures as it has a lower complication rate compared to the open procedure. Double plate osteosynthesis using minifragment plates shows promising results with respect to the incidence of implant-related irritation. Larger prospective studies are still pending. Intramedullary nailing offers a good alternative, especially if material removal is planned anyway, e.g., in the pediatric setting.

Efficacy of intramedullary bridge fixation for midshaft clavicle fractures: a retrospective analysis of a novel technique

BACKGROUND

The aim of this study was to explore the efficacy of a novel intramedullary fixation technique using the ortho-bridge system (OBS) for midshaft clavicle fractures.

METHODS

A total of 63 patients were included in this study: 35 underwent plate internal fixation (LP group) and 28 underwent OBS intramedullary fixation (OBS group). Surgical time, intraoperative blood loss, incision length, fracture healing time, removal of the internal fixation agent, visual analog scale (VAS) score for shoulder pain, Constant-Murley shoulder score and complication occurrence were compared between the two groups.

RESULTS

Preoperative general data, such as sex, age and fracture type, were not significantly different between the two groups (P > 0.05). However, the OBS group exhibited better outcomes than the LP group exhibited in terms of surgical time, intraoperative blood loss and total incision length (P < 0.05). Additionally, the OBS group exhibited a significantly shorter fracture healing time and internal-fixation removal time than the LP group exhibited (P < 0.05). The VAS scores on postoperative day 1, week 1, month 1 and month 3 were lower in the OBS group than in the LP group (P < 0.05). Furthermore, the Constant-Murley shoulder scores at 1, 3, and 6 months postoperatively were higher in the OBS group than in the LP group (P < 0.05), with no significant difference at 1 year after surgery (P > 0.05). None of the patients in the OBS group experienced scarring of the surgical incision, and 6 patients in the LP group experienced scarring of the surgical incision. Finally, the complication incidence in the OBS group was lower than that in the LP group.

CONCLUSION

For midshaft clavicle fractures, OBS intramedullary fixation is better than locking-plate internal fixation because it led to less trauma, a faster recovery, better efficacy, and better esthetic outcomes and comfort. Therefore, this technique may have potential as a novel treatment for midshaft clavicle fractures.

LEVEL OF EVIDENCE

III, retrospective observational study.

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

Background

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

Methods

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

Results

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

Conclusion

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

Minimally invasive plate osteosynthesis for clavicle fractures

OBJECTIVE

Treatment of comminuted clavicle shaft fractures with minimally invasive plate osteosynthesis (MIPO).

INDICATIONS

Multifragmentary (≥ 2 intermediate fragments) clavicle shaft fractures with no need for anatomical reduction (AO 15.2B and 15.2C). Even simple fractures (AO 15.2A) with significant soft tissue injuries Tscherne grade I-III are suitable.

CONTRAINDICATIONS

Medial or lateral clavicle fractures as well as simple fracture pattern where anatomical reduction is indispensable.

SURGICAL TECHNIQUE

Short incision over the medial and lateral end of the main fracture fragments. Either medial or lateral epiperosteal plate insertion. Under image intensifier guidance, the plate is centered either superior or anteroinferior on the clavicle and fixed with a compression wire temporarily (alternatively by a cortical screw) in one of the most lateral holes. Fracture reduction (axis, length, and rotation) over the plate and preliminary fixation medially. After correct reduction has been achieved, further cortical screws and/or locking head screws can be inserted (lag before locking screws). Relative stability is achieved by applying a bridging technique.

POSTOPERATIVE MANAGEMENT

No immobilization is needed. Patients are encouraged to perform functional rehabilitation with active and passive physical therapy. Loading is increased according to radiological signs of bony consolidation.

RESULTS

In a retrospective evaluation from 2001-2021, 1128 clavicle osteosyntheses were performed, of which 908 (80.5%) were treated with plate osteosynthesis and 220 (19.5%) with titanium elastic nail (TEN). Of the 908 plate osteosyntheses, 43 (4.7%) were performed with the MIPO approach. Finally, 42 patients (35 men and 7 women; mean age of 44 ± 15 years) with 43 clavicle shaft fractures were analyzed. The operation was accomplished in 63 ± 28 min, and average fluoroscopy time was 45 ± 42 s. A collective of 27 patients could be evaluated after a median follow-up of 14 months (range 1-51 months). In all, 26 fractures healed in a timely manner. In 1 patient a pseudarthrosis occurred which was treated with re-osteosynthesis and cancellous bone grafting in an open technique. Another patient revealed a wound complication with need of operative wound revision 6 weeks after the index surgery. Further postoperative course was uneventful in both patients. All were pain-free and able to return to work. After an average of 17 ± 8 months, 18 hardware removals (66.7%) were performed.

Effect of MIPO combined with locking compression plate fixation on shoulder and elbow joint function and bone metabolic activity in adult patients with middle humeral shaft fracture

OBJECTIVE

To analyze the effect of minimally invasive percutaneous osteosynthesis (MIPO) combined with locking compression plate fixation on middle humeral shaft fracture in adults.

METHODS

The clinical data of 88 adult patients with middle humeral shaft fracture treated in Xiang'an Hospital from August 2019 to August 2021 were retrospectively analyzed. According to different surgical methods, they were assigned into an anterograde group (treated with anterograde interlocking intramedullary nail fixation, N=42) and a joint group (treated with MIPO technique combined with locking compression plate fixation, N=46 cases). The perioperative indexes and complications were compared between the two groups. The changes of Constant-Murley shoulder joint function score, Mayo elbow joint function score, bone metabolic activity indexes [collagen hydroxyl terminal peptide (CTX), type I procollagen amino acid terminal peptide (PICP), osteoprotegerin (OPG), and osteocalcin (BGP)], and bone quality indexes [bone trabecular spacing (Tb.Sp), bone volume fraction (BV/TV), bone elastic stress (ES), bone trabecula number (Tb.N), and volume organic matter content (VOC)] were observed before and after the operation for 3 months.

RESULTS

The fracture healing time and postoperative hospitalization time in the joint group were shorter than those in the anterograde group. The intraoperative blood loss was less than that in the anterograde group (P<0.05). Three months after the operation, the scores of the Constant-Murley and Mayo, Tb.N, VOC, and ES in the joint group were higher than those in the anterograde group. The Tb.Sp and BV/TV were lower than those in the anterograde group (P<0.05). The serum CTX level in the joint group was lower than that in the anterograde group. The levels of PICP, OPG, and BGP were higher than those in the anterograde group (P<0.05). There was no significant difference in the total incidence of complications between the joint group and the anterograde group (P>0.05).

CONCLUSION

MIPO technique combined with locking compression plate fixation can promote the healing of middle humeral shaft fracture in adults, improve the function of the shoulder joint and the elbow joint, regulate the activity of bone metabolism, and improve bone quality, without significant increase in complications.

Comparison of supraclavicular nerve injuries after clavicle mid-shaft surgery via minimally invasive plate osteosynthesis versus open reduction and internal fixation

INTRODUCTION

Only a few previous studies have evaluated the factors related to supraclavicular nerve (SCN) injury after clavicle mid-shaft fracture surgery. We analyzed the frequency and risk factors for SCN injury after clavicle mid-shaft fracture surgery via open reduction and internal fixation (ORIF) versus minimally invasive plate osteosynthesis (MIPO) MATERIALS AND METHODS: We retrospectively reviewed the cases from 59 patients who had undergone surgery for clavicle mid-shaft fractures between January 2018 and April 2019. Twenty-nine patients had undergone ORIF and 30 had undergone MIPO. The frequency of SCN injury in the two groups was evaluated, and preoperative patient demographics (age, sex, body mass index, smoking, alcohol, diabetes mellitus, and trauma mechanism), and radiological parameters (fracture displacement and shortening) were measured and evaluated as risk factors for SCN injury. When neurological symptoms, such as numbness, were present on the anterior chest wall or at the incision site, electromyography (EMG) was conducted.

RESULTS

Neurological symptoms were present in 12 patients. Numbness in the anterior upper chest around the incision site was present in eight and four patients who underwent ORIF and MIPO, respectively (p < 0.001). Furthermore, fracture displacement evaluated on preoperative three-dimensional computed tomography was significantly associated with the occurrence of SCN injury in patients who underwent MIPO (odds ratio, 1.038; 95% confidence interval, 1.001-1.077; p = 0.047). Although EMG was conducted in all patients with SCN injury, peripheral neuropathy was not found in any cases.

CONCLUSIONS

SCN injury, which is a possible complication of clavicle mid-shaft fracture surgery, occurred significantly less frequently in MIPO than in ORIF. In MIPO, greater preoperative fracture displacement was associated with a higher risk of SCN injury. Additional studies are required to reach a consensus regarding accurate methods to evaluate SCN injuries.

LEVEL OF EVIDENCE

IV, case series, treatment study.

Is minimally invasive orthopedic surgery safer than open? A systematic review of systematic reviews

BACKGROUND

To assess the safety of minimally invasive surgery (MIS) for orthopedic spinal, upper limb and lower limb procedures, this systematic review of systematic reviews compared their complications with open procedures.

MATERIALS AND METHODS

A literature search was conducted electronically (PubMed, Cochrane library and Web of Science; May 8, 2021) without language restriction in the past five years. Reviews that consulted at least two databases, compared MIS with open orthopedic surgery, and reported the following: intraoperative, post-operative or total complications, function, ambulation, pain, hospital stay, reoperation rate and operation time were included. Article selection, quality assessment using AMSTAR-2, and data extraction were conducted in duplicate on predesigned forms. In each review, a subset analysis focusing on prospective cohort and randomized studies was additionally performed.

PROSPERO

CRD42020178171.

RESULTS

The search yielded 531 articles from which 76 reviews consisting of 1104 primary studies were included. All reviews were assessed as being low quality. Compared to open surgery, MIS had fewer total, postoperative and intraoperative complications in 2/10, 2/11 and 2/5 reviews of spinal procedures respectively, 1/3, 1/4 and 1/2 reviews of upper limb procedures respectively, and 4/6, 2/7 and 0/2 reviews of lower limb procedures respectively.

CONCLUSIONS

MIS had greater overall safety compared to open surgery in spinal procedures. In upper limb and lower limb procedures, MIS was not outright superior to open procedures in terms of safety hence a general preference of MIS is not justified on the premise of a better safety profile compared to open procedures.

Protocol of BRICS: Brazilian multicentric pragmatic randomised trial of surgical interventions for displaced diaphyseal clavicle fracture study: MIPO versus ORIF for the treatment of displaced midshaft clavicle fractures

INTRODUCTION

Fractures of the diaphysis of the clavicle are common; however, treatment guidelines for this condition are lacking. Surgery is associated with a lower risk of non-union and better functional outcomes but a higher risk of complications. Open reduction and internal fixation with plates and screws are the most commonly performed techniques, but they are associated with paraesthesia in the areas of incisions, extensive surgical exposure and high rates of implant removal. Minimally invasive techniques for treating these fractures have a lower rate of complications. The aim of this study is to evaluate which surgical treatment option (minimally invasive osteosynthesis or open reduction and internal fixation) has better prognosis in terms of complications and reoperations.

METHODS AND ANALYSIS

The study proposed is a multicentric, pragmatic, randomised, open-label, superiority clinical trial between minimally invasive osteosynthesis and open reduction and internal fixation for surgical treatment of patients with displaced fractures of the clavicle shaft. In the proposed study, 190 individuals with displaced midshaft clavicle fractures, who require surgery as treatment, will be randomised. The assessment will occur at 2, 6, 12, 24 and 48 weeks, respectively. The primary outcome of the study will be the number of complications and reoperations. For sample size calculation, a moderate effective size between the techniques was considered in a two-tailed test, with 95% confidence and 90% power. Complications include cases of infection, hypertrophic scarring, non-union, refracture, implant failure, hypoesthesia, skin irritation and shoulder pain. Reoperations are defined as the number of surgeries for pseudoarthrosis, implant failure, infection and elective removal of the implant.

ETHICS AND DISSEMINATION

Study approved by the institutional ethics committee (number 34249120.9.0000.5505-V.3). The results will be disseminated by publications in peer-reviewed journals and presentations in medical meetings.

TRIAL REGISTRATION NUMBER

RBR-3czz68)/UTN U1111-1257-8953.

Minimally invasive plate osteosynthesis: An update of practise

Since its conception in 1989, minimally invasive plate osteosynthesis (MIPO) has gained widespread popularity. It has been studied in over forty countries with most of the publications originating from Asia, Europe and North America. This review aims to describe the scientific path of MIPO from the very beginning to where it stands in current day times; study the pattern and contributing factors influencing its global spread. Finally, the up to date evidence is discussed with regard to several anatomical regions in which MIPO is mostly used. In the meantime, MIPO treads steadily towards accomplishing the same or better outcomes for more and more indications with the goal to leave a smaller surgical footprint to allow for undisturbed bone healing.