1
|
Marchand LS, Mau M, Stephens A, Haller JM, Higgins TF, Rothberg DL. Operative treatment of clavicle fractures results in more opioids prescribed as compared to non-operative management. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-04058-7. [PMID: 39269465 DOI: 10.1007/s00590-024-04058-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 07/31/2024] [Indexed: 09/15/2024]
Abstract
PURPOSE The operative treatment of mid-shaft clavicle fractures shows benefit in union rates, return to work, and lower pain scores relative to non-operative treatment. We sought to determine if the surgical treatment of isolated mid-shaft clavicle fractures would result in fewer opioids prescribed as compared to those managed non-operatively. METHODS All mid-shaft clavicle fractures treated at a Level 1 trauma center were identified from 2012 to 2016. Demographics, fracture characteristics, surgical complications/outcomes, non-operative outcomes, and all narcotics prescribed for 6 months post-injury were collected. Narcotic prescriptions, in morphine equivalents (ME), were obtained through the state prescription drug monitoring program (PDMP). RESULTS One hundred and ten operative and 48 non-operative patients were included. Age, gender, previous alcohol, tobacco or drug use, and final range of motion were similar between groups. Pre-treatment fracture shortening (1.8 cm vs. 0.7 cm, p < 0.001) and displacement (150% vs. 70%, p < 0.001) were greater in the operative group. Total ME's (604 vs. 187, p < 0.001) and post-operative ME's (420 vs. 187, p < 0.001) were greater for the operative group. In either group, no other variable influenced ME's prescribed. CONCLUSION Clavicles treated operatively receive substantially more opiates than those treated non-operatively, despite data suggesting that operative treatment makes clavicle fractures less painful. The total amount of narcotic analgesics obtained by operatively treated patients was over three times that obtained by non-operatively managed patients, which equates to 55 5 mg oxycodone pills or 85 5 mg hydrocodone pills per patient. While there may certainly be advantages to the operative treatment of clavicle fractures, they must be weighed against the risks of a significant increase in opiate prescribing and potential consumption.
Collapse
Affiliation(s)
- Lucas S Marchand
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
| | - Makoa Mau
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
| | - Andrew Stephens
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
| | - Justin M Haller
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
| | - Thomas F Higgins
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
| | - David L Rothberg
- Department of Orthopaedic Surgery, University of Utah, 590 Wakara Way, Salt Lake City, UT, 84108, USA.
| |
Collapse
|
2
|
Perkins CA, Nepple JJ, Pang JH, Busch MT, Edmonds EW, Ellis HB, Kocher MS, Li Y, Pandya NK, Pennock AT, Sabatini CS, Spence DD, Willimon SC, Wilson PL, Heyworth BE. Changes in Fracture Shortening Occur in the First 2 Weeks Following Completely Displaced Adolescent Clavicle Fractures. J Pediatr Orthop 2024; 44:e686-e690. [PMID: 38712672 DOI: 10.1097/bpo.0000000000002724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
BACKGROUND Shortening of midshaft clavicle fractures has been described as a critical fracture characteristic to guide treatment. The degree to which shortening may change in the initial weeks following injury has not been well studied. The purpose of this study was to evaluate the change in shortening of adolescent clavicle fractures in the first 2 weeks following injury. METHODS This was a multicenter study of prospectively collected data, which was acquired as a part of a cohort study of adolescent clavicle fractures. A consecutive series of patients 10 to 18 years of age with completely displaced diaphyseal clavicle fractures with baseline radiographs 0 to 6 days from the date of injury, as well as 7 to 21 days from the date of injury, were included. Measurements of end-to-end (EES) and cortex-to-corresponding-cortex (CCS) shortening were performed. RESULTS A total of 142 patients were included. Baseline radiographs were obtained at a mean of 1.0 day following injury with mean EES of 22.3 mm, and 69% of patients demonstrating > 20 mm of shortening. Follow-up radiographs obtained at a mean of 13.8 days postinjury demonstrated a mean absolute change in EES of 5.4 mm. Forty-one percentage of patients had >5 mm of change in EES. When analyzing changes in shortening relative to the specific threshold of 20 mm, 18 patients (41%) with <20 mm EES increased to ≥20 mm EES, and 19 patients (19%) with ≥20 mm EES decreased to <20 mm EES at 2-week follow-up. CONCLUSIONS Clinically significant changes in fracture shortening occurred in 41% of adolescents with completely displaced clavicle fractures in the first 2 weeks after injury. In 26% of patients, this resulted in a change from above or below the commonly used shortening threshold of 20 mm, potentially altering the treatment plan by many providers. There is no evidence to suggest that adolescent clavicle fracture shortening affects outcomes, and as such, the authors do not advocate for the use of this parameter to guide treatment. However, among physicians who continue to use this parameter to guide treatment, this study supports that repeat radiographic assessment 2 weeks postinjury may be a better measure of the true shortening of this common adolescent injury. LEVEL OF EVIDENCE Level IV-case series.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Ying Li
- Texas Scottish Rite Hospital for Children, Dallas, TX
| | | | | | | | | | | | | | | |
Collapse
|
3
|
Hung LW, Lu HY, Chen TY, Wang TM, Lu TW. Residual kinematic deviations of the shoulder during humeral elevation after conservative treatment for mid-shaft clavicle fractures. Front Bioeng Biotechnol 2024; 12:1413679. [PMID: 39183820 PMCID: PMC11341403 DOI: 10.3389/fbioe.2024.1413679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 07/29/2024] [Indexed: 08/27/2024] Open
Abstract
Despite residual functional deficits clinically observed in conservatively treated mid-shaft clavicle fractures, no study has reported a quantitative assessment of the treatment effects on the kinematics of the shoulder complex during functional movement. Using computerised motion analysis, the current study quantified the 3D residual kinematic deviations or strategies of the shoulder complex bones during multi-plane elevations in fifteen patients with conservatively treated mid-shaft clavicle fractures and fifteen healthy controls. Despite residual clavicular malunion, the patients recovered normal shoulder kinematics for arm elevations up to 60° in all three tested planes. For elevations beyond 60°, normal clavicle kinematics but significantly increased scapular posterior tilt relative to the trunk was observed in the patient group, leading to significantly increased clavicular protraction and posterior tilt relative to the scapula (i.e., AC joint). Slightly different changes were found in the sagittal plane, showing additional changes of increased scapular upward rotations at 90° and 120° elevations. Similar kinematic changes were also found on the unaffected side, indicating a trend of symmetrical bilateral adaptation. The current results suggest that shoulder kinematics in multi-plane arm elevations should be monitored for any compromised integrated motions of the individual bones following conservative treatment. Rehabilitation strategies, including muscle strengthening and synergy stability training, should also consider compensatory kinematic changes on the unaffected side to improve the bilateral movement control of the shoulder complex during humeral elevation.
Collapse
Affiliation(s)
- Li-Wei Hung
- Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
- Department of Orthopedic Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Hsuan-Yu Lu
- Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - Tsan-Yang Chen
- Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
- Department of Sports Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Ting-Ming Wang
- Department of Orthopedic Surgery, School of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Tung-Wu Lu
- Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
- Department of Orthopedic Surgery, School of Medicine, National Taiwan University, Taipei, Taiwan
- Health Science and Wellness Research Center, National Taiwan University, Taipei, Taiwan
| |
Collapse
|
4
|
M K, Paul S, Gupta RK, Mittal A, Bishnoi S, Garg AM, Malik M, Choudhary A, Agrawal GK. Evaluating the Outcomes of Managing Displaced Clavicular Fractures by Using Precontoured Clavicular Plates. Cureus 2024; 16:e66095. [PMID: 39224714 PMCID: PMC11368436 DOI: 10.7759/cureus.66095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2024] [Indexed: 09/04/2024] Open
Abstract
Background and objective Midshaft clavicular fractures were managed conservatively in the past, with a significant incidence of nonunion and poor functional outcomes in displaced fractures. Anatomically precontoured clavicle plates, since their introduction, have proved to be a superior method for managing these fractures. While open reduction and internal fixation of displaced clavicular fractures with plates have produced successful functional outcomes, complications like plate prominence, scar, postoperative numbness, wound dehiscence, refracture, and infection continue to discourage surgeons from plating these fractures. This study aimed to evaluate whether the precontoured 3.5-mm locking compression plate (LCP) for the clavicle is effective in the management of displaced clavicular fractures with minimum risk of complications. Methods A prospective observational study was conducted among 26 patients with displaced clavicular fractures that were managed with 3.5-mm precontoured LCP. The functional outcome was assessed by using the Constant-Murley Score (CMS) and healing was assessed radiographically six months postoperatively. Results Twenty-five patients were available for the final follow-up at the end of 24 weeks. All of them achieved excellent functional scores. The mean CMS was 94.9. No complication was observed in 85% of the cases. Implant failure was observed in both fractures of a bilateral clavicle fracture patient within a month of surgery. Implant irritation without prominence was seen in one patient and another had a prominent postoperative scar. The mean time for the radiological union was 13.8 weeks with union time ranging from three to five months. Conclusions Based on our findings, employing 3.5-mm precontoured clavicular LCPs is a useful technique that can provide good functional outcomes in displaced clavicular fractures.
Collapse
Affiliation(s)
- Krishna M
- Orthopaedics, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Shagnik Paul
- Orthopaedics, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Rakesh K Gupta
- Orthopaedics, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Amandeep Mittal
- Orthopaedics, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Sanju Bishnoi
- Orthopaedics, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Aksha M Garg
- Orthopaedics, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Manmeet Malik
- Orthopaedics, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Abhay Choudhary
- Orthopaedics, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, IND
| | - Gaurav K Agrawal
- Orthopaedics, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
| |
Collapse
|
5
|
Yurteri A, Mercan N, Uğur L. Comparison of the use of biocompatible materials and titanium in the treatment of midshaft clavicle fractures with a patient-specific plate: a finite element analysis study. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05449-5. [PMID: 39008077 DOI: 10.1007/s00402-024-05449-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 06/30/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Clavicular midshaft fractures treated with titanium plates may encounter complications like implant failure. We assess if alternative biocompatible materials suchs as PLA, PLA/HA, PEEK offer comparable stability. Our study evaluates the biomechanical performance of these materials in surgical management of midshaft clavicle fractures. METHODS We simulated a personalized fixation implant with four different materials and conducted finite element analysis in ANSYS to assess maximum von Mises stress (MvMs). RESULTS The MvMs occurring on the plates, screws, clavicle, and fracture site were recorded. MvMs on titanium material at the 6th hole level (764.79 MPa) and the 6th screw level (503.38 MPa), with the highest stresses observed at 48.52 MPa on the lateral clavicle at the 1st hole level and 182.27 MPa on the medial clavicle at the 6th hole level. In PLA material analyses, the highest MvMs were observed at the 3rd hole level (340.6 MPa) and the 3rd screw level (157.83 MPa), with peak stresses at 379.63 MPa on the lateral clavicle fracture line and 505.44 MPa on the medial clavicle fracture line. In PLA/HA material analyses, the highest MvMs were at the 3rd hole (295.99 MPa) and 3rd screw (128.27 MPa), with peak stresses at 220.33 MPa on the lateral clavicle and 229.63 MPa on the medial clavicle fracture line. In PEEK material analyses, the highest MvMs were at the 3rd hole (234.74 MPa) and 6th screw (114.48 MPa), with peak stresses at 184.36 MPa on the lateral clavicle and 180.1 MPa on the medial clavicle. CONCLUSION Our findings indicate that titanium material shows significantly higher stresses on plates and screws compared to those on the clavicle, suggesting a risk of implant failure. PLA and PLA/HA were inadequate for fixation. Although stress on the plate with PEEK material is higher than on the clavicle, it remains lower than titanium, indicating potential stability at fracture site. Further research is needed to confirm these findings.
Collapse
Affiliation(s)
- Ahmet Yurteri
- Department of Orthopaedics and Traumatology, Konya City Hospital, Konya, 42020, Türkiye
| | - Numan Mercan
- Department of Orthopaedics and Traumatology, Kahramanmaraş Necip Fazıl City Hospital, Kahramanmaraş, 46050, Türkiye.
| | - Levent Uğur
- Mechanical Engineering Department, Amasya University, Amasya, 05100, Türkiye
| |
Collapse
|
6
|
Barret H, Mas V, Boissinot T, Baltassat A, Mansat P, Bonnevialle N. Satisfactory results in five patients with septic clavicle nonunion using the modified Masquelet technique and structural iliac crest autograft. JSES Int 2024; 8:734-739. [PMID: 39035672 PMCID: PMC11258829 DOI: 10.1016/j.jseint.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
Background Indications for clavicle fracture fixation have increased dramatically over the last 20 years. Chronic surgical site infection is a particularly severe complication arising from this procedure and can induce nonunion and clinical disability. In such cases, the modified Masquelet technique using an iliac crest autograft (cancellous or tricortical) enables treatment of any bone infection as well as reconstruction of the segmental defect. The aim of this study was to analyze the clinical and radiological results of this procedure at mid-term follow-up. Methods In this monocentric retrospective study, patients suffering from a septic clavicle nonunion were treated with a modified Masquelet technique and reviewed at a minimum follow-up point of two years. They were clinically assessed using active range of motion, pain score (visual analog scale 0 to 10), Constant score, American Shoulder and Elbow Surgeons score, and subjective shoulder value score. Bone healing was measured using standard X-rays and CT scans. Results Five patients were included (mean age 49 years; range 30 to 62). C. acnes was involved in 80% (n = 4) of these cases. Following the first stage of treatment, the mean bone defect was 3.4 cm (range 2.6 to 6.4 cm). The second stage, performed at a minimum of six weeks (mean 7 ± 1 weeks), used an iliac crest bone autograft in all cases. At a mean follow-up of 5 ± 3 years, the mean pain score was 0.3/10 points (0 to 1), the mean Constant score was 86 points (78 to 96), the mean American Shoulder and Elbow Surgeons score was 98 ± 2%, and the subjective shoulder value score 91 ± 11%, with two "forgotten shoulders" out of five. On CT scan analysis, bone healing was achieved in 100% of cases. One plate (20%) was removed one year following the procedure due to the patient's discomfort; pain and discomfort at the iliac crest site were reported in 5/5 (100%) patients. Conclusion The modified Masquelet technique using an iliac crest autograft is a reliable and effective technique for treating septic nonunion of the clavicle. It both treats the bony defect and eradicates infection when conducted in association with débridement and antibiotics. In the five cases reported here, this approach had satisfactory results, both subjectively and objectively, with a very low reoperation rate despite persistent pain from iliac bone harvesting.
Collapse
Affiliation(s)
- Hugo Barret
- Département d’Orthopédie Traumatologie du CHU de Toulouse, Hôpital Riquet, Toulouse, France
- Clinique Universitaire du Sport, Toulouse, France
| | - Victor Mas
- Département d’Orthopédie Traumatologie du CHU de Toulouse, Hôpital Riquet, Toulouse, France
- Clinique Universitaire du Sport, Toulouse, France
| | - Thomas Boissinot
- Département d’Orthopédie Traumatologie du CHU de Toulouse, Hôpital Riquet, Toulouse, France
- Clinique Universitaire du Sport, Toulouse, France
| | - Antoine Baltassat
- Département d’Orthopédie Traumatologie du CHU de Toulouse, Hôpital Riquet, Toulouse, France
- Clinique Universitaire du Sport, Toulouse, France
| | - Pierre Mansat
- Département d’Orthopédie Traumatologie du CHU de Toulouse, Hôpital Riquet, Toulouse, France
- Clinique Universitaire du Sport, Toulouse, France
- Institut de Recherche Riquet (I2R), Toulouse, France
| | - Nicolas Bonnevialle
- Département d’Orthopédie Traumatologie du CHU de Toulouse, Hôpital Riquet, Toulouse, France
- Clinique Universitaire du Sport, Toulouse, France
- Institut de Recherche Riquet (I2R), Toulouse, France
| |
Collapse
|
7
|
Woo SH, Bae JY, Jung SW, Choi MH, Kang SW. Usefulness of double plate fixation after failed ORIF for clavicle shaft fracture. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2373-2377. [PMID: 38598169 PMCID: PMC11291517 DOI: 10.1007/s00590-024-03927-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 03/20/2024] [Indexed: 04/11/2024]
Abstract
PURPOSE We aimed to evaluate the clinical and radiological outcomes of double plate fixation for failed clavicle shaft fracture surgery. MATERIALS AND METHODS We analyzed 14 patients who underwent double plate fixation due to plate failure after clavicle shaft fracture surgery from March 2016 to March 2021. The study used 3.5 mm locking compression plates for superior clavicle and anterior reconstruction in all patients. In addition, moldable allograft bone was used to fill the bone defect. Clinical and radiological evaluation was performed immediately, at 2 and 4 weeks, and 3, 6, 9, and 12 months postoperatively. The visual analog scale (VAS), University of California at Los Angeles (UCLA) shoulder scale, and American Shoulder and Elbow Surgeons (ASES) scores and range of motion of the shoulder were evaluated as clinical results. For radiological evaluation, anteroposterior, caudal, and cephalad views of both clavicles were used. Successful bone union was defined as complete adjoining of the fracture site through callus formation. RESULTS Successful bone union was achieved in all patients, and the mean time to bone union was 16.7 ± 1.2 weeks (range, 12-24 weeks). Statistically significant improvement in forward flexion and external and internal rotation was observed from 135.5° ± 6.3, 45.2° ± 5.3, and 13° ± 2.3 preoperatively to 157.0° ± 9.3, 68.7° ± 6.3, and 9.8° ± 3.1 at the final follow-up, respectively. The VAS score improved from an average of 6.2 ± 2.8 preoperatively to 1.3 ± 0.7 at the final follow-up, which was statistically significant (P = 0.018). In addition, the ASES score significantly increased from a mean of 52.1 ± 6.3 points preoperatively to 83.6 ± 7.8 points at the final follow-up (P = 0.001). The average UCLA shoulder score was 16.7 ± 1.4 and 31.4 ± 2.2 points preoperatively and at the final follow-up, respectively, which was statistically significant (P = 0.001). CONCLUSION Double plate fixation has shown good results after failed open reduction and internal fixation (ORIF) for clavicle shaft fractures. Therefore, in complicated situations after ORIF, double plate fixation is considered a surgical treatment option.
Collapse
Affiliation(s)
- Seung Hun Woo
- Department of Orthopedics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan, 626-770, Republic of Korea
| | - Jung Yun Bae
- Department of Orthopedics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan, 626-770, Republic of Korea
| | - Sung Won Jung
- Department of Orthopedics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan, 626-770, Republic of Korea
| | - Min-Hyeok Choi
- Department of Preventive and Occupational & Environmental Medicine, Pusan National University School of Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
- Office of Public Healthcare Service, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Suk-Woong Kang
- Department of Orthopedics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Mulgeum-eup, Yangsan, 626-770, Republic of Korea.
| |
Collapse
|
8
|
Ling K, VanHelmond T, Mehta N, Barry A, Wang E, Komatsu DE, Wang ED. Smoking Is Markedly Associated With 30-Day Readmission and Revision Surgery After Surgical Treatment of Clavicle Fracture. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202407000-00002. [PMID: 38996220 PMCID: PMC11239174 DOI: 10.5435/jaaosglobal-d-23-00278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/14/2024] [Accepted: 03/22/2024] [Indexed: 07/14/2024]
Abstract
BACKGROUND A recent database study found that 15.2% of clavicle fractures underwent surgical treatment. Recent evidence accentuates the role of smoking in predicting nonunion. The purpose of this study was to further elucidate the effect of smoking on the 30-day postoperative outcomes after surgical treatment of clavicle fractures. METHODS The authors queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent open reduction and internal fixation of clavicle fracture between 2015 and 2020. Multivariate logistic regression, adjusted for notable patient demographics and comorbidities, was used to identify associations between current smoking status and postoperative complications. RESULTS In total, 6,132 patients were included in this study of whom 1,510 (24.6%) were current smokers and 4,622 (75.4%) were nonsmokers. Multivariate analysis found current smoking status to be significantly associated with higher rates of deep incisional surgical-site infection (OR, 7.87; 95% CI, 1.51 to 41.09; P = 0.014), revision surgery (OR, 2.74; 95% CI, 1.67 to 4.49; P < 0.001), and readmission (OR, 3.29; 95% CI, 1.84 to 5.89; P < 0.001). CONCLUSION Current smoking status is markedly associated with higher rates of deep incisional surgical-site infection, revision surgery, and readmission within 30 days after open reduction and internal fixation of clavicle fracture.
Collapse
Affiliation(s)
- Kenny Ling
- From the Department of Orthopaedics (Dr. Ling, Dr. VanHelmond, Dr. Mehta, Dr. Komatsu, and Dr. Edward D. Wang), and Renaissance School of Medicine at Stony Brook University (Mr. Barry and Mr. Eric Wang), Stony Brook, NY
| | - Taylor VanHelmond
- From the Department of Orthopaedics (Dr. Ling, Dr. VanHelmond, Dr. Mehta, Dr. Komatsu, and Dr. Edward D. Wang), and Renaissance School of Medicine at Stony Brook University (Mr. Barry and Mr. Eric Wang), Stony Brook, NY
| | - Nishank Mehta
- From the Department of Orthopaedics (Dr. Ling, Dr. VanHelmond, Dr. Mehta, Dr. Komatsu, and Dr. Edward D. Wang), and Renaissance School of Medicine at Stony Brook University (Mr. Barry and Mr. Eric Wang), Stony Brook, NY
| | - Alaydi Barry
- From the Department of Orthopaedics (Dr. Ling, Dr. VanHelmond, Dr. Mehta, Dr. Komatsu, and Dr. Edward D. Wang), and Renaissance School of Medicine at Stony Brook University (Mr. Barry and Mr. Eric Wang), Stony Brook, NY
| | - Eric Wang
- From the Department of Orthopaedics (Dr. Ling, Dr. VanHelmond, Dr. Mehta, Dr. Komatsu, and Dr. Edward D. Wang), and Renaissance School of Medicine at Stony Brook University (Mr. Barry and Mr. Eric Wang), Stony Brook, NY
| | - David E. Komatsu
- From the Department of Orthopaedics (Dr. Ling, Dr. VanHelmond, Dr. Mehta, Dr. Komatsu, and Dr. Edward D. Wang), and Renaissance School of Medicine at Stony Brook University (Mr. Barry and Mr. Eric Wang), Stony Brook, NY
| | - Edward D. Wang
- From the Department of Orthopaedics (Dr. Ling, Dr. VanHelmond, Dr. Mehta, Dr. Komatsu, and Dr. Edward D. Wang), and Renaissance School of Medicine at Stony Brook University (Mr. Barry and Mr. Eric Wang), Stony Brook, NY
| |
Collapse
|
9
|
Qvist AH, Jensen SL. Minimal early functional gains after operative treatment of midshaft clavicular fractures: a meta-analysis of 10 randomized controlled trials including 1333 patients. JSES Int 2024; 8:400-406. [PMID: 38707583 PMCID: PMC11064720 DOI: 10.1016/j.jseint.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Background There is substantial evidence that operative treatment reduces the risk of nonunion but offers no long-term functional gains compared with nonoperative treatment. Despite some studies citing quicker recovery with surgery, the promise of accelerated functional recovery remains under-investigated. The aim of this meta-analysis of randomized controlled trials was to investigate the possible early functional gains (≤6 months) after operative treatment of displaced midshaft clavicular fractures compared with nonsurgical treatment. Methods A systematic search was performed to identify randomized controlled trials comparing plate osteosynthesis with nonoperative treatment. We evaluated shoulder function outcomes measured by Constant Score or Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. Other outcomes of interest were sick leave and return to previous activity (work, leisure). Results Ten studies including 1333 patients were included. The mean difference in DASH score after 6 weeks was 9.4 points (95% confidence interval [CI] 13.7-5.1) in favor of operative treatment. At 3 months, the difference was 3.6 points (95% CI 6.9-0.4), and at 6 months, the difference was 3.2 points (95% CI 5.2-1.1), both in favor of operative treatment. Results for Constant Score were similar to that of DASH score. Conclusion This meta-analysis shows that there is an early functional gain at six weeks following plate fixation of midshaft clavicular fractures compared with nonoperative treatment. At three and six months, the functional gain is lesser and not clinically relevant.
Collapse
Affiliation(s)
- Andreas H. Qvist
- Department of Orthopedics, Aarhus University Hospital, Aarhus, Denmark
| | - Steen L. Jensen
- Department of Orthopedics and Orthopaedic Research Unit, Aalborg University Hospital, Aalborg, Denmark
| |
Collapse
|
10
|
Frane N, Watzig B, Vohra A, Deeyor S, Hui C, McKee M, Dehghan N. Immediate Weight-bearing Through Walker or Crutches After Surgical Fixation of Clavicle Fractures in Patients With Lower Extremity Fractures: A Retrospective Cohort Study. J Orthop Trauma 2024; 38:227-233. [PMID: 38251900 DOI: 10.1097/bot.0000000000002773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 01/10/2024] [Indexed: 01/23/2024]
Abstract
OBJECTIVES To assess the safety of immediate upper extremity weight-bearing as tolerated (WBAT) rehabilitation protocol after clavicle fracture open reduction internal fixation (ORIF). METHODS DESIGN Retrospective cohort study. SETTING Three Level 1 trauma centers. PATIENTS SELECTION CRITERIA Patients older than 18 years who had ORIF of mid-shaft clavicle fractures and lower extremity fractures who were allowed immediate WBAT on their affected upper extremity through use of a walker or crutches were included. All clavicles were fixed with either precontoured clavicular plates or locking compression plates. Included patients were those who had clinical/radiographic follow-up until fracture union, nonunion, or construct failure. OUTCOME MEASURES AND COMPARISONS WBAT patients were matched in a one-to-one fashion to a cohort with isolated clavicle fractures who were treated non-weight-bearing (NWB) postoperatively on their affected upper extremity. Matching was done based on age, sex, and temporality of fixation. After matching, treatment and control groups were compared to determine differences in possible confounding variables that could influence the primary outcome, including patient demographics, fracture classification, cortices of fixation, and construct type. All patients were assessed to verify conformity with weight-bearing recommendation. Primary outcome was early hardware failure (HWF) with or without revision surgery. Secondary outcomes included postoperative infections and union of fracture. RESULTS Thirty-nine patients were included in the WBAT cohort; there were no significant differences with the matched NWB cohort based on patient demographics. Both the WBAT and the NWB cohorts had 2.5% chance of acute HWF that required surgical intervention ( P = 1.0). Additionally, there was no difference in overall HWF ( P = 0.49). All patients despite weight-bearing status including those who required revision ORIF for acute HWF had union of their fracture ( P = 1.0). CONCLUSIONS Our data would support that immediate weight-bearing after clavicle fracture fixation in patients with concomitant lower extremity trauma does not lead to an increase in HWF or impact ultimate union. This challenges the dogma of prolonged postoperative weight-bearing restrictions and allow for earlier rehabilitation. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Nicholas Frane
- NorthStar Trauma Network, Allina Orthopaedics, Minneapolis, MN
| | - Benjamin Watzig
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ; and
| | - Arjun Vohra
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ; and
| | - Sorka Deeyor
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ; and
| | - Clayton Hui
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ; and
| | - Michael McKee
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ; and
| | - Niloofar Dehghan
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ; and
| |
Collapse
|
11
|
Polinsky SG, Edmonds EW, Bastrom TP, Manhard CE, Heyworth BE, Bae DS, Busch MT, Ellis HB, Hergott K, Kocher MS, Li Y, Nepple JJ, Pandya NK, Perkins C, Sabatini CS, Spence DD, Willimon SC, Wilson PL, Pennock AT. 5-Year Radiographic and Functional Outcomes of Nonoperative Treatment of Completely Displaced Midshaft Clavicular Fractures in Teenagers. Am J Sports Med 2024; 52:1032-1039. [PMID: 38439558 DOI: 10.1177/03635465241228818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
BACKGROUND Optimal treatment of completely displaced midshaft clavicular fractures in adolescents remains controversial, with some favoring surgical management and others favoring a nonoperative approach. Few studies have comprehensively assessed longer-term nonoperative outcomes. PURPOSE To prospectively assess patient-reported outcomes (PROs) and radiographic remodeling ≥5 years after injury in teenagers undergoing nonoperative treatment of completely displaced clavicular fractures. STUDY DESIGN Case series; Level of evidence, 4. METHODS Adolescent patients previously enrolled in a prospective study from a single institution with nonoperatively treated, completely displaced midshaft clavicular fractures ≥5 years from injury were eligible for the study. Patients were clinically evaluated for scapular dyskinesia and strength deficits. Bilateral clavicular imaging assessed residual shortening, displacement, and angulation. PROs included the American Shoulder and Elbow Surgeons (ASES), the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), Marx Shoulder Activity Scale, cosmesis, and return to sports data. RESULTS A total of 24 patients were available for the follow-up, of whom 17 (71%) consented to additional imaging. The mean cohort age at the time of injury was 14.5 ± 1.1 years, with 88% being male. At a mean follow-up of 6.1 years, all fractures had healed, with no patient requiring secondary interventions. Significant remodeling was observed across all measurements, with improvements of 70% in shortening (22.8 to 6.8 mm; P < .001), 73% in superior displacement (13.4 to 3.6 mm; P < .001), and 83% in angulation (10.4° to 1.8°; P < .001). Thirteen patients (72%) had a >2-cm initial shortening, and all remodeled to <2 cm. PROs were almost universally excellent, with mean ASES, QuickDASH, and Marx activity scores of 99 ± 3, 1 ± 3, and 20 ± 1, respectively, with 79% of patients reporting perfect scores in all 3 domains. Most patients (58%) were completely satisfied with their shoulder appearance, 38% were more satisfied than not, 1 patient (4%) was neither satisfied nor dissatisfied, and no patients were dissatisfied. All patients except 1 who were interested in sports returned to sporting activities. PROs were not associated with bony remodeling (P > .05). CONCLUSION Teenaged patients with completely displaced clavicular fractures treated nonoperatively can expect excellent radiographic and clinical outcomes 5 years after injury.
Collapse
Affiliation(s)
- Samuel G Polinsky
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA; University of California, San Diego, San Diego, California, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Eric W Edmonds
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA; University of California, San Diego, San Diego, California, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Tracey P Bastrom
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Claire E Manhard
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Benton E Heyworth
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Donald S Bae
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Michael T Busch
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Henry B Ellis
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Katelyn Hergott
- Division of Sports Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Mininder S Kocher
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Ying Li
- C.S. Mott Children's Hospital, Ann Arbor, Michigan, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Jeffrey J Nepple
- Department of Orthopaedic Surgery, Washington University in Saint Louis, Saint Louis, Missouri, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Nirav K Pandya
- UCSF Benioff Children's Hospital, Oakland, California, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Crystal Perkins
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Coleen S Sabatini
- UCSF Benioff Children's Hospital, Oakland, California, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - David D Spence
- Department of Orthopaedic Surgery, Campbell Clinic, Memphis, Tennessee, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Samuel C Willimon
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Philip L Wilson
- Texas Scottish Rite Hospital for Children, Dallas, Texas, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| | - Andrew T Pennock
- Department of Orthopedic Surgery, Rady Children's Hospital, San Diego, California, USA; University of California, San Diego, San Diego, California, USA
- Investigation performed at Rady Children's Hospital, San Diego, California, USA
| |
Collapse
|
12
|
Muthu S, Annamalai S, Kandasamy V. Lateral clavicle fracture-plating options and considerations. World J Clin Cases 2024; 12:1039-1044. [PMID: 38464924 PMCID: PMC10921304 DOI: 10.12998/wjcc.v12.i6.1039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/21/2023] [Accepted: 01/12/2024] [Indexed: 02/20/2024] Open
Abstract
Clavicle fractures are among the most prevalent types of fractures with numerous treatment strategies that have evolved over time. In the realm of lateral-third clavicle fracture management, several surgical methods are available, with plate and screw constructs being one of the most frequently employed options. Within this construct, numerous choices exist for fixing the fracture. This editorial provides an overview of the common plate options utilized in the management of distal third clavicle fractures underscoring the critical considerations and approaches that guide clinicians in selecting the most appropriate fixation techniques, considering the complex landscape of clavicle fractures and their challenging management.
Collapse
Affiliation(s)
- Sathish Muthu
- Department of Orthopaedics, Orthopaedic Research Group, Coimbatore 641045, Tamil Nadu, India
- Department of Biotechnology, Karpagam Academy of Higher Education, Coimbatore 641021, Tamil Nadu, India
- Department of Orthopaedics, Government Karur Medical College, Karur 639004, Tamil Nadu, India
| | - Saravanan Annamalai
- Department of Orthopaedics, Government Thiruvallur Medical College, Thiruvallur 631203, Tamil Nadu, India
| | - Velmurugan Kandasamy
- Department of Orthopaedics, Government Kilpauk Medical College, Chennai 600010, Tamil Nadu, India
| |
Collapse
|
13
|
Carroll PJ, Gaafer M, O'Briain D, Hynes D, Flannery O, Mullett H, O'Shea K. Glenohumeral joint osteoarthritis is not associated with clavicle fractures in a large arthroplasty cohort. J Orthop 2024; 48:68-71. [PMID: 38106625 PMCID: PMC10724473 DOI: 10.1016/j.jor.2023.11.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/19/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction A recent study based on a large osteological collection reported an association between clavicle fractures and osteoarthritis of the glenohumeral joint. No clinical study has yet addressed this potential association. Other radiographic parameters such as the critical shoulder angle have been associated with the risk of glenohumeral joint osteoarthritis. The primary outcome of this study was to determine if there is an association between glenohumeral joint arthritis and clavicle fractures. The secondary outcome was to determine the association between critical shoulder angle and glenohumeral joint arthritis in our patient cohort. Methods We retrospectively analysed 572 consecutive shoulder arthroplasty surgeries. Osteoarthritis was the indication for 343 shoulder arthroplasties. 229 shoulder arthroplasties were performed due to another diagnosis such as trauma or fracture, cuff arthropathy, or revision surgery. Three fellowship trained consultant shoulder surgeons assessed the pre- and post-operative radiographs of all patients. Results A clavicle fracture was suspected in 5/343 (1.5 %) shoulder arthroplasties performed due to osteoarthritis and 5/229 (2.1 %) shoulder arthroplasties performed for another diagnosis. Interobserver variability was assessed using a Fisher Exact test and showed no significant relationship between osteoarthritis and a fracture of the clavicle (p = 0.531). Critical shoulder angle results correlated with the previously published literature regarding critical shoulder angle and osteoarthritis and rotator cuff arthropathy. Conclusion Clavicle fractures were not associated with glenohumeral osteoarthritis in our patient cohort of shoulder arthroplasty patients. Critical shoulder angle results were consistent with published literature. Further research in the form of prospective long term studies are needed to establish if any association exists between clavicle fractures and osteoarthritis of the glenohumeral joint. Level of evidence Level III. Retrospective analysis.
Collapse
Affiliation(s)
- Patrick J. Carroll
- Department of Trauma & Orthopaedic Surgery, National Orthopaedic Hospital Cappagh, Cappagh Rd, Northside, Dublin 11, D11 EV29, Ireland
- Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin 2, D02 YN77, Ireland
| | - Mohamed Gaafer
- Department of Trauma & Orthopaedic Surgery, National Orthopaedic Hospital Cappagh, Cappagh Rd, Northside, Dublin 11, D11 EV29, Ireland
- Department of Trauma & Orthopaedic Surgery, Sports Surgery Clinic, Northwood Ave., Santry, Dublin 9, Ireland
| | - David O'Briain
- Department of Trauma & Orthopaedic Surgery, National Orthopaedic Hospital Cappagh, Cappagh Rd, Northside, Dublin 11, D11 EV29, Ireland
- Department of Trauma & Orthopaedic Surgery, Sports Surgery Clinic, Northwood Ave., Santry, Dublin 9, Ireland
| | - Darragh Hynes
- Department of Trauma & Orthopaedic Surgery, National Orthopaedic Hospital Cappagh, Cappagh Rd, Northside, Dublin 11, D11 EV29, Ireland
| | - Olivia Flannery
- Department of Trauma & Orthopaedic Surgery, National Orthopaedic Hospital Cappagh, Cappagh Rd, Northside, Dublin 11, D11 EV29, Ireland
| | - Hannan Mullett
- Department of Trauma & Orthopaedic Surgery, National Orthopaedic Hospital Cappagh, Cappagh Rd, Northside, Dublin 11, D11 EV29, Ireland
- Department of Trauma & Orthopaedic Surgery, Sports Surgery Clinic, Northwood Ave., Santry, Dublin 9, Ireland
| | - Kieran O'Shea
- Department of Trauma & Orthopaedic Surgery, National Orthopaedic Hospital Cappagh, Cappagh Rd, Northside, Dublin 11, D11 EV29, Ireland
- Department of Trauma & Orthopaedic Surgery, Blackrock Clinic, Rock Rd., Blackrock, Co. Dublin, A94 E4X7, Ireland
| |
Collapse
|
14
|
Spence DD, Wilson PL, Pennock AT, Nepple JJ, Pandya NK, Perkins CA, Li Y, Ellis HB, Sabatini CS, Edmonds EW, Willimon SC, Bae DS, Busch MT, Kocher M, Heyworth BE. Treatment of Severely Shortened or Comminuted Clavicular Fractures in Older Adolescent Athletes. Am J Sports Med 2024; 52:423-430. [PMID: 38238901 DOI: 10.1177/03635465231219248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
BACKGROUND Recent evidence suggests that for completely displaced midshaft clavicular fractures, surgery offers no clear benefit over nonoperative treatment in a general adolescent population from 10 to 18 years of age. However, the comparative outcomes of comminuted and/or severely shortened clavicular fractures specifically in older adolescent athletes have not been explored in a focused, methodologically rigorous fashion. HYPOTHESIS The study hypothesis was that outcomes would be superior in older adolescent athletes who underwent operative treatment compared with nonoperative treatment for comminuted and/or severely shortened clavicular fractures. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS A level 2, multicenter, prospective cohort study investigating the outcomes of midshaft fractures in adolescents between 2013 and 2017 was filtered to analyze the subcohorts of athletes 14 to 18 years of age with either fracture comminution or fracture shortening of ≥25 mm or both. Patient characteristics, injury mechanisms, fracture characteristics, and treatments were compared. Complications, rates, timing of return to sports (RTS), and patient-reported outcomes (PROs) were analyzed. RESULTS The 2 treatment groups, which included 136 older adolescent athletes (69 nonoperative, 67 operative), showed similar distributions of primary sport type, competition level, comminution, shortening, and 2-year PRO response rate (n = 99; 73%). The operative group demonstrated 3 mm-greater mean superior displacement, which was therefore statistically controlled for as a confounder in the comparative PRO analysis. No 2-year differences in nonunion, delayed union, symptomatic malunion, refracture, clinically significant complications, or rates of RTS were detected between treatment groups. The difference in timing of RTS (operative, 10.3 weeks; nonoperative, 13.5 weeks) was statistically significant. After controlling for the minor difference in superior displacement, regression analysis and matched comparison cohorts demonstrated no differences between the nonoperative and operative groups in mean or dichotomized PRO scores. CONCLUSION In this prospective, multicenter cohort study investigating older adolescent athletes with comminuted and/or severely shortened clavicular fractures, contrary to the study hypothesis, there were no differences in complications, RTS, or PROs between nonoperatively and operatively treated patients at 2 years. Comparably excellent outcomes of severe clavicular fractures in adolescent athletes can be achieved with nonoperative treatment.
Collapse
Affiliation(s)
- David D Spence
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center - Campbell Clinic, Memphis, Tennessee, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Philip L Wilson
- Sports Medicine Center, Texas Scottish Rite Hospital, Dallas, Texas, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Andrew T Pennock
- Department of Orthopedics, Rady Children's Hospital, San Diego, California, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jeffrey J Nepple
- Department of Orthopedic Surgery, School of Medicine, Washington University, St. Louis, Missouri, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Nirav K Pandya
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Crystal A Perkins
- Department of Orthopedic Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ying Li
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Henry B Ellis
- Sports Medicine Center, Texas Scottish Rite Hospital, Dallas, Texas, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Coleen S Sabatini
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eric W Edmonds
- Department of Orthopedics, Rady Children's Hospital, San Diego, California, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - S Clifton Willimon
- Department of Orthopedic Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Donald S Bae
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michael T Busch
- Department of Orthopedic Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mininder Kocher
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| | - Benton E Heyworth
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA)
- Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
15
|
Kang Y, Zhang Q, Ma Y, Zhou M, Jia X, Lin F, Wu Y, Rui Y. Clinical effect of nice knot-assisted minimally invasive titanium elastic nail fixation to treat Robinson 2B midshaft clavicular fracture. BMC Musculoskelet Disord 2024; 25:59. [PMID: 38216916 PMCID: PMC10787378 DOI: 10.1186/s12891-024-07197-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 01/11/2024] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND The treatment of completely displaced midshaft clavicle fractures is still controversial, especially Robinson 2B fractures. Titanium elastic nail (TEN) fixation is a good option for simple fractures, but no reports exist on its use in complex fractures. This study aimed to present a surgical method using the Nice knot-assisted TEN fixation to treat Robinson 2B midshaft clavicular fractures. METHODS A retrospective analysis of 29 patients who underwent fixation with TEN and had a 1-year postoperative follow-up between 2016 and 2020 was performed. The fractures were classified as Robinson type 2B1 in 17 cases and type 2B2 in 12 cases. Length of the incision, postoperative shoulder function Disability of Arm Shoulder and Hand (DASH) score and Constant score, complications rate, and second surgical incision length were recorded. RESULTS The length of the incision was 2-6 cm (average 3.7 cm). All incisions healed by first intention, and no infection or nerve injury occurred. The Constant score was 92-100 (average 96) and the DASH score was 0-6.2 (mean, 2.64). TEN bending and hypertrophic nonunion occurred in one case (3.4%) and implant irritation occurred in four cases (13.8%) Fixation implants were removed at 12-26 months (mean, 14.6 months) after surgery, and the length of the second incision was 1-2.5 cm (average 1.3 cm). CONCLUSIONS Intramedullary fixation by TEN is approved as a suitable surgical technique in clavicular fracture treatment. Nice knot-assisted fixation provides multifragmentary fracture stabilization, contributing to good fracture healing. Surgeons should consider this technique in treating Robinson 2B midshaft clavicular fractures. TRIAL REGISTRATION Retrospectively registered. This study was approved by the Ethics Committee of Wuxi Ninth People's Hospital (LW20220021).
Collapse
Affiliation(s)
- Yongqiang Kang
- Medical College, Soochow University, Suzhou, Jiangsu, China
| | - Qingqing Zhang
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital, Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China
| | - Yunhong Ma
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital, Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China
| | - Ming Zhou
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital, Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China
| | - Xueyuan Jia
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital, Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China
| | - Fang Lin
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital, Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China
| | - Yongwei Wu
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital, Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China.
| | - Yongjun Rui
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital, Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China.
| |
Collapse
|
16
|
Alito A, Fenga D, Tropeano G, Milardi D, Leonetti D, Migliorato A, Tisano A, D’Andrea D, Filardi V. Screw Stress Distribution in a Clavicle Fracture with Plate Fixation: A Finite Element Analysis. Bioengineering (Basel) 2023; 10:1402. [PMID: 38135993 PMCID: PMC10740883 DOI: 10.3390/bioengineering10121402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
Clavicle midshaft fractures are mostly treated surgically by open internal reduction with a superior or anteroinferior plate and screws or by intramedullary nailing. Screw positioning plays a critical role in determining the stress distribution. There is a lack of data on the screw position and the appropriate number of cortices required for plate fixation. The aim of this study is to evaluate the mechanical behavior of an anterior plate implanted in a fractured bone subjected to 120° of lateral elevation compared to a healthy clavicle using numerical simulations. Contact forces and moments used were obtained from literature data and applied to the healthy and fractured finite element models. Stresses of about 9 MPa were found on the healthy clavicle, while values of about 15 MPa were calculated on the plate of the fractured one; these stress peaks were reached at about 30° and 70° of elevation when the stress shielding on the clavicle sums all the three components of the solicitation: compression, flexion, and torsion. The stress distribution in a clavicle fracture stabilized with plates and screws is influenced by several factors, including the plate's position and design, the type of screw, and the biomechanical forces applied during movements.
Collapse
Affiliation(s)
- Angelo Alito
- Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98125 Messina, Italy; (A.A.); (G.T.); (D.M.); (D.L.); (A.M.)
| | - Domenico Fenga
- Department of Orthopaedics and Traumatology, University Hospital A.O.U. “G. Martino”, 98125 Messina, Italy;
| | - Giada Tropeano
- Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98125 Messina, Italy; (A.A.); (G.T.); (D.M.); (D.L.); (A.M.)
| | - Demetrio Milardi
- Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98125 Messina, Italy; (A.A.); (G.T.); (D.M.); (D.L.); (A.M.)
| | - Danilo Leonetti
- Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98125 Messina, Italy; (A.A.); (G.T.); (D.M.); (D.L.); (A.M.)
| | - Alba Migliorato
- Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98125 Messina, Italy; (A.A.); (G.T.); (D.M.); (D.L.); (A.M.)
| | - Adriana Tisano
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy;
| | - Danilo D’Andrea
- Department of Engineering, University of Messina, 98158 Messina, Italy;
| | - Vincenzo Filardi
- D.A. Scientific Research and Internationalization, University of Messina, 98121 Messina, Italy
| |
Collapse
|
17
|
Dhodapkar MM, Modrak M, Halperin SJ, Joo P, Luo X, Grauer JN. Trends in and Factors Associated With Surgical Management for Closed Clavicle Fractures. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202312000-00015. [PMID: 38149938 PMCID: PMC10752468 DOI: 10.5435/jaaosglobal-d-23-00226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 10/30/2023] [Accepted: 11/18/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION Clavicle fractures are common and have historically been managed nonsurgically. Over time, there are increasing surgical considerations for such injuries. Nonetheless, trends over the past decade are not well characterized. METHODS Adult patients presenting for first diagnosis of clavicle fractures were identified from the 2010 to 2020 PearlDiver M151 database. Patients were defined to have undergone surgical management if they received clavicular open reduction and internal fixation within 90 days after fracture diagnosis. Patient age, sex, Elixhauser Comorbidity Index (ECI), geographic region, insurance coverage, fracture anatomic location, and polytraumatic diagnoses were extracted. Factors independently associated with surgical management versus nonsurgical management were assessed with multivariable analysis. RESULTS Overall, 50,980 patients with clavicle fractures were identified of whom 6,193 (12.1%) were managed surgically. This proportion increased significantly over the study period (7.4% in 2015 to 13.9% in 2020, P < 0.001). Independent predictors of surgical management included fracture diagnosis in 2020 (versus 2015, odds ratio [OR] 2.36), anatomic location (relative to lateral end, shaft OR 1.84 and sternal OR 3.35), and Midwest region of service (OR 1.26, relative to South) (P < 0.001 for all). DISCUSSION A small but increasing minority of patients with clavicle fractures are managed surgically. Clinical factors and nonclinical factors were associated with surgical management.
Collapse
Affiliation(s)
- Meera M. Dhodapkar
- From the Yale Department of Orthopaedics and Rehabilitation, New Haven, CT
| | - Maxwell Modrak
- From the Yale Department of Orthopaedics and Rehabilitation, New Haven, CT
| | - Scott J. Halperin
- From the Yale Department of Orthopaedics and Rehabilitation, New Haven, CT
| | - Peter Joo
- From the Yale Department of Orthopaedics and Rehabilitation, New Haven, CT
| | - Xuan Luo
- From the Yale Department of Orthopaedics and Rehabilitation, New Haven, CT
| | - Jonathan N. Grauer
- From the Yale Department of Orthopaedics and Rehabilitation, New Haven, CT
| |
Collapse
|
18
|
Irfan SA, Ali AA, Ashkar A, Akram U, Fatima S, Baig MMA, Khan MW. Predictors requiring special attention to prevent clavicle fracture nonunion: a systematic review of literature. Trauma Surg Acute Care Open 2023; 8:e001188. [PMID: 38020862 PMCID: PMC10679979 DOI: 10.1136/tsaco-2023-001188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 11/12/2023] [Indexed: 12/01/2023] Open
Abstract
Background Clavicle fracture (CF) is the tenth most prevalent fracture, accounting for an annual incidence of 37/10,000. This systematic review highlights the factors contributing to the nonunion union of the clavicular fracture. Method A systematic search was conducted using three web-based databases up to August 12, 2022, for conducting qualitative analysis. Articles were screened for relevance, and only studies that met inclusion criteria based on PECOS; P (patients): participants diagnosed with clavicular fracture; E (exposure): nonunion, C (control): not applicable; O (outcomes): factors contributing to nonunion or delayed union; S (studies): trials and observational studies. The Newcastle-Ottawa Scale was used to assess the quality of the cohort studies. The Cochrane risk of bias tool was used to assess the bias in randomized control trials. Results Ten studies were selected after the final literature search. Two thousand seven hundred and sixty-six adult participants who were radiologically and clinically diagnosed with nonunion clavicular fracture were included to pool the qualitative results. Fall was the most dominant cause of clavicular fracture, followed by road traffic collisions. Open reduction was widely used to treat nonunion correction. The qualitative results suggested a prominent correlation of nonunion with advancing age, female gender, high energy trauma, high Disabilities of the Arm, Shoulder, and Hand Score, smoking, fracture displacement, clavicular shortening, the callus on radiography, and fracture movement. The mid-shaft fracture was the most dominant type of fracture in the included studies; highly associated with nonunion in comparison to medial or lateral CF. The previous history of operation was an independent factor contributing to nonunion. Conclusion The results of this systematic review suggested the predictors contributing to nonunion in the CF. Demographic factors such as advancing age with female gender are at higher risk of developing clavicular nonunion. Smoking was the most dominantly highlighted environmental factor contributing to nonunion. Diaphyseal or midshaft fracture was the most common site for nonunion. Therefore, we suggested that patients with the predictors mentioned above require special attention to prevent nonunion of the CFs. More studies should be conducted on this subject to assess the factors that pose a risk associated with the nonunion of the bone for better clinical management and outcomes of the fracture.
Collapse
Affiliation(s)
- Shayan Ali Irfan
- Orthopedic, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Abid Anwar Ali
- Orthopedic, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Anusha Ashkar
- Orthopedic, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Usama Akram
- Orthopedic, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Sameen Fatima
- Orthopedic, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | - Mirza M Ali Baig
- Orthopedic, Dow University of Health Sciences, Karachi, Sindh, Pakistan
| | | |
Collapse
|
19
|
Machado do Amaral F, Angeli Malavolta E, Brandao Andrade E Silva F, Garcia JC, da Silva Moura J, Assunção JH, Pecora JR. Comparative study of patients with midshaft clavicle fracture fixed with a locked plate via an open versus percutaneous approach. Injury 2023; 54 Suppl 6:110746. [PMID: 38143119 DOI: 10.1016/j.injury.2023.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/23/2023] [Accepted: 04/14/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVE To compare the results of surgical treatment of midshaft clavicle fractures, treated with the technique of minimally invasive plate osteosynthesis (MIPO) with locking compression plate versus open reduction and internal fixation (ORIF) with locked plate. METHODS Quasi-randomized comparative study, evaluating displaced midshaft clavicle fractures treated with MIPO versus ORIF, with procedures performed by a single surgeon. We evaluated patients at 12 months using the University of California at Los Angeles (UCLA) scale and radiographically at 8, 12, 26 and 52 weeks, in addition to describing complications. RESULTS We evaluated 44 patients; 22 submitted to MIPO and 22 to ORIF. The median UCLA scores at 12 months were 35 in the ORIF group and 35 in the MIPO group (p = 0.712). All patients had fracture healing at 3 months (p > 0.999). The mean surgery time was 87.5 min in the ORIF group and 47.5 in the MIPO (p < 0.001) group. As complications, 1 suture dehiscence (4.5%), 2 protruding plates (9.1%) and 1 change in sensitivity around the surgical wound (4.5%) were observed in the MIPO group, while in the ORIF group, 15 changes in sensitivity (68.2%) and 3 hypertrophic scars (13.6%) were observed. The only complication that showed a difference between the groups was the change in sensitivity (p < 0.001). No cases of pseudarthrosis or failure of osteosynthesis were identified in either technique. CONCLUSION This study demonstrated that the two treatments, ORIF and MIPO, are equally effective in the treatment of displaced middle third clavicle fractures. However, MIPO is superior to ORIF in regard to reduced surgical time and preservation of supraclavicular nerve sensitivity.
Collapse
Affiliation(s)
- Felipe Machado do Amaral
- Hospital Universitário HU, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
| | - Eduardo Angeli Malavolta
- Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil; HCor - Hospital do Coração, São Paulo, SP, Brazil
| | | | | | | | - Jorge Henrique Assunção
- Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Jose Ricardo Pecora
- Hospital Universitário HU, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| |
Collapse
|
20
|
Maheshwari P, Peshin C, Agarwal D. Functional Outcomes in Surgically Treated Clavicle Fractures: A Longitudinal Observational Study. Cureus 2023; 15:e48081. [PMID: 38046489 PMCID: PMC10689976 DOI: 10.7759/cureus.48081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/31/2023] [Indexed: 12/05/2023] Open
Abstract
Introduction The clavicle is the most unique long bone and has a significant incidence in terms of fractures. Operative fixation for clavicle fractures has seen a steep rise in terms of technique as well as type of implant. Although extensive studies have been carried out in relation to clavicle fractures and their treatment modalities, no proper guidelines or approach has been identified as ideal, and hence, this study was carried out to evaluate operative fixation as a viable strategy. Objective The objective of this article was to assess functional outcomes of plate fixation in clavicle fractures. Materials and methods This longitudinal prospective observational study included 30 patients treated for clavicle fractures with plate fixation in the Orthopedics Department of Himalayan Institute Hospital Trust (HIHT), Jollygrant, Dehradun, over a period of one year. Functional outcomes were assessed as Constant-Murley shoulder scores, and complications were recorded. Radiological assessment was done on the basis of time to union through follow-up skiagrams. Statistical analysis was performed using the SPSS statistical package version 17.0 (IBM Inc., Armonk, New York). Continuous variables are presented as mean ± SD, and categorical variables are presented as absolute numbers and percentages. Continuous variables and constant score values over time within the groups were analyzed using repeated measures analysis of variance (ANOVA) followed by Bonferroni's post hoc testing. A p-value of <0.05 was considered statistically significant. Results The mean age of patients undergoing surgical fixation of clavicle fractures was 36 ± 12.53 years, ranging from 18-65 years. Of the entire study group, 83.3% were males and 16.7% were females. Road traffic accident (RTA) was the most common cause of clavicle fracture, constituting 76.7% of the entire study population, followed by fall on the floor (20.0%), and one patient sustained trauma by being hit by a bull (3.3%). Our study demonstrated a mean Constant score of 73.87 ± 2.64, 82.80 ± 2.20, and 92.40 ± 2.37 at one-month, two-month, and four-month follow-up times, respectively, which was found to be statistically significant in terms of progression (p value<0.001). The mean union time of clavicle fractures in our study population was 12.1 weeks. Two patients in our study developed implant impingement. Conclusion Our study revealed that patients with clavicle fractures treated with plate fixation had statistically significant good functional outcome (Constant) scores at sequential follow-ups, consistent with available literature. Mean union time was also comparable to existing literature. Non-union was not noted in our study, and only two cases developed implant impingement. Hence, we conclude that early primary plate fixation for displaced clavicle fractures is a promising technique with good overall functional outcomes and patient satisfaction, especially in young, active patients.
Collapse
Affiliation(s)
- Prakhar Maheshwari
- Orthopedics, Royal Oldham Hospital, Manchester, GBR
- Orthopedic Surgery, Himalayan Institute of Medical Sciences, Dehradun, IND
| | - Chetan Peshin
- Orthopedics, Himalayan Institute of Medical Sciences, Dehradun, IND
| | | |
Collapse
|
21
|
Makaram NS, Simpson AHRW. Explanatory and pragmatic trials in orthopaedics - Have we done the right studies? Injury 2023; 54 Suppl 5:110905. [PMID: 37400326 DOI: 10.1016/j.injury.2023.110905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/12/2023] [Accepted: 06/16/2023] [Indexed: 07/05/2023]
Abstract
Recent decades have seen marked advances in the quality of clinical orthopaedic trauma research, and with this has come a rise in the number of randomised clinical trials (RCTs) being conducted in orthopaedic trauma. These trials have been largely valuable in driving evidence-based management of injuries which previously had clinical equipoise. However, though RCTs are traditionally seen as the 'gold standard' of high-quality research, this research method is comprised primarily of two entities, explanatory and pragmatic designs, each with its own strengths and limitations. Most orthopaedic trials lie within a continuum between these designs, with varying degrees of both pragmatic and explanatory features. In this narrative review we provide a summary of the nuances within orthopaedic trial design, the advantages and limitations of such designs, and suggest tools which may aid clinicians in the appropriate selection and evaluation of trial designs.
Collapse
Affiliation(s)
- N S Makaram
- Specialty Registrar (StR) in Trauma and Orthopaedics, Edinburgh Orthopaedics, The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SU, United Kingdom.
| | - A Hamish R W Simpson
- Professor of Orthopaedics and Trauma, Edinburgh Orthopaedics, The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SU, United Kingdom
| |
Collapse
|
22
|
Gobbell W, Edwards CM, Engel SR, Coyner KJ. Getting Athletes Back on the Field: Management of Clavicle Fractures and Return to Play. Clin Sports Med 2023; 42:649-661. [PMID: 37716728 DOI: 10.1016/j.csm.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
This chapter provides an overview of the prevalence of clavicle fractures in athletes. The evaluation and management of clavicle fractures in athletes is summarized, including surgical considerations, rehabilitation protocols, and return to sport guidelines. In this population, high rates of union are observed, but careful timing of return to sport is paramount to optimize performance and prevent reinjury.
Collapse
Affiliation(s)
- Wade Gobbell
- UConn Health Department of Orthopedic Surgery, 263 Farmington Avenue, Farmington, CT 06030, USA
| | - Christopher M Edwards
- UConn Health Department of Orthopedic Surgery, 263 Farmington Avenue, Farmington, CT 06030, USA
| | - Samuel R Engel
- UConn Health Department of Orthopedic Surgery, 263 Farmington Avenue, Farmington, CT 06030, USA
| | - Katherine J Coyner
- UConn Health Department of Orthopedic Surgery, 263 Farmington Avenue, Farmington, CT 06030, USA.
| |
Collapse
|
23
|
Ajit Singh V, Ho SC, Abdul Rashid ML, Santharalinggam RD. Functional and radiological outcome of non-operative treated clavicle fractures and its association with acromioclavicular joint arthrosis. J Orthop Surg (Hong Kong) 2023; 31:10225536231208242. [PMID: 37824849 DOI: 10.1177/10225536231208242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Clavicle fractures are traditionally treated non-operatively. This study determines the functional outcome of midshaft clavicle fractures treated non-operatively, the factors influencing it, and the incidence of acromioclavicular joint (ACJ) arthrosis. METHODS Patients with midshaft clavicular fractures treated non-operatively between 16 and 50 years old with no prior AC joint problems were assessed. Demographics, hand dominance, type of occupation, and smoking status were documented. Functional scoring using DASH score, CM score, and radiological evaluation was done with special tests to diagnose AC joint arthrosis. Two or more positive special tests were considered significant for this study. RESULTS 101 patients were recruited, 83 male and 18 female patients. The average age of 34.7 ± 13.93 years. The average follow-up was 32.7 months (range: 24-75; SD ± 9.9 months). 48.5% were blue-collar workers, and 60.4% involved the dominant upper limb. 44.6% were cigarette smokers. There was 20 mm and more shortening in 21.8% of subjects. 40.6% had a significant special test, and 36.6% had radiological changes of AC joint osteoarthritis. Positive two or more special tests were significantly associated with radiological evidence of arthrosis (p = .00). The mean DASH score was 28.28 ± 17.4, and the mean CM score was 27.58 ± 14.34. Most have satisfactory to excellent scores. Hand dominance, smoking, and blue-collar work were significantly associated with poorer CM scores, and hand dominance was significant for Dash scores. CONCLUSION There is an equal distribution poor, satisfactory and excellent functional outcomes in patients with midshaft clavicle fractures treated non-operatively. The poor outcomes may be attributed to ACJ arthrosis. Hand dominance, smoking and blue-collar work affected the functional outcome. Shortening of the clavicle had no bearing on the clinical and radiological findings of osteoarthritis and functional scores. The presence of two or more positive special tests is an accurate predictor of AC joint arthritis.
Collapse
Affiliation(s)
- Vivek Ajit Singh
- National Orthopaedic Centre of Excellence in Research & Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Shu Chien Ho
- National Orthopaedic Centre of Excellence in Research & Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Muhammad Lutfi Abdul Rashid
- National Orthopaedic Centre of Excellence in Research & Learning (NOCERAL), Department of Orthopaedic Surgery, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Rupini Devi Santharalinggam
- Department of Orthopaedic Surgery (NOCERAL), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
24
|
Han Z, Luo Q, Deng G, Bi C, Yin G, Lin H, Wu J, Wu X. Canceling Notch Improves the Mechanical Safety of Clavicle Locking Plate: A 3D Finite Element Study. Orthop Surg 2023; 15:2152-2156. [PMID: 36349872 PMCID: PMC10432472 DOI: 10.1111/os.13558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Implant failure is a disastrous complication of the operative treatment of midshaft clavicle fractures, and improving the osteosynthesis plate is a strategy for preventing this. We aimed to investigate whether canceling the notch and adding screw-hole inserts enhanced the mechanical properties of the plate. METHODS A clavicle model was generated based on the CT images of six adult volunteers (age range, 20-40 years; three males and three females; height range 160-175) using dedicated software, and a midshaft fracture model was created. The domestically made seven-hole locking plate commonly used for midshaft clavicle fractures was simulated (Model I); modifications were made to the plate (Model II). Using 3D finite element analysis, we simulated the fracture construct under three different load conditions-downward cantilever bending, axial compression, and axial torsion-and compared the stress distribution. RESULTS We found that under axial compression, Model II experienced its maximum stress on the plate at 551.9MPa, which was less than that in Model I (790.4 MPa). Moreover, a greater stress concentration at the fracture site was observed under axial torsion, despite the maximum stress of both the models being similar. CONCLUSION Canceling the notch and filling the screw holes near the fracture can ameliorate stress concentration on the internal fixation construct and enhance its reliability under axial compression. This improvement has substantial effects on the mechanical properties of implants and potentially prevents implant failure. Modern osteosynthesis anatomical implants need to be improved.
Collapse
Affiliation(s)
- Zhihua Han
- Trauma Center, Department of Orthopaedics and Traumatology, Shanghai General HospitalShanghai Jiaotong UniversityShanghaiChina
- Sino‐Euro Orthopaedics NetworkBerlinGermany
| | - Qian Luo
- Department of Radiology, Shanghai General HospitalShanghai Jiaotong UniversityShanghaiChina
| | - Guoying Deng
- Trauma Center, Department of Orthopaedics and Traumatology, Shanghai General HospitalShanghai Jiaotong UniversityShanghaiChina
| | - Chun Bi
- Trauma Center, Department of Orthopaedics and Traumatology, Shanghai General HospitalShanghai Jiaotong UniversityShanghaiChina
| | - Gang Yin
- Trauma Center, Department of Orthopaedics and Traumatology, Shanghai General HospitalShanghai Jiaotong UniversityShanghaiChina
| | - Haodong Lin
- Trauma Center, Department of Orthopaedics and Traumatology, Shanghai General HospitalShanghai Jiaotong UniversityShanghaiChina
| | - Jianhong Wu
- Trauma Center, Department of Orthopaedics and Traumatology, Shanghai General HospitalShanghai Jiaotong UniversityShanghaiChina
| | - Xiaoming Wu
- Trauma Center, Department of Orthopaedics and Traumatology, Shanghai General HospitalShanghai Jiaotong UniversityShanghaiChina
| |
Collapse
|
25
|
Dietrich G, Terrier A, Favre M, Elmers J, Stockton L, Soppelsa D, Cherix S, Vauclair F. Influence of smoking on the healing of conservatively treated displaced midshaft clavicle fractures. Bone Joint J 2023; 105-B:801-807. [PMID: 37391206 DOI: 10.1302/0301-620x.105b7.bjj-2022-1336.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
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.
Collapse
Affiliation(s)
- Gilles Dietrich
- Department of Orthopaedic Surgery & Traumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Alexandre Terrier
- Department of Orthopaedic Surgery & Traumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Laboratory of Biomechanical Orthopaedics, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Melissa Favre
- Department of Orthopaedic Surgery & Traumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jolanda Elmers
- Medical Library, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Laurie Stockton
- Department of Orthopaedic Surgery & Traumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Dino Soppelsa
- Department of Orthopaedic Surgery & Traumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Stéphane Cherix
- Department of Orthopaedic Surgery & Traumatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Frederic Vauclair
- Department of Orthopaedic Surgery & Traumatology, Bone and Motion Center, Hirslanden Clinique Bois-Cerf, Lausanne, Switzerland
| |
Collapse
|
26
|
Biz C, Pozzuoli A, Belluzzi E, Scucchiari D, Bragazzi NL, Rossin A, Cerchiaro M, Ruggieri P. An Institutional Standardised Protocol for the Treatment of Acute Displaced Midshaft Clavicle Fractures (ADMCFs): Conservative or Surgical Management for Active Patients? Healthcare (Basel) 2023; 11:1883. [PMID: 37444717 PMCID: PMC10341159 DOI: 10.3390/healthcare11131883] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/20/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Carlo Biz
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University-Hospital of Padova, Via Giustiniani 3, 35128 Padova, Italy
- Centre for Mechanics of Biological Materials, University of Padova, 35131 Padova, Italy
| | - Assunta Pozzuoli
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University-Hospital of Padova, Via Giustiniani 3, 35128 Padova, Italy
- Centre for Mechanics of Biological Materials, University of Padova, 35131 Padova, Italy
- Musculoskeletal Pathology and Oncology Laboratory, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
| | - Elisa Belluzzi
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University-Hospital of Padova, Via Giustiniani 3, 35128 Padova, Italy
- Centre for Mechanics of Biological Materials, University of Padova, 35131 Padova, Italy
- Musculoskeletal Pathology and Oncology Laboratory, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
| | - Davide Scucchiari
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University-Hospital of Padova, Via Giustiniani 3, 35128 Padova, Italy
| | - Nicola Luigi Bragazzi
- Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, Toronto, ON M3J 1P3, Canada
| | - Alessandro Rossin
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University-Hospital of Padova, Via Giustiniani 3, 35128 Padova, Italy
| | - Mariachiara Cerchiaro
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University-Hospital of Padova, Via Giustiniani 3, 35128 Padova, Italy
| | - Pietro Ruggieri
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University-Hospital of Padova, Via Giustiniani 3, 35128 Padova, Italy
- Centre for Mechanics of Biological Materials, University of Padova, 35131 Padova, Italy
| |
Collapse
|
27
|
Amaral FMDO, Malavolta EA, Silva FBDEAE, Altoé LS, Nunes CV, Pécora JR. MINIMALLY INVASIVE OSTEOSYNTHESIS FOR CLAVICULAR FRACTURE WITH LOCKED PLATE. ACTA ORTOPEDICA BRASILEIRA 2023; 31:e263742. [PMID: 37151728 PMCID: PMC10158968 DOI: 10.1590/1413-785220233102e263742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 06/28/2022] [Indexed: 05/09/2023]
Abstract
Objective To evaluate the clinical and radiographic results of the surgical treatment of fractures of the middle third of the clavicle, using the technique of minimally invasive plate osteosynthesis (MIPO) with locking. Methods Prospective case series, evaluating displaced fractures of the middle third of the clavicle submitted to MIPO with locking, with procedures performed by a single surgeon. Patients were evaluated at 12 months using the University of Los Angeles (UCLA) scale and anteroposterior radiographs of the clavicles with 45° cranial and caudal inclination, as well as reporting complications. Results In total, 15 patients were evaluated. The median of surgical time was 50 minutes (IQR 35). The UCLA scale had a median of 35 (IQR 2) at 12 months. All patients presented fracture healing. Minor complications occurred in three cases (20%), with two (13.3%) evolving with plate prominence and one (6.7%) with local paresthesia, while major complications occurred in only one case (6.7%), with suture dehiscence requiring surgical re-approach. Conclusion MIPO with locking is a viable option for the treatment of displaced fractures of the middle third of the clavicle, with excellent results according to the UCLA scale, fracture healing in all cases, and a low rate of complications. Level of Evidence IV, Case Series.
Collapse
Affiliation(s)
| | - Eduardo Angeli Malavolta
- Universidade de Sao Paulo, Hospital das Clínicas, Faculdade de Medicina, Sao Paulo, SP, Brazil
- Hospital do Coração, Sao Paulo, SP, Brazil
| | | | | | | | - José Ricardo Pécora
- Universidade de Sao Paulo, Hospital Universitário, Departamento de Ortopedia, Sao Paulo, SP, Brazil
| |
Collapse
|
28
|
Sepehri A, Guy P, Roffey DM, O’Brien PJ, Broekhuyse HM, Lefaivre KA. Assessing the Change in Operative Treatment Rates for Acute Midshaft Clavicle Fractures: Incorporation of Evidence-Based Surgery Results in Orthopaedic Practice. JB JS Open Access 2023; 8:JBJSOA-D-22-00096. [PMID: 37123504 PMCID: PMC10132723 DOI: 10.2106/jbjs.oa.22.00096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
In 2007, a randomized controlled trial (RCT) by the Canadian Orthopaedic Trauma Society (COTS) demonstrated better functional outcomes and a lower proportion of patients who developed malunion or nonunion following operative, compared with nonoperative, treatment of midshaft clavicle fractures. The primary aim of the present study was to compare the proportion of midshaft clavicle fractures treated operatively prior to and following the publication of the COTS RCT. An additional exploratory aim was to assess whether the proportion of midshaft clavicle fractures that were treated with surgery for malunion or nonunion decreased. Methods This retrospective cohort analysis used population-level administrative health data on the residents of British Columbia, Canada. Cases were identified by International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes and procedure fee codes. Adult patients (≥18 years) with closed middle-third clavicle fractures between 1997 and 2018 were included. Multivariable logistic regression modeling compared the proportion of clavicle fractures treated operatively before and after January 1, 2007, controlling for patient factors. The Pearson chi-square test compared the proportion of fractures treated operatively for malunion or nonunion in the cohorts. Results A total of 52,916 patients were included (mean age, 47.5 years; 65.6% male). More clavicle fractures were treated operatively from 2007 onward: 6.9% compared with 2.2% prior to 2007 (odds ratio [OR] = 3.35, 95% confidence interval [CI] = 3.03 to 3.70, p < 0.001). Male sex, moderate-to-high income, and younger age were associated with a greater proportion of operative fixation. The rate of surgery for clavicle malunion or nonunion also increased over this time period (to 4.1% from 3.4%, OR = 1.26, 95% CI = 1.15 to 1.38, p < 0.001). Conclusions We found a significant change in surgeon practice regarding operative management of clavicle fractures following the publication of a Level-I RCT. With limited high-quality trials comparing operative and nonoperative management, it is important that clinicians, health-care institutions, and health-authority administrations determine what steps can be taken to increase responsiveness to new clinical studies and evidence-based guidelines. Level of Evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Aresh Sepehri
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Pierre Guy
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Darren M. Roffey
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Peter J. O’Brien
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Henry M. Broekhuyse
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Kelly A. Lefaivre
- Department of Orthopaedics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver Coastal Health, Vancouver, British Columbia, Canada
- Email for corresponding author:
| |
Collapse
|
29
|
Campbell RJ, Handford C, Donaldson MJ, Sivakumar BS, Jiang E, Symes M. Surgical management of clavicle fractures in Australia: an analysis of Australian Medicare Benefits Schedule database from 2001 to 2020. ANZ J Surg 2023; 93:656-662. [PMID: 36754600 DOI: 10.1111/ans.18312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND There is no consensus on the optimal management of clavicle fractures, with advocates of both operative and non-operative management. The objective of this study is to assess the trends in the management of clavicle fractures in Australia over the past two decades. METHODS The incidence of surgical fixation of clavicle fractures from 2001 to 2020 was analysed using the Australian Medicare Benefits Schedule database, reflective of operations performed on privately insured patients, thus excluding public patients and compensable cases. An offset term was utilized with data from the Australian Bureau of Statistics to account for population changes over the study period. RESULTS A total of 17 089 procedures for the management of clavicle fractures were performed from 2001 to 2020. The incidence of operative intervention increased from 1.87 per 100 000 in 2001 to a peak of 6.63 per 100 000 in 2016. An overall increase was seen in males (310%) and females (347%) over the study period, as well as across all age groups. A greater proportion of operative interventions was performed on males (n = 14 075, 82%) than females (n = 3014, 18%, P < 0.001). The greatest increase in intervention was noted in those aged 65 or older (14% increase per year, 95% CI 11%-17%, P < 0.05). In 2020, the incidence of operative intervention decreased to a level last seen in 2013. CONCLUSIONS The incidence of operative interventions for clavicle fractures has increased in Australia over the 20-year study period. This increase is in keeping with recent evidence suggesting several advantages when displaced mid-shaft clavicle fractures are operatively managed.
Collapse
Affiliation(s)
- Ryan J Campbell
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Cameron Handford
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Matthew J Donaldson
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Brahman S Sivakumar
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Department of Hand and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Discipline of Surgery, Sydney Medical School, the Faculty of Medicine and Health, the University of Sydney, Sydney, New South Wales, Australia
- Department of Orthopaedic Surgery, Hornsby Ku-ring-gai Hospital, Sydney, New South Wales, Australia
- Department of Orthopaedic Surgery, Nepean Hospital, Sydney, New South Wales, Australia
| | - Eric Jiang
- Surgical Education Research and Training Institute, Royal North Shore Hospital, Northern Sydney Local Health District, Sydney, New South Wales, Australia
| | - Michael Symes
- Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Department of Orthopaedic Surgery, St George Hospital, Sydney, New South Wales, Australia
- St George and Southerland Clinical School, University of New South Wales Medicine, Sydney, New South Wales, Australia
| |
Collapse
|
30
|
Anteroinferior plating is an independent factor for decreasing symptomatic implant removal rates after plate fixation for midshaft clavicle fractures. OTA Int 2023; 6:e253. [PMID: 36846523 PMCID: PMC9953037 DOI: 10.1097/oi9.0000000000000253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 12/23/2022] [Indexed: 02/10/2023]
Abstract
Objectives The factors that significantly influence the symptomatic implant removal rates after plate fixation for midshaft clavicle fractures remain controversial. The purpose of this study was to compare the symptomatic implant removal rates between 2 different types of plating technique and to evaluate independently associated factors. Design Retrospective cohort study. Setting Acute care center. Patients/Participants A total of 71 patients 16 years or older who were diagnosed with displaced midshaft clavicle fractures from April 2016 to March 2020. Intervention Thirty-nine patients were treated with superior plating (Group SP), and the remaining 32 patients were treated with anteroinferior plating (Group AIP). Main Outcome Measurements Symptomatic implant removal rates after plate fixation for midshaft clavicle fractures. Results Symptomatic implant removal rates were significantly lower in Group AIP (28.1%) than in Group SP (53.8%) (P = 0.033). Multivariate analyses showed that symptomatic implant removal rates were significantly decreased by three independent factors, namely AIP (odds ratio [OR] = 0.323) (P = 0.037), greater age (45 years or older) (OR = 0.312) (P = 0.029), and high body mass index (≥25 kg/m2) (OR = 0.117) (P = 0.034). Conclusions AIP significantly and independently decreased the symptomatic implant removal rate. Among the three explanatory factors showing significant difference, plating technique is the only factor that can be altered by medical institutions. Therefore, we recommend this technique for displaced midshaft clavicle fractures to reduce a second surgery such as symptomatic implant removal. Level of Evidence Level 3, retrospective cohort study.
Collapse
|
31
|
Minimally invasive plate osteosynthesis for clavicle fractures. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023; 35:92-99. [PMID: 36723629 DOI: 10.1007/s00064-023-00798-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/22/2022] [Accepted: 08/01/2022] [Indexed: 02/02/2023]
Abstract
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.
Collapse
|
32
|
Yetter T, Harper J, Weatherby PJ, Somerson JS. Complications and Outcomes After Surgical Intervention in Clavicular Nonunion: A Systematic Review. JBJS Rev 2023; 11:01874474-202301000-00012. [PMID: 36722838 DOI: 10.2106/jbjs.rvw.22.00171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Surgical repair of clavicle fractures is being employed more frequently, although most fractures are still treated conservatively. Both can result in nonunion. Current treatments for clavicle nonunion include open reduction with internal fixation (ORIF) plating without bone graft, ORIF plating with bone graft, and intramedullary pin fixation. METHODS We performed a systematic review and meta-analysis of studies reporting outcome, complication, and reoperation rates following surgical treatment for clavicle nonunion. Subgroup analysis was undertaken for outcome and complication rates between single plating and intramedullary pin fixation, bone graft use, and nonunion time length definition. RESULTS Fifty-three studies met inclusion criteria (1,258 clavicle nonunions). Mean clinical follow-up was 2.6 years. Seventy-two percent of nonunions were of the middle third, 1% were proximal third, 12% were distal third, and 15% were not reported. Forty-eight percent of nonunions were atrophic or oligotrophic and 17% were hypertrophic (35% not reported). Mean time to union was 13.6 weeks. Ninety-five percent of patients achieved union after the primary nonunion surgery. Overall complication rate was 17%. Single-plating fixation had significantly faster union time (15.2 vs. 19.8 weeks), lower reoperation rate (23% vs. 37%), and hardware removal rate (20% vs. 34%) than intramedullary pin fixation. Bone graft had significantly lower rates of delayed union (0.6% vs. 3.6%) but higher complication (15% vs. 8%) and reoperation rates (29% vs. 14%) than the other groups. Studies that defined nonunion after 3 months had significantly faster union times than the 6-month studies (13 vs. 16 weeks). The 3-month group had a significantly lower overall complication rate (12% vs. 25%) and hardware/fixation failure rate (3% vs. 5.5%) than the 6-month group. CONCLUSIONS This systematic review is the largest report of complications, reoperations, and patient outcomes of clavicle nonunions after surgical intervention in the current literature. Plating showed faster time to union and lower reoperation rates than intramedullary pin fixation. Bone graft use showed lower rates of delayed union but substantially higher rates of complications and reoperations. Reports with a definition of nonunion at 3 months showed faster union times and lower complication rates compared to reports with a definition of nonunion that was 6 months or greater. Surgery could be considered at 3 months post-injury in cases of symptomatic non-united clavicle fracture, and plating results in reliable outcomes. Adjuvant bone grafting requires further study to determine its value and risk/benefit ratio. LEVEL OF EVIDENCE Level IV, Systematic Review. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Thomas Yetter
- John Sealy School of Medicine, The University of Texas Medical Branch, Galveston, Texas
| | - Jacob Harper
- John Sealy School of Medicine, The University of Texas Medical Branch, Galveston, Texas
| | - Paul J Weatherby
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
| | - Jeremy S Somerson
- Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
| |
Collapse
|
33
|
Traumatic brain injuries are ignored or discriminated in prospective clinical trials on shoulder fractures: a systematic review. INTERNATIONAL ORTHOPAEDICS 2023; 47:17-50. [PMID: 36435944 DOI: 10.1007/s00264-022-05642-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/10/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Current literature suggests a significant epidemiological association between traumatic brain injury (TBI) and proximal upper limb fractures in addition to major clinical consequences. A systematic review was conducted to assess how TBI is taken into consideration in interventional studies on shoulder fractures. METHODS The following data sources were used: MEDLINE, EMBASE, EBM Reviews, CINAHL, and OpenGrey databases. Study selection included interventional randomized clinical trials and prospective cohort studies on shoulder fractures published in English or French between 2008 and 2020. Studies on pathologic fractures, chronic fracture complications, nonhuman subjects, and biomechanics were excluded. Articles were reviewed by two independent authors according to the PRISMA guidelines. Baseline characteristics, exclusion criteria, and input relevant to TBI were recorded. Methodological quality was assessed with the Cochrane risk of bias tool for randomized clinical trials and the Newcastle-Ottawa Scale for cohort studies. RESULTS One-hundred-thirteen studies met the inclusion criteria. None discussed the possible impact of TBI on their results. Only three (2.7%) studies considered TBI relevant and included these patients in their cohort. Furthermore, 43/113 (38.1%) excluded patients with injuries or mechanisms strongly related to traumatic brain injuries: head injuries (4); moderate and/or severe TBI (7); high energy traumas (3); Polytrauma subjects (33). CONCLUSION TBI are ignored or discriminated in prospective clinical trials on shoulder fractures. The exclusion of these cases impacts generalizability as their prevalence is significant. Considering the major impact of TBI on important outcomes, its presence should always be assessed to ensure high quality evidence. LEVEL OF EVIDENCE Systematic Review, Therapeutic Level II.
Collapse
|
34
|
Rawal A, Mannambeth R, Murray S, Moaveni A. Clavicular osteotomy to assess subclavian vein injury during internal fixation of midshaft clavicle fractures. Shoulder Elbow 2022; 14:642-647. [PMID: 36479011 PMCID: PMC9720870 DOI: 10.1177/17585732211047206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 08/21/2021] [Accepted: 08/21/2021] [Indexed: 11/17/2022]
Abstract
Midshaft clavicle fractures are commonly fixed with locking plates. The subclavian vein risks injury during this procedure and the consequences can be fatal. The purpose of this present study is to describe a clavicular osteotomy technique in order to equip orthopaedic surgeons with a means of rapidly accessing a subclavian vein injury. The osteotomy should only be performed following an urgent intraoperative vascular surgery assessment. There must be shared consensus from both orthopaedic and vascular surgery that direct repair of the subclavian vein is necessary, and further exposure is required. The results of the technique performed on thirteen embalmed cadaveric specimens are also included. The osteotomy was able to expose 3.16 cm (SD = 0.60) of the subclavian vein and both the fracture and osteotomy site of all clavicles (100%) were able to be reduced and fixed using a single pre-contoured fifteen-hole lateral plate intended for use on the contralateral shoulder. This surgical technique study confirms that in the rare circumstance that the osteotomy is utilized, adequate exposure of the subclavian vein is achieved.
Collapse
Affiliation(s)
- Aziz Rawal
- The Department of Orthopaedic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
- The Department of Anatomy and Neuroscience, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rejith Mannambeth
- The Department of Orthopaedic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Simon Murray
- The Department of Anatomy and Neuroscience, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ash Moaveni
- The Department of Orthopaedic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
35
|
Kumar AV, Ramachandra Kamath K, Salian PRV, Krishnamurthy SL, Annappa R, Keerthi I. Operative stabilisation versus non-operative management of mid-shaft clavicle fractures. SICOT J 2022; 8:45. [PMID: 36426961 PMCID: PMC9879146 DOI: 10.1051/sicotj/2022046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/06/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Fractures of the mid-shaft clavicle are commonly encountered in clinical practice. These can be managed either by conservative method or operative by internal fixation. This study aims to compare the outcomes of conservative and operative management. METHODS Forty patients with displaced and comminuted mid-shaft clavicle fractures were included in the study, among which twenty-five patients were treated conservatively and 15 patients underwent surgery and were followed up for a period of 1 year. Time taken for union, functional outcome, complications, and patient satisfaction were compared. RESULTS In the non-operative group, 28% of the fractures took less than twelve weeks to unite, whereas in the operative group 60% of them took less than 12 weeks to unite. At the end of 1 year, there was no statistical difference in mean UCLA (University of California and Los Angeles) score and the mean DASH score of the non-operative group and operative group. There were more complications in the operative group. Re-operative rate in the operative group was 40%. Patient satisfaction was 80% in the non-operative group, whereas 48% of patients were satisfied in the operative group. CONCLUSION Displaced and comminuted mid-shaft clavicle fractures treated conservatively have more advantages when compared to surgically treated fractures.
Collapse
Affiliation(s)
- Alla Vasanth Kumar
- Department of Orthopaedics, Asram Medical College Eluru Andhra Pradesh India
| | - K. Ramachandra Kamath
- Department of Orthopaedics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education Manipal Karnataka 576104 India
| | - Preetham Raj V. Salian
- Department of Orthopaedics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education Manipal Karnataka 576104 India
| | - Sunil Lakshmipura Krishnamurthy
- Clinical Fellow in Sports Injury and Arthroscopy, Department of Orthopaedics, Division of Sports Injury and Arthroscopy, St John’s Medical College Bangalore Karnataka 560034 India
| | - Rajendra Annappa
- Department of Orthopaedics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education Manipal Karnataka 576104 India
,Corresponding author:
| | - Ishwara Keerthi
- Department of Orthopaedics, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education Manipal Karnataka 576104 India
| |
Collapse
|
36
|
Khoriati AA, Fozo ZA, Al-Hilfi L, Tennent D. Closed midshaft clavicle fractures. Bone Jt Open 2022; 3:850-858. [DOI: 10.1302/2633-1462.311.bjo-2022-0083.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Aims The management of mid-shaft clavicle fractures (MSCFs) has evolved over the last three decades. Controversy exists over which specific fracture patterns to treat and when. This review aims to synthesize the literature in order to formulate an appropriate management algorithm for these injuries in both adolescents and adults. Methods This is a systematic review of clinical studies comparing the outcomes of operative and nonoperative treatments for MSCFs in the past 15 years. The literature was searched using, PubMed, Google scholar, OVID Medline, and Embase. All databases were searched with identical search terms: mid-shaft clavicle fractures (± fixation) (± nonoperative). Results Using the search criteria identified, 247 studies were deemed eligible. Following initial screening, 220 studies were excluded on the basis that they were duplicates and/or irrelevant to the research question being posed. A total of 27 full-text articles remained and were included in the final review. The majority of the meta-analyses draw the same conclusions, which are that operatively treated fractures have lower nonunion and malunion rates but that, in those fractures which unite (either operative or nonoperative), the functional outcomes are the same at six months. Conclusion With regard to the adolescent population, the existing body of evidence is insufficient to support the use of routine operative management. Regarding adult fractures, the key to identifying patients who benefit from operative management lies in the identification of risk factors for nonunion. We present an algorithm that can be used to guide both the patient and the surgeon in a joint decision-making process, in order to optimize patient satisfaction and outcomes. Cite this article: Bone Jt Open 2022;3(11):850–858.
Collapse
|
37
|
Chen W, Wang B, Liu Z. A fluoroscopic view for midshaft clavicular fracture reduction and internal fixation: posteroanterior 25° skyline projection. BMC Surg 2022; 22:371. [PMID: 36309726 PMCID: PMC9618203 DOI: 10.1186/s12893-022-01813-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background Open reduction and internal fixation have been frequently applied for displaced midshaft clavicular fracture. Plate and screw fixation of clavicular fractures could provide rigid fixation and rotational control. Proper implant positioning in surgical fixation is critical to prevent iatrogenic complications. Fluoroscopy plays an important role in the intraoperative evaluation of implants. This study aimed to introduce a new fluoroscopic projection to evaluate the positioning of plates and screws. Methods Adult patients with a diagnosis of acute displaced midshaft clavicular fracture were included in this study. The slope angle of the midshaft clavicle was measured on sagittal reconstructions of preoperative computed tomography (CT) scans. The incidence of screw revision based on intraoperative standard posteroanterior (PA) and PA 25° cephalic skyline projections was compared. The interobserver agreement for the two projections was calculated. Results Twenty-nine patients with midshaft clavicular fractures were enrolled from January 2020 to June 2021. The PA 25° skyline projection could clearly display the tangential line of the plate and inferior border of the clavicle. The slope angle on the superior surface of the midshaft clavicle was 26.0 ± 5.8° (range: 18.5–38.3°). The incidence of screw revision using the PA projection (72.4%) was significantly different from that using the PA 25° skyline projection (34.5%) (P < 0.05). The concordance of the screw revision rate based on the standard PA and PA 25° skyline projections was strong, with kappa coefficients of 0.680 (95% CI: 0.394–0.968) and 0.776 (95% CI: 0.537–0.998). Conclusion The PA 25° skyline projection corresponds to the slope angle of the midshaft clavicle. It can provide more accurate information regarding the proper screw length and be applied as a routine method for intraoperative evaluation.
Collapse
|
38
|
Wall KC, Reddy GB, Corrigan KL, Toth AP, Garrigues GE. Operative Versus Nonoperative Management of Displaced Midshaft Clavicle Fractures: A Cost-effectiveness Analysis. Orthopedics 2022; 45:e243-e251. [PMID: 35700404 DOI: 10.3928/01477447-20220608-08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
To date, the optimal management of displaced midshaft clavicle fractures remains unknown. Operatively, plate or nail fixation may be used. Nonoperatively, the options are sling or harness. Given the equivocal effectiveness between approaches, the costs to the health care system and the patient become critical considerations. A decision tree model was constructed to study plate and sling management of displaced midshaft clavicle fractures. Primary analysis used 6 randomized controlled trials that directly compared open reduction and internal fixation with a plate to sling. Secondary analysis included 18 studies that studied either plate, sling, or both. Incremental cost-effectiveness ratios (ICERs) were calculated using quality-adjusted life-years (QALYs). Second-order Monte Carlo probabilistic sensitivity analysis (PSA) was subsequently conducted. In primary analysis, at a willingness-to-pay (WTP) threshold of $100,000, operative management was found to be less cost-effective relative to nonoperative management, with an ICER of $606,957/QALY (0.03 additional QALYs gained for an additional $16,120). In PSA, sling management was cost-effective across all WTP ranges. In secondary analysis, the ICER decreased to $75,230/QALY. Primary analysis shows that plate management is not a cost-effective option. In secondary analysis, the incremental effectiveness of plate management increased enough that the calculated ICER is below the WTP threshold of $100,000; however, the strength of evidence in secondary analysis is lower than in primary analysis. Thus, because neither option is dominant in this model, both plate and sling remain viable approaches, although the cost-conscious decision will be to treat these fractures with a sling until future data suggest otherwise. [Orthopedics. 2022;45(5):e243-e251.].
Collapse
|
39
|
Heyworth BE, Pennock AT, Li Y, Liotta ES, Dragonetti B, Williams D, Ellis HB, Nepple JJ, Spence D, Willimon SC, Perkins CA, Pandya NK, Kocher MS, Edmonds EW, Wilson PL, Busch MT, Sabatini CS, Farley F, Bae DS. Two-Year Functional Outcomes of Operative vs Nonoperative Treatment of Completely Displaced Midshaft Clavicle Fractures in Adolescents: Results From the Prospective Multicenter FACTS Study Group. Am J Sports Med 2022; 50:3045-3055. [PMID: 35984091 DOI: 10.1177/03635465221114420] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The optimal treatment of midshaft clavicle fractures is controversial. Few previous comparative functional outcome studies have investigated these fractures in adolescents, the most commonly affected epidemiologic subpopulation. PURPOSE/HYPOTHESIS The purpose was to prospectively compare the outcomes of operative versus nonoperative treatment in adolescents with completely displaced midshaft clavicle fractures. The study hypothesis was that surgery would yield superior outcomes. STUDY DESIGN Cohort study; Level of evidence, 2. METHODS Patients aged 10 to 18 years treated for a midshaft clavicle fracture over a 5-year period at 1 of 8 pediatric centers were prospectively screened, with independent treatment decisions determined by individual musculoskeletal professionals. Demographics, radiographic clinical features, complications, and patient-reported outcomes (PROs) were prospectively recorded for 2 years. Regression and matching techniques were utilized to adjust for potential age- and fracture severity-based confounders for creation of comparable subgroups for analysis. RESULTS Of 416 adolescents with completely displaced midshaft clavicle fractures, 282 (68) provided 2-year PRO data. Operative patients (n = 88; 31%) demonstrated no difference in sex (78% male) or athletic participation but were older (mean age, 15.2 vs 13.5 years; P < .001), had more comminuted fractures (49.4% vs 26.3%; P < .001), and had greater fracture shortening (25.5 vs 20.7 mm; P < .001) than nonoperative patients (n = 194; 69%). There was no difference in mean PRO scores or rates of "suboptimal" scores (based on threshold values established a priori) between the operative and nonoperative treatment groups (American Shoulder and Elbow Surgeons, 96.8 vs 98.4; shortened version of the Disabilities of the Arm, Shoulder and Hand, 3.0 vs 1.6; EuroQol [EQ] visual analog scale, 93.0 vs 93.9; EQ-5 Dimensions index, 0.96 vs 0.98), even after regression and matching techniques adjusted for confounders. Operative patients had more unexpected subsequent surgery (10.4% vs 1.4%; P = .004) and clinically significant complications (20.8% vs 5.2%; P = .001). Overall, nonunion (0.4%), delayed union (1.9%), symptomatic malunion (0.4%), and refracture (2.6%) were exceedingly rare, with no difference between treatment groups. CONCLUSION Surgery demonstrated no benefit in patient-reported quality of life, satisfaction, shoulder-specific function, or prevention of complications after completely displaced clavicle shaft fractures in adolescents at 2 years after injury. REGISTRATION NCT04250415 (ClinicalTrials.gov identifier).
Collapse
Affiliation(s)
- Benton E Heyworth
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Andrew T Pennock
- Department of Orthopedics, Rady Children's Hospital, San Diego, California, USA
| | - Ying Li
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Brittany Dragonetti
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - David Williams
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Henry B Ellis
- Sports Medicine Center, Texas Scottish Rite Hospital, Dallas, Texas, USA
| | - Jeffrey J Nepple
- Department of Orthopedic Surgery, School of Medicine, Washington University, St Louis, Missouri, USA
| | - David Spence
- Department of Orthopaedic Surgery, Campbell Clinic Orthopaedics, Memphis, Tennessee, USA
| | | | - Crystal A Perkins
- Department of Orthopedic Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Nirav K Pandya
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Mininder S Kocher
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eric W Edmonds
- Department of Orthopedics, Rady Children's Hospital, San Diego, California, USA
| | - Philip L Wilson
- Sports Medicine Center, Texas Scottish Rite Hospital, Dallas, Texas, USA
| | - Michael T Busch
- Department of Orthopedic Surgery, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Coleen S Sabatini
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Frances Farley
- Department of Orthopaedic Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Donald S Bae
- Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Investigation performed at Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
40
|
Fox B, Clement ND, MacDonald DJ, Robinson M, Nicholson JA. Plate fixation of midshaft clavicle fractures for delayed union and non-union is a cost-effective intervention but functional deficits persist at long-term follow-up. Shoulder Elbow 2022; 14:360-367. [PMID: 35846398 PMCID: PMC9284296 DOI: 10.1177/1758573221990367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/27/2020] [Accepted: 12/31/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The primary aim of this study was to compare the long-term functional outcome of midshaft clavicle fracture fixation for delayed (≥3 month) and non-union (≥6 month) compared to a matched cohort of patients that achieved union with non-operative management. The secondary aim was to assess cost-effectiveness of fixation. METHODS A consecutive series of patients over 10-years were retrospectively reviewed using the QuickDASH, Oxford Shoulder Score and EuroQol five-dimension summary index (EQ-5D). These patients were compared to a matched cohort that achieved union after non-operative management using propensity score matching. RESULTS Sixty patients (follow-up 79%, n = 60/76) at 4.1 years post-operative (1.1-10.0 years) had a QuickDASH of 16.5 (95% CI 11.6-21.5), Oxford Shoulder Score 41.5 (39.0-44.1) and EQ-5D 0.7621 (0.6822-0.8421). One in five patients were dissatisfied with their final outcome (n = 13/60). Functional outcome was inferior following fixation when compared to patients that united with non-operative management (QuickDASH 16.5 vs. 5.5, p < 0.001 and EQ-5D 0.7621 vs. 0.9073, p = 0.001). However, significant improvements were found when compared to pre-operative scores (QuickDASH p < 0.001 and EQ-5D p < 0.001). The cost per QALY for fixation was £5624.62 for the study cohort. CONCLUSIONS Clavicle fixation for delayed and non-union is a cost-effective intervention but outcomes are worse compared to patients that unite with non-operative management.
Collapse
Affiliation(s)
- Ben Fox
- Jamie A Nicholson, Department of Trauma and
Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK.
| | | | | | | | | |
Collapse
|
41
|
Ankers T, Sawalha S, Nixon M, Kenyon P, Webb M. Does a skin incision along Langer's lines reduce complications following fixation of displaced middle-third clavicle fractures? Arch Orthop Trauma Surg 2022; 142:1003-1007. [PMID: 33555400 DOI: 10.1007/s00402-021-03766-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/01/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Internal fixation of displaced middle-third clavicle fractures is a widely used treatment but is frequently associated with post-operative complications. The aim of this study is to investigate whether or not using a skin incision along Langer's lines, as opposed to a traditional transverse incision, reduces complications. METHODS We retrospectively reviewed data on 108 patients who underwent open reduction and internal fixation of mid-shaft clavicle fractures between 2014 and 2018. Either an oblique incision along Langer's lines or a transverse incision was used according to surgeon's preference. A pre-contoured diaphyseal locking plate was used in all cases. We collected data on fracture classification, minor complications (irritation from plate, chest wall numbness, superficial wound infection) and major complications (irritation from plate necessitating metalwork removal, periprosthetic fracture, deep infection, neurovascular injury and non-union). Statistical analysis was performed using multivariant regression analysis and Fisher's exact tests. RESULTS Fifty-seven patients underwent fixation using the oblique incision and 51 via the transverse incision. Age, gender and fracture pattern in the two groups were comparable. There were 14 minor and 6 major complications in the oblique group. In the transverse group, there were 16 minor and 5 major complications. The major complication rate was 10.5% in the oblique group and 9.8% in the transverse group. The overall major complication rate was 10.2%. No statistically significant difference in the rate of complications between the two groups was identified. CONCLUSION Based on our data, an incision following Langer's lines does not reduce the rate of complications following fixation of displaced middle-third clavicle fractures.
Collapse
Affiliation(s)
- Thomas Ankers
- Countess of Chester Hospital, Chester, UK. .,Countess of Chester Hospital, Liverpool Road, Chester, CH2 1UL, UK.
| | - Seif Sawalha
- Countess of Chester Hospital, Liverpool Road, Chester, CH2 1UL, UK
| | - Matthew Nixon
- Countess of Chester Hospital, Liverpool Road, Chester, CH2 1UL, UK
| | - Peter Kenyon
- Countess of Chester Hospital, Liverpool Road, Chester, CH2 1UL, UK
| | - Mark Webb
- Countess of Chester Hospital, Liverpool Road, Chester, CH2 1UL, UK
| |
Collapse
|
42
|
Shi F, Hu H, Tian M, Fang X, Li X. Comparison of 3 treatment methods for midshaft clavicle fractures: A systematic review and network meta-analysis of randomized clinical trials. Injury 2022; 53:1765-1776. [PMID: 35459544 DOI: 10.1016/j.injury.2022.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/01/2022] [Accepted: 04/05/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Our study aims to evaluate the fracture nonunion rate and the functional score of plate and screw fixation, intramedullary nailing and non-surgical treatment in midshaft clavicle fractures patients using a network meta-analysis of data from clinical randomized controlled trials. MATERIAL/METHODS The studies were abstracted from Medline, Embase, Web of Science, Google Scholar and the Cochrane Central Register of Controlled Trials. RCTs meeting the inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 14.0 (Stata Corporation, College Station, Texas, USA). RESULTS 24 randomized controlled trials involving 2161 participants were included. The studies were published between 2007 and 2019. A total of 3 treatment methods-plate and screw fixation, intramedullary nailing and non-surgical treatment- were included in the literature. The treatments were ranked based on the Surface Under the Cumulative Ranking Curve (SUCRA) probability. In terms of the constant score, the treatment methods were ranked as follows: intramedullary nailing, plate and screw fixation and non-surgical treatment. In terms of the DASH index, the treatment methods were ranked as follows: intramedullary nailing, plate and screw fixation and non-surgical treatment. In terms of the nonunion rate, the treatment methods were ranked as follows: intramedullary nailing, plate and screw fixation and non-surgical treatment. CONCLUSION Non-surgical treatment has a high rate of nonunion for clavicular fractures with obvious displacement and notable comminution. Surgical treatment reduces the nonunion rate leads to better functional scores at long-term follow-up, although there may be no significant clinical differences. The fracture nonunion rate of plate screw fixation group and intramedullary nail group was low and the functional prognosis was similar. More RCTs focused on clavicular fractures are needed to further substantiate this conclusion.
Collapse
Affiliation(s)
- Fangling Shi
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, Ningbo 315040, China
| | - Haoliang Hu
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, Ningbo 315040, China
| | - Mintao Tian
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, Ningbo 315040, China
| | - Xuanliang Fang
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, Ningbo 315040, China
| | - Xueyuan Li
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, Ningbo 315040, China.
| |
Collapse
|
43
|
Biz C, Scucchiari D, Pozzuoli A, Belluzzi E, Bragazzi NL, Berizzi A, Ruggieri P. Management of Displaced Midshaft Clavicle Fractures with Figure-of-Eight Bandage: The Impact of Residual Shortening on Shoulder Function. J Pers Med 2022; 12:759. [PMID: 35629181 PMCID: PMC9145303 DOI: 10.3390/jpm12050759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Carlo Biz
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (C.B.); (D.S.); (E.B.); (P.R.)
| | - Davide Scucchiari
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (C.B.); (D.S.); (E.B.); (P.R.)
| | - Assunta Pozzuoli
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (C.B.); (D.S.); (E.B.); (P.R.)
- Musculoskeletal Pathology and Oncology Laboratory, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
| | - Elisa Belluzzi
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (C.B.); (D.S.); (E.B.); (P.R.)
- Musculoskeletal Pathology and Oncology Laboratory, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 3, 35128 Padova, Italy
| | - Nicola Luigi Bragazzi
- Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, Toronto, ON M3J 1P3, Canada;
| | - Antonio Berizzi
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (C.B.); (D.S.); (E.B.); (P.R.)
| | - Pietro Ruggieri
- Orthopedics and Orthopedic Oncology, Department of Surgery, Oncology and Gastroenterology DiSCOG, University of Padova, Via Giustiniani 3, 35128 Padova, Italy; (C.B.); (D.S.); (E.B.); (P.R.)
| |
Collapse
|
44
|
Yan MZ, Yuen WS, Yeung SC, Wing-yin CW, Wong SCY, Si-qi WW, Tian E, Rashed S, Yung CSY, Fang CX. Operative management of midshaft clavicle fractures demonstrates better long-term outcomes: A systematic review and meta-analysis of randomised controlled trials. PLoS One 2022; 17:e0267861. [PMID: 35486618 PMCID: PMC9053819 DOI: 10.1371/journal.pone.0267861] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/16/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Midshaft clavicular fractures are common amongst young adults. Conservative or surgical treatment for definitive fracture management has been widely debate, both with their pros and cons. Previous meta-analyses compared the clinical outcomes between conservative and surgical treatment options of midshaft clavicular fractures but failed to elucidate any difference in functional improvement. We postulate that functional improvement after fracture union plateaus and the clinical outcome after treatment varies at different time points. This meta-analysis will focus on the synthesis comparison of outcomes at early, short-term results (3 months), intermediate-term (6 to 12 months) and long-term (>24 months) clinical outcomes. Methods A systematic search was done on databases (Pubmed, Embase, Medline, Cochrane) in June 2021. Search keywords were: midshaft clavicular fractures and clinical trials. Clinical trials fulfilling the inclusion criteria were selected for comparison and the clinical outcomes of midshaft clavicular fractures using surgical and non-surgical interventions in terms of improvement in the Disabilities of the Arm, Shoulder and Hand (DASH) score, Constant-Murley Score (CMS), time to union and risk ratio of treatment related complications were analysed in correlation with post-treatment timeframe. Results Of the 3094 patients of mean age 36.7 years in the 31 selected studies, surgical intervention was associated with improved DASH score (standard-mean difference SMD -0.22, 95% CI -0.36 to -0.07, p = 0.003; mean difference MD -1.72, 95% CI -2.93 to -0.51, p = 0.005), CMS (SMD 0.44, 95% CI 0.17–0.72, p = 0.001; MD 3.64, 95% CI 1.09 to 6.19, p = 0.005), time to union (non-adjusted SMD -2.83, 95% CI -4.59 to -1.07, p = 0.002; adjusted SMD -0.69, 95% CI -0.97 to -0.41, p<0.001) and risk ratio of bone-related complications including bone non-union, malunion and implant failure (0.21, 95% CI 0.1 to 0.42; p<0.001). Subgroup analysis based on time period after treatment showed that surgical intervention was far superior in terms of improved DASH score at the intermediate-term results (6–12 months later, SMD -0.16, 95% CI -0.30 to -0.02, p = 0.02; and long term results (>24 months SMD -4.24, 95% CI -7.03 to -1.45, p = 0.003) and CMS (>24 months, SMD 1.03, 95% CI 0.39 to 1.68, p = 0.002; MD 5.77, 95% CI 1.63 to 9.91, p = 0.006). Surgical outcome is independent of fixation with plates or intra-medullary nails. Conclusion Surgical intervention was associated with better clinical outcomes compared with non-surgical approach for midshaft clavicular fractures in terms of improvement in functional scores DASH, CMS, time to union and fracture related complications, although not to the minimal clinically significant difference. Benefits in the long-term functional improvements are more pronounced.
Collapse
Affiliation(s)
- Michael Zhipeng Yan
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Wing-sze Yuen
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Sung-ching Yeung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Christie Wong Wing-yin
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Sonia Choi-ying Wong
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Walter Wang Si-qi
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Elaine Tian
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Shireen Rashed
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Colin Shing Yat Yung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Christian Xinshuo Fang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
- * E-mail:
| |
Collapse
|
45
|
Mendes Junior AF, Tavares AK, Oppe IG, Pires RE, Belangero WD, Labronici PJ. Pre-contoured superior locking plates offer poor bone fit for midshaft clavicle fracture fixation: cadaveric analysis of 4 commercially available systems. Rev Col Bras Cir 2022; 49:e20223177. [PMID: 35588535 PMCID: PMC10578834 DOI: 10.1590/0100-6991e-20223177en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/08/2021] [Indexed: 10/18/2023] Open
Abstract
OBJECTIVE The goal of this study is to verify how commercially available pre-contoured superior plates fit on clavicle midshaft fractures. METHODS 100 cadaveric clavicles were evaluated by three distinct observers applying the clavicle congruence score and comparing four different 6 to 8-hole pre-contoured anatomic locking-plate systems. RESULTS the inter-observer agreement was considered moderate by the percentage agreement and fair by the Fleiss' Kappa, with no significant differences between evaluations. Only 1 of the 8 plates presented an anatomic fit greater than 70%. Long plates (8 holes) presented a poor fit compared to short plates (6 or 7 holes). CONCLUSIONS the overall evaluation showed that currently-available pre-contoured superior plate systems provide a poor fit on clavicles for midshaft fracture fixations. Long plates present a worse fit compared to short ones.
Collapse
Affiliation(s)
- Adriano Fernando Mendes Junior
- - Hospital Universitário da Universidade Federal de Juiz de Fora, Serviço de Ortopedia e Traumatologia - Juiz de Fora - MG - Brasil
| | - Augusto Khede Tavares
- - Hospital Santa Teresa, Serviço de Ortopedia e Traumatologia - Petropolis - RJ - Brasil
| | - Igor Gerdi Oppe
- - Hospital Universitário da Universidade Federal de Juiz de Fora, Serviço de Ortopedia e Traumatologia - Juiz de Fora - MG - Brasil
| | - Robinson Esteves Pires
- - Universidade Federal de Minas Gerais, Faculdade de Medicina - Belo Horizonte - MG - Brasil
| | | | - Pedro José Labronici
- - Universidade Federal Fluminense, Faculdade de Medicina - Niterói - RJ - Brasil
| |
Collapse
|
46
|
Ferguson DP, Baker HP, Dillman D, Theriault P, Trask K, MacDonald S, Trenholm A. Dual mini-fragment plate fixation of midshaft clavicle fractures is biomechanically equivalent to anatomic pre-contoured plating. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:1109-1116. [PMID: 35412150 DOI: 10.1007/s00590-022-03268-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/05/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To biomechanically compare the stiffness of midshaft synthetic clavicle osteotomies fixed with either superior anatomic pre-contoured locking plates, anterior anatomic pre-contoured locking plates, or short-segment dual orthogonal mini-plate fixation. DESIGN AND SETTING Controlled laboratory study. Specimens Twenty-one synthetic pre-osteotomized clavicles were separated into three groups: superior plating, anterior plating, or dual-plating. Each clavicle was sequentially tested in non-destructive cycles of axial compression, three-point bending, and torsion. Load and displacement were recorded. Stiffness was calculated. RESULTS No statistically significant differences were found between construct stiffness during axial compression, three-point bending, or torsional testing. One superior plated clavicle suffered catastrophic failure during axial compression. One dual mini-fragment plated clavicle suffered catastrophic failure during torsion. CONCLUSIONS Orthogonal dual mini-fragment fixation of transverse clavicle fractures is biomechanically similar to superior and anterior pre-contoured anatomic locking plate fixation. No statistically significant differences in construct stiffness were found in axial compression, three-point bending, or torsion testing. Further clinical research is required to determine the long-term stability of dual mini-fragment plate fixation. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Devin P Ferguson
- Division of Orthopaedic Surgery, Dalhousie University, Halifax, NS, Canada
| | - Hayden P Baker
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL, 60637, USA.
| | - Daryl Dillman
- Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL, 60637, USA
| | - Patrick Theriault
- Division of Orthopaedic Surgery, Dalhousie University, Halifax, NS, Canada
| | - Kelly Trask
- Nova Scotia Health Authority, Halifax, NS, Canada
| | | | - Andrew Trenholm
- Division of Orthopaedic Surgery, Dalhousie University, Halifax, NS, Canada
| |
Collapse
|
47
|
Youn SM, Kim JD, Jeong HY, Ro K, Kim MS, Rhee YG, Rhee SM. Antegrade Intramedullary Fixation for Clavicular Shaft Fracture: A Technical Trick. J Orthop Trauma 2022; 36:e116-e121. [PMID: 34629395 DOI: 10.1097/bot.0000000000002198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/03/2021] [Indexed: 02/02/2023]
Abstract
SUMMARY The standard open reduction and internal fixation technique with a plate and screws for a simple mid shaft clavicular fracture necessitates a relatively large incision and can also lead to variable amount of keloid scar formation. Historically, other techniques of more minimally invasive retrograde intramedullary fixation with the entry point posterolaterally on the shoulder have shown their own disadvantages and complications. We present a surgical technique of antegrade intramedullary fixation for mid shaft clavicular fractures and an illustrative case series.
Collapse
Affiliation(s)
- Seung-Min Youn
- Department of Orthopaedic Surgery, Myongji Hospital, Shoulder and Elbow Clinic, Goyang-si, Korea
| | - Jong Dae Kim
- Department of Orthopaedic Surgery, College of Medicine, Shoulder and Elbow Clinic, Kyung Hee University, Seoul, Korea; and
| | - Ho Yeon Jeong
- Department of Orthopaedic Surgery, College of Medicine, Shoulder and Elbow Clinic, Kyung Hee University, Seoul, Korea; and
| | - Kyunghan Ro
- Department of Orthopaedic Surgery, College of Medicine, Shoulder and Elbow Clinic, Kyung Hee University, Seoul, Korea; and
| | - Myung Seo Kim
- Department of Orthopaedic Surgery, College of Medicine, Shoulder and Elbow Clinic, Kyung Hee University at Kangdong, Seoul, Korea
| | - Yong Girl Rhee
- Department of Orthopaedic Surgery, Myongji Hospital, Shoulder and Elbow Clinic, Goyang-si, Korea
| | - Sung-Min Rhee
- Department of Orthopaedic Surgery, College of Medicine, Shoulder and Elbow Clinic, Kyung Hee University, Seoul, Korea; and
| |
Collapse
|
48
|
Wolf S, Chitnis AS, Manoranjith A, Vanderkarr M, Plaza JQ, Gador LV, Holy CE, Sparks C, Lambert SM. Surgical treatment, complications, reoperations, and healthcare costs among patients with clavicle fracture in England. BMC Musculoskelet Disord 2022; 23:135. [PMID: 35139854 PMCID: PMC8830003 DOI: 10.1186/s12891-022-05075-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/20/2022] [Indexed: 11/10/2022] Open
Abstract
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.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Chantal E Holy
- Medical Devices Epidemiology, Johnson & Johnson, New Brunswick, NJ, USA.
| | | | | |
Collapse
|
49
|
Current trends in patient-reported outcome measures for clavicle fractures: a focused systematic review of 11 influential orthopaedic journals. J Shoulder Elbow Surg 2022; 31:e58-e67. [PMID: 34619348 DOI: 10.1016/j.jse.2021.08.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/27/2021] [Accepted: 08/29/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Many patient-reported outcome measures (PROMs) have been used to follow clavicle fractures, providing an objective means to track outcomes. However, lack of standardization of PROM usage makes cross-study comparison difficult. Therefore, we reviewed articles on clavicle fractures from 11 of the most influential orthopedic journals to assess trends in PROM usage over time and based on geographic location. METHODS A focused systematic review of 11 of the most influential orthopedic journals was performed using PubMed. All articles published between 1981 and 2020 with greater than 9 patients reporting clinical outcomes of clavicle fractures were included. For each article, patient demographics, treatment modality, geographic location, and outcome measures used were recorded. Temporal trends were identified using the Cochran-Armitage test for trend and linear regression. Pearson chi-square and Kruskal-Wallis tests were used to compare between journals, geographic location, study type, and fracture classification. RESULTS From the initial literature search of 623 articles, 151 studies reporting on 15,853 primary clavicle fractures were included. Fractures of the middle one-third of the clavicle were most studied in the included literature (71%). Seventeen different PROMs were used, with an average of 1.6 outcome measures per study, and there was a significant increase in the number of PROMs used per article over time (P < .001). The Constant-Murley score was the most-reported outcome measure (44%) followed by the Disabilities of the Arm, Shoulder, and Hand score (27%), visual analog scale for pain (23%), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES; 14%). There was a significant difference between the measures used based on geography (P = .002), the most notable being that North American authors use the ASES score more frequently. CONCLUSIONS The use of PROMs in studies evaluating clavicle fracture treatment outcomes has increased over time, with recent studies reporting more PROMs than older studies, and there are notable differences in usage of the various scores based on geography and journal. Although there is no consensus on the most reliable PROM for assessing clavicle fractures, we recommend the use of at least 2 of the commonly reported PROMs in future studies to facilitate cross-study comparisons.
Collapse
|
50
|
MENDES JUNIOR ADRIANOFERNANDO, TAVARES AUGUSTOKHEDE, OPPE IGORGERDI, PIRES ROBINSONESTEVES, BELANGERO WILLIAMDIAS, LABRONICI PEDROJOSÉ. Placas pré-moldadas superiores possuem adaptação ruim para fixação de fraturas do terço médio da clavícula: análise cadavérica de quatro sistemas disponíveis comercialmente. Rev Col Bras Cir 2022. [DOI: 10.1590/0100-6991e-20223177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Objetivo: verificar como as placas superiores pré-moldadas disponíveis no mercado se adaptam às fraturas do terço médio da clavícula. Método: 100 clavículas de cadáveres foram avaliadas por três observadores distintos, aplicando-se o escore de congruência da clavícula e comparando quatro sistemas diferentes de placas bloqueadas anatômicas pré-moldadas de seis a oito furos. Resultados: a concordância interobservador foi considerada moderada pelo percentual de concordância e regular pelo índice Kappa de Fleiss, sem diferenças significativas entre as avaliações. Apenas uma das oito placas apresentou encaixe anatômico maior que 70%. As placas longas (oito furos) apresentaram um encaixe ruim em comparação com as placas curtas (seis ou sete furos). Conclusões: os sistemas de placa superior pré-moldadas disponíveis atualmente fornecem um encaixe inadequado às clavículas para fixações de fraturas do terço médio. Placas longas apresentam um encaixe pior que as curtas.
Collapse
|