Rate of and Risk Factors for Reoperations After Open Reduction and Internal Fixation of Midshaft Clavicle Fractures: A Population-Based Study in Ontario, Canada

Changes in Fracture Shortening Occur in the First 2 Weeks Following Completely Displaced Adolescent Clavicle Fractures

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.

Pneumothorax After Superior Plating of Clavicle Fractures: Are the Concerns Warranted?

PURPOSE

The primary goal of this study was to determine the anatomic relationship between the clavicle and the apical lung segment. The secondary goal was to determine the incidence of pneumothorax (PTX) in patients who underwent clavicle ORIF to analyze the utility of postoperative chest radiographs.

METHODS

Six hundred thirty-one patients with a midshaft clavicle fracture who underwent superior plating at a single institution were identified. Forty-two patients had a CT scan of the chest. Three points on the uninjured clavicle were defined: 2 cm from the medial end of the clavicle, the mid-point of the clavicle, and 2 cm from the lateral end of the clavicle. At each point, the distance from both the inferior cortex and the superior cortex of the clavicle to the apical lung segment was measured. All 631 patients who underwent Open Reduction and Internal Fixation had a postoperative chest radiograph to evaluate implant placement, restoration of clavicular length, and presence of PTX.

RESULTS

From the lateral end of the clavicle, the mean distance of the lung was 60.0 ± 14.9 mm (20.1 to 96.1 mm) from the inferior cortex of the clavicle. At the mid-point, the mean distance of the lung was 32.3 ± 7.2 mm (20.4 to 45.5 mm) from the inferior cortex of the clavicle. At the medial end, the mean distance of the lung was 18.0 ± 5.5 mm (8.1 to 28.9 mm) from the inferior cortex of the clavicle. A review of postoperative radiographs for all 631 patients revealed none (0%) with a postoperative iatrogenic PTX.

CONCLUSION

The risk of injury is minimal in all three zones. Postoperative chest radiographs after clavicle fracture repair to rule out PTX are unnecessary.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Clavicle fixation to reduce short-term analgesia and improve respiratory function in patients with chest wall injuries

INTRODUCTION

The objective of this study was to determine if operative fixation of clavicle fractures in patients with non-operatively treated ipsilateral rib fractures is associated with a lower overall analgesic requirement and improved respiratory function.

MATERIALS AND METHODS

A retrospective matched cohort study was conducted involving patients admitted to a single tertiary trauma centre having sustained a clavicle fracture with ipsilateral rib fracture/s between January 2014 and June 2020. Patients were excluded if brain, abdominal, pelvic, or lower limb trauma was identified. 31 patients with operative clavicle fixation (study group) were matched 1:1 to 31 patients with non-operative management of the clavicle fracture (control group) based on age, sex, number of rib fractures and injury severity score. The primary outcome was the number of analgesic types used, and the secondary outcome was respiratory function.

RESULTS

The study group required a mean of 3.50 types of analgesia prior to surgery which decreased to 1.57 post-surgery. The control group required 2.92 types of analgesia, reducing to 1.65 after the date of surgery in the study group. A General Linear Mixed Model indicated that the intervention (operative vs. non-operative management) had statistically significant effects on the number of required analgesic types (p < 0.001, [Formula: see text] = 0.365), oxygen saturation (p = 0.001, [Formula: see text] = 0.341, 95% CI 0.153-0.529) and temporal decline in daily supplemental oxygen requirement (p < 0.001, [Formula: see text] = 0.626, 95% CI 0.455-0.756).

CONCLUSION

This study supported the hypothesis that operative clavicle fixation reduces short-term in-patient analgesia use and improves respiratory parameters in patients with ipsilateral rib fractures.

LEVEL OF EVIDENCE

Level III therapeutic study.

Supraclavicular nerve sparing versus sacrifice during open reduction internal fixation of acute midshaft clavicle fracture

BACKGROUND

The branches of the supraclavicular nerve are often sacrificed during open reduction and internal fixation (ORIF) for clavicle fracture. No consensus exists on whether the supraclavicular nerve should be routinely identified and protected during ORIF.

METHODS

We developed a simple method to make nerve sparing easier; Wide-Awake Local Anesthesia No Tourniquet (WALANT) solution is locally injected prior to the surgical incision being made. This retrospective study enrolled 340 patients and divided them into supraclavicular-nerve-sparing (n = 45) and supraclavicular-nerve-sacrifice (n = 295) groups. Surgical outcomes-including operative time, estimated blood loss, postoperative pain, union rate, time to union, functional score, paresthesia, complications, implant removal rate, and complication rate-were recorded.

RESULTS

Incisional or anterior chest wall numbness and intraoperative blood loss were significantly less (p < 0.001) in the nerve-sparing group. The operative time was similar in the two groups. No significant differences were discovered in QuickDASH score, postoperative pain score, union rate, time to union, implant removal rate, complication rate, or revision rate.

CONCLUSIONS

Our study demonstrated that the outcomes of supraclavicular nerve sparing during ORIF with WALANT can reduce postoperative incisional and anterior chest wall numbness and intraoperative blood loss without increasing the operative time or complication rate.

SURGICAL TREATMENT OF CLAVICLE FRACTURES: A DESCRIPTIVE ANALYSIS OF 88 CASES

Clavicle fractures are one of the most common types of bone injuries in adults. Recently, the treatment protocol for these fractures has undergone changes.

Objective

To better understand the epidemiological and behavioral profile of these lesions when they require surgical treatment.

Methods

This is an analysis of a series of cases. Our sample included individuals undergoing surgical treatment for clavicle fractures.

Results

In total, 88 subjects fulfilled the predetermined criteria. Among these, 75 (85.22%) were male; automobile accidents corresponded to the largest etiological group, reaching 48% of prevalence; there was a slight predominance of the right side, totaling 45 cases (51%); most fractures were classified as Allman type I; an infection rate was observed in 1.13% of the cases; and the development of pseudarthrosis was identified in 2.27% of the patients.

Conclusion

The incidence of clavicle fracture is higher in young men, mainly caused by car accidents, being mostly located in the middle third. No statistical significance was found between the synthesis material data and the postoperative complication rate, revealing the absence of risk superiority between the different types of surgical approaches used. Level of Evidence IV, Case Series.

Return to Sport After Operative Fixation of Midshaft Clavicle Fractures in Professional Jockeys

OBJECTIVE

Clavicle fractures are the most commonly observed fracture sustained in professional horse racing. This study is the first to report on time lost from injury and functional recovery after surgical fixation of midshaft clavicle fractures in professional jockeys.

DESIGN

Retrospective cohort study.

SETTING

Professional Horse Racing Ireland; Patients (or Participants): Professional Jockeys in Ireland with midshaft clavicular fractures managed with Open Reduction Internal Fixation. Interventions (or Assessment of Risk Factors or Independent Variables): Operative fixation with Open Reduction Internal Fixation.

MAIN OUTCOME MEASURES

Assessment of postoperative Quick Disabilities of Arm Shoulder and Hand (QuickDASH) score and Patient Reported Outcome Measures assessing for associated complications and time to return to competition among professional athletes.

RESULTS

Between 07/06/2013 and 29/09/2022, 22 patients met the predetermined inclusion criteria. Ninety-five percent of patients returned to competition at their preinjury level, one patient failed to return to competition for reasons unrelated to his injury. The mean time for return to competition was 68.14 days postinjury. Few complications were reported, whereas functional recovery was excellent across the cohort, with an average QuickDASH score of 0.85 (0.0-2.3).

CONCLUSIONS

Plate fixation of midshaft clavicle fractures is effective and safe in the setting of professional horse racing. Ninety-five percent of patients can be expected to return within 14 weeks of injury. Patients returning at less than 7 weeks after injury had no adverse outcomes, suggesting a potential role for more aggressive rehabilitation postoperatively and ultimately, a quicker return to competition.

Pseudoaneurysm of the subclavian artery as a delayed complication of a clavicle fracture

Vascular complications are relatively rare following surgical fixation of midshaft clavicle fractures. Here, we report a case of a woman in her 30s presenting 10 years after right clavicular open reduction and internal fixation with revision 6 years prior with sudden and rapidly progressive neck swelling. Physical examination revealed a soft pulsating mass in her right supraclavicular fossa. Ultrasound and CT angiography of the head and neck showed a pseudoaneurysm of her right subclavian artery with a surrounding haematoma. She was admitted to the vascular surgery team for endovascular repair with stenting. Postoperatively, she developed arterial thrombi requiring thrombectomy (twice) and is now on lifelong anticoagulation. It is crucial to be aware of complications that can develop in patients with a history of clavicular fracture managed non-operatively or operatively even years later and highlights the importance of risk and benefit discussions and counselling.

The fifty most-cited articles regarding midshaft clavicle fractures

Introduction

The clavicle is the most frequently fractured bone in the human body, and up to 80% of clavicle fractures occur in the middle third diaphyseal region of the clavicle (midshaft). We conducted a bibliometric analysis to identify and evaluate the 50 most-cited publications pertaining to midshaft clavicle fractures (MCF).

Materials and methods

Two independent reviewers conducted separate queries on Web of Science in December 2021 for "midshaft clavicle fractures". The publications yielded were organized from highest to lowest number of citations. We included articles, review articles, and editorial materials and excluded other document types. Both reviewers independently reviewed all abstracts until 50 studies pertaining to MCF were included.

Theory

We hypothesized that most articles would be published between 2000 and 2019, pertain to outcomes, and those with a greater (lower numeric) level of evidence would correlate with number of citations.

Results

The most prolific decade was from 2010 to 2019, with 50% (25/50) of articles published. Average citation density was 6.3 ± 5.5 (range, 1.3-33.1), defined as the average number of citations per year since publication. The median level of evidence (LOE) was 3.5 (IQR: 3). One-way ANOVA tests were used to compare the effects of LOE on total citations and citation density. There were statistically significant differences in total citations (F value = 12.07, p = 0.001) and citation density (F value = 21.14, p < 0.001) between LOE groups. The median number of total citations, grouped by LOE of 1 through 5, were as follows: 110, 66, 66, 51, 52.

Conclusions

This review provides an overview of the 50 most cited papers regarding MCF. This should be used as a reference for physicians and other providers who treat patients with MCF for treatment guidance and for those in teaching roles as a student and resident/fellow educational resource.

Refracture after plate removal of midshaft clavicle fractures after bone union-incidence, risk factors, management and outcomes

INTRODUCTION

There is a great debate on the routine use of open reduction and internal fixation (ORIF) for midshaft clavicle fractures, and one concern is the adverse events after ORIF, such as implant removal after bone union. In this retrospective study, we assessed the incidence, risk factors, management and outcomes of refracture after plate removal of midshaft clavicle fractures after bone union.

MATERIALS AND METHODS

Three hundred fifty-two patients diagnosed with acute midshaft clavicle fractures who had complete medical records from primary fractures to refracture were recruited. Details of imaging materials and clinical characteristics were carefully reviewed and analysed.

RESULTS

The incidence rate of refracture was 6.5% (23/352), and the average interval from implant removal to refracture was 25.6 days. Multivariate analysis showed that the risk factors were Robinson type-2B2 and fair/poor reduction. Females were 2.4 times more likely to have refracture, although it was not significant in multivariate analysis (p = 0.134). Postmenopausal females with a short interval (≤ 12 months) from primary surgery to implant removal had a significant risk for refracture. Tobacco use and alcohol use during bone healing were potential risk factors for male patients, although they were not significant in multivariate analysis. Ten patients received reoperation with or without bone graft, and they had a higher rate of bone union than 13 patients who refused reoperation.

CONCLUSION

The incidence of refracture following implant removal after bone union is underestimated, and severe comminute fractures and unsatisfactory reduction during primary surgery are risk factors. Implant removal for postmenopausal female patients is not recommended due to a high rate of refracture.

Return to Full Function in Patient with Nonoperative Management of a Comminuted, Displaced Clavicle Fracture: A Case Report

Case

Clavicle fractures are common skeletal injuries that account for 2%-10% of adult fractures. Surgical indications include presence of an open fracture, severe angulation, comminution, displacement, skin tenting with a threat of skin perforation, neurovascular compromise, symptomatic nonunion, or fracture shortening >1.5-2cm. In this case, the patient had a comminuted, displaced fracture - thus meeting criteria for operative treatment. However, the patient opted for nonoperative management.

Conclusion

After 3 months, the patient regained full strength and range-of-motion. This case highlights the current heterogenous mixture of studies in the literature surrounding the best management for midshaft clavicle fractures. The patient was informed that data concerning the case would be submitted for publication and provided consent.

Clinical and radiographic outcomes of revision with autogenous "structured" bone grafting combined with superior plate for recalcitrant atrophic nonunion of clavicular midshaft: a retrospective study

PURPOSE

To assess the efficacy of autogenous "structured" bone grafting (ASBG), it was combined with superior plate (SP) revision operations for recalcitrant clavicular midshaft aseptic nonunion (CMAN).

METHODS

This retrospective study included 12 patients who suffered from failure of autologous cancellous bone grafting (ACBG) and SP fixation because of CMAN. Visual analogue scale (VAS) data for pain and disabilities of arm, shoulder, and hand (DASH) scores of patients who underwent these procedures from January 2019 to December 2020, obtained before surgery and at the final follow-up time, were analysed.

RESULTS

The average time between primitive fracture and this operative treatment was 29 months (15-38 months). The average duration of surgery was 153 minutes (range, 115-230 min), and the average blood loss was 560 ml (range, 350-860 ml). Complications occurred in two cases (16.67%): one was persistent pain at the donor site, and the other was a calf muscle vein thrombosis. No tissue infection was observed during follow-up. The mean follow-up time was 18 months (range, 12-30 months). All fractures progressed to osseous healing at a mean time of 14 weeks (range, 12-16 weeks). The mean pain VAS score significantly improved, from 4.8 ± 1.7 pre-operatively to 1.9 ± 1.1 at the final follow-up (P = 0.01). The mean DASH score improved significantly from 30.1 ± 11.2 pre-operatively to 7.8 ± 4. 2 at the final follow-up (P < 0.01).

CONCLUSIONS

ASBG combined with SP revision surgery achieved excellent clinical outcomes in patients with recalcitrant CMAN.

Are two plates better than one? A systematic review of dual plating for acute midshaft clavicle fractures

BACKGROUND

The rate of operative fixation of acute midshaft clavicle fractures has exponentially increased in recent years; however, the rate of reoperation for symptomatic hardware removal remains high and the optimal fixation strategy unknown. This systematic review aimed to summarize available evidence for dual plating of acute displaced midshaft clavicle fractures.

METHODS

EMBASE, MEDLINE, and PubMed searches identified clinical studies evaluating dual plate fixation of acute midshaft clavicle fractures. Pooled analysis was performed using a random-effects model in RevMan 5.3.

RESULTS

Eleven studies including 672 patients were included. Hardware removal occurred in 4.4% and 12.3% of patients undergoing dual and single plate fixation, respectively. Compared to single plating, dual plating had significantly lower odds of hardware removal (P = 0.001) with no difference in union rates. There were no significant differences in reoperation (excluding hardware removal), complications, and patient-reported outcomes between the two groups (P > 0.05).

CONCLUSIONS

This study suggests that dual plating of acute displaced midshaft clavicle fractures may lead to lower rates of reoperation for symptomatic hardware removal without compromising fracture healing. Ultimately, well-designed randomized trials are needed to further investigate the findings from this systematic review.

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

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).

Dual Plate Minifragment Fixation of Clavicle Fractures- Technique and Approach

SUMMARY

The treatment of midshaft clavicle fractures continues to evolve, with a variety of fixation techniques and constructs used. Symptomatic hardware is a common complication related to plate fixation of the clavicle, and often results in secondary surgery for implant removal. The minifragment dual plate fixation technique for clavicle fractures provides a construct that may result in fewer implant related complications with comparable fixation stability to precontoured locking plates. Our case presentation demonstrates our approach to midshaft clavicle fractures, the benefits of this surgical technique, and reported outcomes from this fixation method.

Risk factors for nonunion following surgically managed, traumatic, diaphyseal fractures: a systematic review and meta-analysis

Background

Methods

Results

Conclusion

Surgical Treatment of Clavicular Fractures, Refractures, Delayed and Non-Unions Using a Resorbable, Gentamicin-Eluting Calcium Sulphate/Hydroxyapatite Biocomposite

Objective

This study describes clinical and radiological outcomes following treatment of displaced primary fractures, refractures, delayed unions and non-unions of the clavicle with open reduction and internal fixation (ORIF) with a plate plus filling of the residual bone defect and/or implant augmentation with a gentamicin-loaded bone graft substitute (CERAMENT G, BONESUPPORT).

Patients and Methods

Patients who underwent surgical treatment either for displaced clavicle fractures, refractures, delayed unions or non-unions between June 2018 and May 2021 were enrolled in this retrospective study. Bony consolidation, complication rate, and functional outcomes, including overall health, were assessed.

Results

A total of 26 clavicles in 25 patients with a mean age of 50.7 (16–85) years, 16 male and 9 female, were enrolled in the study. The mean follow-up was 14.9 (6–31) months. There were 18 cases of displaced clavicle fractures, four refractures, two delayed unions and two non-unions. The majority of the clavicle lesions were located at the middle third (17/26, 65.4%), seven at the lateral third (26.9%) and two at the medial third (7.7%) of the clavicle. A mean Goldberg score of 7 indicated complete bony union and remodeling of the bone graft substitute in all cases. No complications occurred. The mean University of California at Los Angeles Shoulder Score and the mean Quick Disability of the Arm, Shoulder and Hand Score were 34.6±0.8 (32–35) points and 0.6±1.6 (0–5.4) points, respectively, and revealed excellent functional results. The mean 12-item Short-Form Survey physical component questionnaire was 57.7±1.7 (54.1–58.9) points, and no patient experienced any pain at the last follow-up.

Conclusion

Our initial experience suggests that ORIF using a plate plus bone defect filling and/or implant augmentation with a gentamicin-eluting bone graft substitute may be useful not only for complication management after clavicle fractures but also in the initial treatment of challenging clavicular fractures.

Safe and Effective Treatment of Compromised Clavicle Fracture of the Medial and Lateral Third Using Focused Shockwaves

A delay or failure to heal is the most common possible complication in clavicle fractures, especially in cases primarily treated conservatively. As the current standard therapy, surgical revision achieves good healing results, but is associated with potential surgery-related complications. Shockwave therapy as a non-invasive therapy shows similar reasonable consolidation rates in the non-union of different localizations, but avoids complications. Compromised clavicle fractures in the middle and lateral third treated with focused high-energy shockwave therapy were compared with those treated with surgical revision (ORIF). In addition, a three-dimensional computer simulation for evaluating the pressure distribution during shockwave application accompanied the clinical study. A comparable healing rate in bony consolidation was achieved in both groups. Significantly fewer complications, however, occurred in the shockwave group. The simulations showed safe application in this instance, particularly in avoiding lung tissue affection. When applied correctly, shockwaves represent a safe and promising therapy option for compromised clavicle fractures in the middle and lateral third.

Antegrade Intramedullary Fixation for Clavicular Shaft Fracture: A Technical Trick

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.

Risk factors for nonunion following open reduction and internal fixation for proximal humerus fractures

PURPOSE

The incidence of proximal humerus fractures (PHF) is rising and surgical intervention carries risk for fracture nonunion. The purpose was (1) to compare patient demographics of those that developed nonunion and (2) identify patient risk factors that predispose to nonunion following open reduction and internal fixation (ORIF) for PHF.

METHODS

A retrospective review of the Medicare Claims Database from 2005 to 2014 for patients who underwent primary ORIF for PHFs. Patients who developed nonunion were identified as the study group (n = 1020) and compared to a control group (n = 51,209). Primary endpoints were to compare demographics of the study group and the comparison cohorts and to identify patient-related risk factors associated with nonunion within 6-months following the index procedure. A logistic regression model was constructed to determine the association of comorbid conditions on developing a nonunion. A p value of 0.001 was the significance threshold.

RESULTS

Patients who developed nonunion were younger, more likely to be male, and had higher Elixhauser-Comorbidity Index scores (7 vs. 5; p < 0.0001) when compared with controls. Iron deficiency anemia (OR: 1.32; p = 0.0001), tobacco use (OR: 1.32; p = 0.0004), rheumatoid arthritis (OR: 1.29; p = 0.0001), depression (OR: 1.28; p = 0.0002), and BMI range from 30-39 kg/m² (OR: 1.21; p = 0.001) were significant risk factors for nonunion.

CONCLUSIONS

Certain patient risk factors including tobacco use, iron deficiency anemia, rheumatoid arthritis, depression, and a BMI in the range of 30-39 were associated with nonunion within 6 months of ORIF for PHF. This study may help in the risk stratification of these patients.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Results of pre-contoured titanium anterior plating of midshaft clavicle fractures

BACKGROUND

Plating midshaft clavicle fractures anteriorly is gaining popularity because of low complication rates. Improvements in plate fixation constructs for midshaft clavicle fractures have unclear clinical significance. The purpose of this study was to present the early clinical and radiographic outcomes of pre-contoured titanium anterior plates for the treatment of midshaft clavicle fractures.

METHODS

Skeletally mature patients who underwent plate fixation of a midshaft clavicular fracture from 2008 to 2015 using pre-contoured titanium anterior plates were included in this retrospective investigation. The primary outcome measures were union rate and hardware removal rate. The secondary outcome measures included reoperation for all causes and mechanical implant failure.

RESULTS

A total of 26 patients were included. Complete healing occurred in 96% of patients without further surgical intervention, and all patients achieved union. Medical complications occurred in 2 patients (7.7%), consisting of cellulitis (n = 1) and chronic pain (n = 1). In 1 patient (3.8%), delayed union occurred and the use of a bone stimulator was required postoperatively to achieve union. Finally, 2 patients (7.7%) had symptomatic implants that required removal.

CONCLUSIONS

In the acute fracture setting, the anterior plating system used in this study led to a high rate of union with decreased rates of implant irritation. Only 7.7% of patients required hardware removal for symptomatic hardware, as opposed to the estimated 20%-60% reported in the literature in patients with symptomatic superior clavicle plates.

Rates of readmission and reoperation after operative management of midshaft clavicle fractures in adolescents

BACKGROUND

The national rates of readmission and reoperation after open reduction internal fixation (ORIF) of midshaft clavicle fractures in adolescents is unknown.

AIM

To determine rates of and risk factors for readmission and reoperation after ORIF of midshaft clavicle fractures in adolescents.

METHODS

This retrospective study utilized data from the Healthcare Cost and Utilization Project State Inpatient Database for California and Florida and included 11728 patients 10–18 years of age that underwent ORIF of midshaft clavicle fracture between 2005 and 2012. Readmissions within ninety days, reoperations within two years, and differences in patient demographic factors were determined through descriptive, univariate, and multivariate analyses.

RESULTS

In total, 3.29% (n = 11) of patients were readmitted within 90 d to a hospital at an average of 18.91 ± 18 d after discharge, while 15.87% (n = 53) of patients underwent a reoperation within two years at an average of 209.53 ± 151 d since the index surgery. The most common reason for readmission was a postoperative infection (n < 10). Reasons for reoperation included implant removal (n = 49) at an average time of 202.39 ± 138 d after surgery, and revision ORIF (n < 10) with an average time of 297 ± 289 d after index surgery. The odds of reoperation were higher for females (P < 0.01) and outpatients (P < 0.01), while the odds of reoperation were lower for patients who underwent surgery in California (P = 0.02).

CONCLUSION

There is a low rate of readmission and a high rate of reoperation after ORIF for midshaft clavicle fractures in adolescents. There are significant differences for reoperation based on patient sex, location, and hospital type.

A review of outcomes after operative fixation of clavicular fractures over a 10-year period—a single tertiary trauma unit experience

Background

Early definitive fixation of clavicular fractures is rising in popularity when compared with conservative management. Despite this, the relative risk of subsequent hardware removal or revision surgery is relatively undocumented in the literature. The aim of this study was to review all clavicle fractures treated operatively in a single tertiary referral trauma unit and determine the true incidence of hardware removal and revision rates among this cohort.

Methods

A retrospective electronic review was performed in a single tertiary trauma unit for all open reduction internal fixation of clavicle fractures over 10 years (2010-2019 inclusive). All patients were cross referenced for hardware removal during the same period. Patients identified as having undergone ORIF clavicle were reviewed via the National Integrated Medical Imaging System to identify the fracture pattern, fixation method, radiographic nonunion, or radiographic malunion. Age, gender, time from injury to fixation, and time from insertion to removal of hardware where relevant were also collected.

Results

Over the 10-year period from 2010 to 2019, 352 patients underwent ORIF of clavicular fractures. After application of inclusion and exclusion criteria, 346 patients (76% male and 24% female) were analyzed with a mean age of 34.46 years old (95% confidence interval [33.02-35.91]). In total, 54 (15.6%) patients underwent removal of hardware. When fracture type and fixation method were accounted for, only 11% of plate fixations for mid-shaft fractures (n = 29) were removed, whereas 76% of clavicular hook plates for distal fractures (n = 25) underwent removal (P < .001). No distal clavicle fractures treated with locking plates underwent removal (n = 23). Women were almost 3 times more likely to undergo removal of hardware than men (28.6% vs. 11.5%, P < .001). Seven patients (2%) underwent revision ORIF in the 10-year period for nonunion (n = 3), malunion (n = 2), and failure of fixation (n = 2). The mean follow-up time was 1 year (366 days) for those who underwent subsequent surgery and 5.7 years (2087 days) for those who did not.

Conclusion

Clavicular fracture fixation using either locking or hook plates is a safe method of treatment with a very low reoperation rate for either hardware removal or revision. Women are more likely to request plate removal. Distal locking plates are a safe alternative to hook plates for distal one-third clavicle fractures with lower reoperation rates. Newer techniques are emerging for the management of distal fractures such as tight rope fixation and locking plates which also appear to be successful.

Influence of surgical stabilization of clavicle fractures in multiply-injured patients with thoracic trauma

Thoracic trauma has decisive influence on the outcome of multiply-injured patients and is often associated with clavicle fractures. The affected patients are prone to lung dysfunction and multiple organ failure. A multi-center, retrospective analysis of patient records documented in the TraumaRegister DGU was performed to assess the influence of surgical stabilization of clavicle fractures in patients with thoracic trauma. A total of 3,209 patients were included in the analysis. In 1362 patients (42%) the clavicle fracture was treated operatively after 7.1 ± 5.3 days. Surgically treated patients had a significant reduction in lung failure (p = 0.013, OR = 0.74), multiple organ failure (p = 0.001, OR = 0.64), intubation time (p = 0.004; -1.81 days) and length of hospital stay (p = 0.014; -1.51 days) compared to non-operative treatment. Moreover, surgical fixation of the clavicle within five days following hospital admission significantly reduced the rates of lung failure (p = 0.01, OR = 0.62), multiple organ failure (p = 0.01, OR = 0.59) and length of hospital stay (p = 0.01; -2.1 days). Based on our results, multiply-injured patients with thoracic trauma and concomitant clavicle fracture may benefit significantly from surgical stabilization of a clavicle fracture, especially when surgery is performed within the first five days after hospital admission.

Conversion to Total Hip Arthroplasty After Hip Arthroscopy: A Cohort-Based Survivorship Study With a Minimum of 2-Year Follow-up

INTRODUCTION

The purpose of this study was to determine which patient, provider, and surgical factors influence progression to total hip arthroplasty (THA) after hip arthroscopy (HA) through a large cohort-based registry.

METHODS

All patients ≥18 years who underwent unilateral HA in Ontario, Canada, between October 1, 2010, and December 31, 2016, were identified with a minimum of 2-year follow-up. The rate of THA after HA was reported using Kaplan-Meier survivorship analyses. A Cox proportional hazard model was used to assess which factors independently influenced survivorship.

RESULTS

A total of 2,545 patients (53.2% female, mean age 37.4 ± 11.8 years) were identified. A total of 237 patients (9.3%) were identified to have undergone THA at a median time of 2 years after HA, with an additional 6.3% requiring a revision arthroplasty at a median time of 1.1 years. Patients who underwent isolated labral resection (hazard ratio [HR]: 2.55, 95% confidence interval [CI]: 1.51 to 4.60) or in combination with osteochondroplasty (OCP) [HR: 2.11, 95% CI: 1.22 to 3.88] were more likely to undergo THA versus patients who underwent isolated labral repair or in combination with an OCP, respectively. Older age increased the risk for THA (HR: 14.0, 95% CI: 5.76 to 39.1), and treatment by the highest-volume HA surgeons was found to be protective (HR: 0.55, 95% CI: 0.33 to 0.89).

DISCUSSION

Using our methods, the rate of THA after HA was 9.3% at 2 years. The rate of revision arthroplasty was 6.3% at 1 year. Patients who underwent labral resection, isolated OCP, and/or were of increased age were at increased independent risk of conversion to THA. Those treated by the highest-volume HA surgeons were found to be at reduced risk of conversion to THA.

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

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

Current concepts in the treatment of midshaft clavicle fractures in adults

Midshaft clavicle fractures are the most common fracture of the clavicle accounting for 80% of all clavicle fractures. Traditionally, midshaft clavicle fractures are treated with conservative treatment even when prominent displacement is observed; however, recent studies revealed that nonunion or malunion rate may be higher with conservative treatment. Moreover, recent studies have shown better functional results and patient satisfaction with surgical treatment. This review article provides a review of clavicle anatomy, describes the current clavicle fracture classification system, and outlines various treatment options including current surgical options for clavicle fracture in adults.

Risk of Total Hip Arthroplasty After Acetabular Fracture Fixation: The Importance of Age

BACKGROUND

Geriatric patients are the most rapidly growing cohort of patients sustaining acetabular fractures (AFs). The purpose of this study was to examine the risk of a secondary total hip arthroplasty (THA) in older patients (>60 year old) with a prior AF open reduction internal fixation (ORIF) compared with younger patients (<60 year old) with an AF ORIF on a large population level.

METHODS

Using administrative health care data from 1996 to 2010 inclusive of all 202 hospitals in Ontario, Canada, all adult patients with an AF ORIF and a minimum of two year follow-up were identified and included. The risk of THA was examined using a Cox proportional hazards model adjusting for patient risk factors. Secondary outcomes included surgical complications and all-cause mortality.

RESULTS

A total of 1725 patients had an AF ORIF; 1452 (84.2%, mean age of 38.3 ± 12.1 years) aged <60 years ("younger") and 273 (15.8%, mean age of 69.9 ± 7.8 years) > 60 years ("older"). The mean (SD) follow-up time for all patients was 6.9 (4.2) years. In older patients, 19.4% (53 of 273) went on to receive a secondary THA with a median time to event of 3.9 years, compared with 12.9% (187 of 1452) in the younger patient cohort with a median time of 6.9 years (HR 1.7, 95% CI: 1.2-2.3). As expected, older patients had a higher 90-day mortality rate compared with younger patients (7.7% vs. 0.7%, respectively; HR 9.2, 95% CI: 4.3-19.9; P < .001).

CONCLUSION

Older patients with an AF ORIF are at a significantly higher risk for a secondary THA than younger patients with an AF ORIF.

Dual plating for bipolar clavicle fractures: A case report

Clavicular fractures are common, accounting for 4% of all adult fractures. However, simultaneous medial and lateral fractures occurring in the same clavicle (the so-called ‘bipolar clavicle fracture’) are rare. Treatment for this type of fracture is not well established. Herein, we report our experience of the operative management of a bipolar clavicle fracture using two anatomical locking plates.

The patient was an 82-year-old woman who presented with left-sided clavicle pain after falling to the ground. Plain radiography revealed midshaft and distal clavicular fractures. Open reduction and internal fixation were performed using two different plates, the VA-LCP anterior clavicle plate (DePuy Synthes, West Chester, PA, USA) for the midshaft fracture and the LCP superior anterior clavicle plate with lateral extension (DePuy Synthes) for the distal clavicle fracture. Bony union was achieved 4 months postoperatively without any complications.

In conclusion, dual plating is an effective surgical procedure for treating bipolar clavicle fractures.

Refracture after locking compression plate removal in displaced midshaft clavicle fractures after bony union: a retrospective study

Background

A midshaft clavicle fracture is a common fracture that typically responds well to open reduction and internal fixation (ORIF). However, refracture can occur after implant removal (IR). This study aimed to analyze the rate of refracture and related factors after removal of the locking compression plate (LCP) for displaced midshaft clavicle fractures.

Methods

We retrospectively reviewed the medical records of 201 patients who had undergone ORIF with LCP for midshaft clavicle fractures after IR after bony union from January 2011 to May 2018 at our institute. We evaluated basic demographic characteristics and radiographic parameters. All patients were treated with an LCP for primary fracture. The patients were divided into two groups: a refracture group that experienced a second fracture within 1 year after IR and a no-fracture group.

Results

There were four cases (1.99%) of refracture; three were treated conservatively, while one was treated surgically. All patients achieved bony union. The average interval between refracture and IR was 64 days (range, 6–210 days). There was a significant difference in classification of fractures (AO Foundation/Orthopaedic Trauma Association [AO/OTA] classification) between the two groups. However, other patient demographics and radiographic measurements between refracture and IR, such as bone diameter, showed no significant difference between the two groups.

Conclusions

This study showed that one in 50 patients suffered from refracture after removal of the LCP. Thus, if patients desire IR, the surgeon should explain that there is a relatively higher possibility of refracture for cases with simple or segmental fractures than for other types of fracture.

Mechanical Evaluation of 2.7- Versus 3.5-mm Plating Constructs for Midshaft Clavicle Fractures

OBJECTIVES

This study compares the mechanical performance of 2.7- and 3.5-mm plating constructs for the treatment of midshaft clavicle fractures.

METHODS

Twenty-four synthetic clavicles were randomly divided into four treatment groups-Synthes 2.7-mm cold-worked calcaneal reconstruction plate with 6 (CRP6) or 8 bicortical screws (CRP8); Synthes 3.5-mm LCP reconstruction plate (RP; and Synthes 3.5-mm LCP precontoured superior-anterior clavicle plate (PCRP). All clavicles were plated, a wedge-shaped inferior cortical defect was created, and testing was performed using a cantilever bending model to determine bending stiffness and yield point for each construct.

RESULTS

Bending stiffness for the 3.5-mm PCRP construct was markedly higher when compared with the other three constructs, whereas the 3.5-mm RP construct was markedly stiffer than both of the 2.7-mm CR constructs. The yield point for the 3.5-mm PCRP construct was greater than the other three constructs; however, the yield point for the 2.7-mm CRP with six screws and with eight screws was higher than the 3.5-mm RP construct. The amount of displacement required to reach the yield point was highest for the 2.7-mm CRP with six screws. and this was markedly higher than the values for the other three constructs.

DISCUSSION

The 3.5-mm plates demonstrated increased bending stiffness compared with the 2.7-mm plates. Despite the lower resistance to bending forces, the cold-worked 2.7-mm plate exhibited a markedly higher yield point and required markedly more superior to inferior displacement to initiate plastic deformation when compared with the 3.5-mm LCP RP.

LEVEL OF EVIDENCE

Level IV.

Outcomes and complications after dual plate vs. single plate fixation of displaced mid-shaft clavicle fractures: A systematic review and meta-analysis

INTRODUCTION

Open reduction and internal fixation (ORIF) of displaced midshaft clavicle fractures is associated with higher union rates and earlier functional recovery. However, ORIF with plate fixation is associated with complications including implant irritation and implant failure. Dual plate fixation provides fixation in orthogonal planes, and uses a lower profile fixation technique in comparison to pre-contoured and surgeon-contoured small-fragment locking plates, which may be more prominent. The objective of this study was to conduct a systematic review to summarize outcomes and complications associated with surgical fixation of displaced acute midshaft clavicle fractures with dual plate fixation.

METHODS

Using a predetermined study protocol in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, the databases MEDLINE, EMBASE, and CENTRAL were searched from inception to 2020 to identify studies reporting outcomes in acute midshaft clavicle fractures treated with dual plate fixation. All clinical studies which reported on outcomes of dual plating in patients with acute midshaft clavicle fractures were included. Baseline demographics, plate fixation constructs, fracture union rates, implant removal rates, maintenance of reduction, symptomatic implant rates, wound complications, and functional outcomes were extracted. All extracted data were recorded, and descriptive statistics were summarized. Meta-analysis was performed on fracture union rates and implant removal rates using random-effects modeling using Mantel-Haenszel weighting.

RESULTS

Our literature search identified 2226 unique abstracts, of which eight studies met our study inclusion criteria following review. A total of 278 patients made up of 79.8% male with an average age of 36.0 years were included. The overall dual plate implant removal rate was 4.2% with excellent rates of union reported. Moreover, single plate fixation was associated with a 3.9-fold increased implant removal rate compared to dual plate fixation.

CONCLUSION

Results from this systematic review demonstrate that ORIF of displaced midshaft clavicle fractures using a dual plate fixation technique is a viable option to reduce the incidence of implant removal, without negatively impacting the rate of fracture union.

LEVEL OF EVIDENCE

Therapeutic Level III.

Risk factors for hardware removal following operative treatment of middle- and distal-third clavicular fractures

BACKGROUND

The incidence of hardware removal (HWR) after operative fixation of clavicular fractures varies widely. Risk factors related to HWR remain incompletely understood. The aim of this study was to evaluate the incidence of and risk factors for HWR after plate fixation of middle- and distal-third clavicular fractures. We hypothesized that (1) the total HWR incidence would be <20%, (2) the HWR incidence of operatively treated distal- and middle-third clavicular fractures would not be statistically different, and (3) symptomatic implants would be the most common HWR indication.

METHODS

We performed a multi-hospital retrospective study of skeletally mature patients who underwent plate fixation of middle- and distal-third clavicular fractures from November 2008 to November 2018. Data included patient demographic characteristics, mechanism of injury, operative records, hardware-related symptoms, subsequent HWR, and complications.

RESULTS

A total of 103 patients (aged 16-75 years, 76.7% male patients) were included. Of the patients, 87 (84.5%) underwent plate fixation for midshaft clavicular fractures and 16 (15.5%) underwent plate fixation for distal-third clavicular fractures. HWR was performed in 13 patients (12.6%). A significantly higher percentage of HWR procedures were performed for distal clavicular fractures (50%) than for middle-third clavicular fractures (4.9%, P < .0001). An initial high-energy mechanism of injury was associated with HWR (P = .0025). The most common indication for HWR was symptomatic hardware (69.2%). The overall complication rate was 14.5%.

CONCLUSION

The overall incidence of clavicular HWR was 12.6%. A distal fracture location was associated with a significantly higher incidence of HWR. An initial high-energy mechanism of injury was a significant risk factor for HWR. The primary indication for HWR was symptomatic hardware.

The treatment of the atrophic clavicular nonunion by double-plate fixation with autogenous cancellous bone graft: a prospective study

Background

The objective of this study is to assess prospectively the effectiveness of double-plate fixation combined with autogenous cancellous bone graft in the treatment for the atrophic clavicular nonunion.

Methods

Between February 2013 and November 2017, a total of 12 patients with atrophic clavicular nonunion (mean age, 40.4 ± 9.0 years, range, 27–60 years) were treated by double-plate fixation with autogenous cancellous bone graft in our institute. The Constant Score System was used to evaluate the preoperative and final outcomes. The Short Form-36 (SF-36) outcome questionnaire was used to assess the final clinical results.

Results

All patients were followed-up, with the average follow-up of 34.7 ± 6.7 months (range, 24–48 months). The healing rate was 100% in our study. The mean time of bony union was 9 weeks (range, 8–10 weeks). One patient had a postoperative superficial infection, and the patient was cured by oral antibiotics and wound dressing. No implant-related complications (plate-screw loosening or breakage) were observed postoperatively. No vascular injury, neural impairment, or thoracic outlet syndrome was discovered preoperatively or postoperatively. There is a statistical significance between the preoperative and the postoperative constant scores (P < 0.05). All the patients were satisfied with their final clinical results by SF-36 outcome questionnaire. Average scores of the physical function and bodily pain components of the SF-36 were 94.2 ± 7.3 and 92.5 ± 5.8, respectively.

Conclusion

Our results presented that double-plate fixation with autogenous cancellous bone graft is an effective treatment for atrophic clavicular nonunion, especially for those with a significant bone defect.

Plunging Dangerously: A Quantitative Assessment of Drilling the Clavicle

Bicortical drilling of the clavicle is associated with risk of iatrogenic damage from plunging given the close proximity of neurovascular structures. This study determined plunge depth during superior-to-inferior clavicle drilling using a standard drill vs drill-sensing technology. Two orthopedic surgeons drilled 10 holes in a fresh cadaveric clavicle with drill-sensing technology in freehand mode (functions as standard orthopedic drill) and another 10 holes with drill-sensing technology in bicortical mode (drill motor stops when the second cortex is breached and depth is measured in real time). The drill-measured depths were compared with computed tomography-measured depths. Distances to the neurovascular structures were also measured. The surgeons' plunge depths were compared using an independent t test. With freehand (standard) drilling, the mean plunge depth was 8.8 mm. For surgeon 1, the range was 5.6 to 15.8 mm (mean, 10.9 mm). For surgeon 2, the range was 3.3 to 11.0 mm (mean, 6.4 mm). The surgeons' plunge depths were significantly different. In bicortical mode, the drill motor stopped when the second cortex was penetrated. Drill-measured depths were verified by computed tomography scan, with a mean difference of 0.8 mm. Mean distances from the clavicle to the neurovascular structures were 15.5 mm for the subclavian vein, 18.0 mm for the subclavian artery, and 8.0 mm for the brachial plexus. Plunge depths differed between surgeons. However, both surgeons' plunge depths were greater than distances to the neurovascular structures, indicating a risk of injury due to plunging. Although a nonspinning drill bit may still cause soft tissue damage, drill-sensing technology may decrease the risk of penetrating soft tissue structures due to plunging. [Orthopedics. 2021;44(1):e36-e42.].

Low Surgeon and Hospital Volume Increase Risk of Early Conversion to Total Knee Arthroplasty After Tibial Plateau Fixation

BACKGROUND

Some orthopaedic procedures exhibit volume-outcome relationships that suggest benefits associated with a triage and treatment by higher volume surgeons and hospitals. The purpose of this study was to determine whether this association is present for open reduction internal fixation (ORIF) of tibial plateau fractures regarding the outcome of conversion to total knee arthroplasty (TKA).

METHODS

The Florida State Inpatient Database was queried to identify patients who underwent ORIF of a tibial plateau fracture between 2006 and 2009. The annual volumes of surgeons and hospitals were determined. The outcome of interest was any subsequent hospitalization for TKA within 5 years. Comparing the rates of this outcome, cut points were established to define high and low volume. Survival analysis, including Cox proportional hazards modeling, was used to estimate the effect of volume on rates of TKA while controlling for patient factors and injury characteristics.

RESULTS

In this cohort of 3,921 patients, 172 patients (4.4%) underwent TKA within 5 years of ORIF of the tibial plateau. This included 5.0% of patients treated by low-volume surgeons versus 2.1% treated by high-volume surgeons and 4.8% treated at low-volume hospitals versus 2.0% treated at high-volume hospitals. High-volume surgeons and hospitals were defined by annual volumes greater than or equal to 7 and 29, respectively. After adjustment, treatment at a low-volume hospital was associated with a larger hazard of conversion to TKA (hazard ratio = 2.05; 95% confidence interval = 1.11 to 3.80). Treatment by a low-volume surgeon was also associated with a larger hazard of conversion to TKA (hazard ratio = 2.17; 95% confidence interval = 1.31 to 3.59).

DISCUSSION

High-volume treatment of tibial plateau fractures is associated with a lower rate of conversion to TKA, suggesting that the regionalization of care for these injuries may improve outcomes.

LEVEL OF EVIDENCE

Level III.

Can 3D-printing avoid discomfort-related implant removal in midshaft clavicle fractures? A four-year follow-up

INTRODUCTION

Due to the variation in shape and curvature of the clavicle, plates often have to be adjusted during surgery to acquire a good fit. Poorly fitted plates can cause discomfort, eventually requiring implant removal. 3D-printed replicas of the fractured clavicle can assist in planning of the surgical approach, plate selection and, if necessary, adjustment of the plate prior to surgery. We hypothesized this method of preoperative preparation would reduce implant-related discomfort resulting in a reduced reoperation rate MATERIALS AND METHODS: In a prospective cohort study, perioperative plate handling and clavicle fixation were timed and follow-up data were collected from participants undergoing operative treatment for a midshaft clavicle fracture. The control group (n = 7) received conventional surgery with standard precontoured plates. For the intervention group (n = 7), 3D-printed replicas of the fractured clavicle and a mirrored version of the healthy contralateral clavicle were available prior to surgery for planning of the surgical approach, and for plate selection and contouring. Primary outcome was reoperation rate due to implant-related discomfort. Secondary outcomes were complications and time differences in the different surgical phases (reduction, fixation and overall operation time) RESULTS: More participants in the control group had the plate removed due to discomfort compared to the intervention group (5/7 vs. 0/6; P = 0.012). One participant was excluded from the intervention group due to a postoperative complication; an infection occurred at the implant site. No relevant time difference in surgical plate handling was found between both groups.

CONCLUSIONS

Preoperative preparation using 3D-printed replicas of the clavicle fracture may reduce implant removal caused by plated-related discomfort. No relevant effect on surgery time was found.

TRIAL REGISTRATION

Registered with 'toetsingonline.nl', trial number NL51269.075/14, 17-02-2015.

Tibial plateau fractures in Belgium: epidemiology, financial burden and costs curbing strategies

PURPOSE

We describe the incidence of tibial plateau fractures and the evolution of its management and financial burden in Belgium, perform a similar audit at University Hospitals Leuven, and define strategies to curb the increasing cost.

METHODS

National data on tibial plateau fractures were collected from the NIHDI and compared to our performance. Several clinical parameters, such as age, sex, treatment modality and length-of-stay, were included. The total healthcare costs are considered as the sum of hospitalization costs and ambulatory care costs.

RESULTS

Between 2006 and 2018, a total number of 35,226 tibial plateau fractures were diagnosed in Belgium and 861 at our center. The incidence increased 41% over time (mean 25/100,000 persons per year). The mean rate of surgery in Belgium was 37% and slightly decreased over time, due to a larger increase of non-operatively treated tibial plateau fractures. The rate of surgery at the UHL was 49%. Surprisingly, the average cost per patient was equal for operatively and non-operatively treated patients in Belgium, and driven by the length-of stay.

CONCLUSION

Since length-of-stay is the main driver of the total healthcare costs of tibial plateau fractures, guidelines on appropriate length-of-stay can help to decrease variability and curb the total healthcare costs, particularly of the non-operatively treated patients. Our performance was in line with this.

LEVEL OF EVIDENCE

Level IV.

Prognostic factors and outcomes of secondary surgery after plate fixation for midshaft clavicle fracture: Comparison of traditional DCP and pre-contoured locking plate

OBJECTIVES

This study aimed to evaluate the prognostic factors of reoperation after plate fixation for midshaft clavicle fracture and compare outcomes of dynamic compression plates (DCP) and pre-contoured locking plates.

DESIGN

Retrospective comparative study.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

We recruited 274 consecutive patients who underwent plate fixation for midshaft clavicle fracture from 2007 to 2017 and completed at least 1 year of follow-up.

INTERVENTION

235 patients underwent surgery with DCP, while 39 patients were treated with locking plate.

MAIN OUTCOME MEASUREMENTS

We reviewed the possible variables of secondary surgeries, and documented complications from the medical records. Patients with a DCP or locking plate were further divided for outcome comparisons.

RESULTS

150 (54.7%) patients underwent reoperation after the initial surgery, and plate removal represented the major etiology. On multivariate analysis, superficial wound infection and prominent implant were identified as significant risk factors for reoperation, while aging, locking plate usage, and higher body mass index (BMI) were protective factors (all P < 0.05). The locking plate featured a significantly decreased implant removal rate (7.7% vs. 60.9%, P < 0.05).

CONCLUSIONS

Patients with risk factors for superficial wound infection or a prominent implant tended to require a secondary operation after surgery for midshaft clavicle fracture, while aging, pre-contoured locking plate usage, and higher BMI decreased the risk. Compared with DCP, patients with locking plates tended to have better prognosis and significantly lower implant removal rates.

LEVEL OF EVIDENCE

Prognostic III.

Trauma fellowship impact on trends and complications of operatively treated clavicle fractures in recently trained orthopedic surgeons

PURPOSE

The purpose of this study was to evaluate whether fellowship training affected trends and complications of operative clavicle fracture treatment in newly trained orthopedic surgeons.

METHODS

The American Board of Orthopedic Surgery (ABOS) database was utilized to identify cases of open treatment of clavicle fractures submitted by ABOS Part-II Board Certification candidates. From 2005 to 2017, 3148 candidates performed at least one open clavicle fracture treatment. Overall, 6919 cases were included; 3516 of these had over 6 weeks of follow-up. Candidates were divided by fellowship type into 5 groups: Trauma, Sports Medicine, Hand and Upper Extremity or Shoulder, multiple, and other or no fellowship(s). Group differences were analyzed with ANOVA and Bonferroni post hoc analysis. Complications, reoperations, nonunion rates, and readmissions between groups were evaluated with Chi-squared test and logistic regression analyses.

RESULTS

Case volume during the study period was significantly higher after 2007. Trauma candidates performed significantly more operations for clavicle fracture per candidate while candidates with other or no fellowship(s) performed significantly fewer operations per candidate. Patients treated by Trauma candidates were significantly older, had significantly fewer early surgical complications and significantly more early medical complications. Nonunion rates were not significantly different between groups.

CONCLUSION

Candidates treated clavicle fractures surgically more often in 2007 and beyond. Trauma candidates treated older patients, had fewer early surgical complications, and had more medical complications. Reoperation, readmission and nonunion rates were not significantly different between groups.

Comparison of plate fixation vs. intramedullary fixation for the management of mid-shaft clavicle fractures: A systematic review and meta-analysis of randomised controlled trials

A number of meta-analyses have compared clinical outcomes following plate vs. intramedullary fixation for midshaft clavicle fractures (MSCF), but with conflicting results. There is a requirement for updated level-1 evidence to guide clinicians managing MSCF. The aim of the present systematic review and meta-analysis was to compare clinical outcomes following plate vs. intramedullary fixation of MSCF. The PubMed, Scopus, BioMed Central, Cochrane Central Register of Controlled Trials and Google Scholar databases were searched for records added until 1st July 2019. A total of 10 randomised controlled trials (RCTs) were included. Shoulder function was assessed using the Constant-Murley Shoulder Outcome questionnaire and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). There was no statistically significant difference in Constant-Murley scores between plate and intramedullary fixation [Mean difference (MD)=0.75; 95% CI: -2.49 to 3.99; P=0.65; I²=85%]. Similarly, there was no statistically significant difference in DASH scores between the two groups (MD=1.55; 95% CI: -1.12 to 4.23; P=0.26; I²=89%). There was no statistically significant difference in complications requiring non-routine surgery between plate and intramedullary fixation [risk ratio (RR)=1.80, 95%CI: 0.80-4.05, P=0.15; I²=0%]. There was an increased risk of complications that did not require non-routine surgery with plate fixation as compared to intramedullary fixation (RR=2.38, 95%CI: 1.22-4.62, P=0.01; I²=70%). Plate fixation was also associated with an increased risk of infection and complications of cosmetic dissatisfaction. The present results indicated no difference in long-term functional outcomes between plate and intramedullary fixation of MSCF. Plate fixation was associated with an increased risk of complications not requiring non-routine surgery. Further high-quality RCTs shall strengthen the evidence on this subject.

Transient Brachial Plexopathy After Fixation of a Clavicle Fracture Nonunion: A Case Report

CASE

A 54-year-old man presented with a comminuted left midclavicle fracture that progressed to a symptomatic nonunion after nonsurgical management. Nonunion open reduction and internal fixation (ORIF) was performed, but a left brachial plexopathy developed 48 hours postoperatively. Imaging failed to demonstrate an emergent cause. The patient was monitored and completely recovered, with occasional neuralgia and mildly limited forward elevation of the shoulder.

CONCLUSION

Development of a brachial plexopathy 48 hours after routine clavicle nonunion ORIF using plate fixation is an unusual complication. Future studies are needed to determine if this "wait-and-see" approach can be generalized to similar cases.

Dual Mini-Fragment Plating Is Comparable With Precontoured Small Fragment Plating for Operative Diaphyseal Clavicle Fractures: A Retrospective Cohort Study

OBJECTIVES

To compare precontoured (Pc) small fragment plating to dual mini-fragment plating (DmF) for open reduction and internal fixation of diaphyseal clavicle fractures.

DESIGN

Retrospective cohort.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

A total of 133 patients with displaced fractures of the diaphyseal clavicle (OTA/AO 15-B1, -2, and -3) treated with open reduction and internal fixation with a minimum of 1 year follow-up or until radiographic and clinical union.

INTERVENTION

Two patient cohorts were identified: (1) patients treated with orthogonal DmF plate constructs and (2) patients treated with Pc clavicle-specific plates.

OUTCOME MEASUREMENTS

Union rate and implant removal were assessed using standard descriptive statistics. Odds ratios, 95% confidence intervals, and P values (P) were calculated.

RESULTS

There were 60 DmF and 74 Pc patients. There were no significant differences between groups with respect to age, sex, surgeon, body mass index, or mode of fixation. There was no significant difference in union (98.3% DmF; 100% Pc, P = 0.45) or maintenance of reduction (98.3% DmF; 100% Pc, P = 0.45). A total of 8% of DmF patients had symptomatic implant removal compared with 20% of Pc patients (odds ratio 0.36, confidence interval 0.12-1.05, P = 0.061).

CONCLUSIONS

This retrospective comparative study found no difference in union or maintenance of reduction for diaphyseal clavicle fractures fixed with DmF compared with Pc plating. Patients treated with DmF plates may have lower rates of symptomatic implant removal.

LEVEL OF EVIDENCE

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

No Difference in Risk of Implant Removal Between Orthogonal Mini-fragment and Single Small-fragment Plating of Midshaft Clavicle Fractures in a Military Population: A Preliminary Study

BACKGROUND

Clavicle fractures are common, especially in military personnel. A persistent problem of open reduction and internal fixation (ORIF) of the clavicle is the high percentage of symptomatic implants needing removal. Prominent implants can lead to discomfort in military service members performing activities such as carrying rucksacks and firing high-caliber weapons, potentially resulting in a high removal of implant rate. Alternative approaches to plate fixation may mitigate this, but to our knowledge, only limited evidence is available comparing various plate-fixation approaches.

QUESTIONS/PURPOSES

In a military population, we asked (1) Is there a difference in implant removal rates after midshaft clavicle fixation using orthogonal plating with 2.7-mm reconstruction plates versus a single 3.5-mm locking compression plate? (2) What complications are associated with each fixation approach? (3) Is there a difference in surgical time between the approaches?

METHODS

Between January 2010 and May 2015, three surgeons performed 99 ORIF procedures of midshaft clavicle fractures, always using a single small-fragment plate, and one surgeon performed 34 procedures, always using two mini-fragment plates with an orthogonal plating construct. Of those, 89 (90%) in the small-fragment plating group were available for analysis in this retrospective study and 33 (97%) were available for analysis in the mini-fragment plating group, both groups with a minimum of 2 years of followup. There were no between-group differences in terms of gender, tobacco use, injured side, hand dominance, 100% displacement, comminution, shortening, and active-duty status. We analyzed the proportion of patients who had their plates removed for any complications recorded in their charts. Assessment bias for indications for symptomatic removal of implant was minimized as there was always another fellowship-trained trauma surgeon at our institution available for a second opinion if the operative surgeon did not agree with a patient request for implant removal. A posthoc power calculation indicated that with the numbers available, we had 80% power to detect a between-group difference in implant removal proportion of 14.5% at the p < 0.05 level.

RESULTS

We found no difference between the small-fragment plating group and the mini-fragment group in the frequency of plate removal (9% [8 of 89] versus 0% [0 of 33]; odds ratio, 3.38 [95% confidence interval 0.41 to 27.68]; p = 0.11); a worst-case analysis that assumed all patients lost to follow-up underwent plate removal did not change this no-difference finding. All cases of implant removal were performed secondary to a symptomatic implant. With the numbers available, there were no differences between the two groups in nonunion, delayed union, infection, or other complications. There was a longer mean operative time in the mini-fragment group than in the small-fragment group (173.7 minutes versus 118.7 minutes; mean difference, 55 minutes [95% CI 38.71 to 71.23]; p < .001). Our overall implant removal percentage for the two groups combined was 6.6% (8 of 122).

CONCLUSIONS

Our study was underpowered to show differences in implant removal but may serve as a pilot for larger randomized controlled trials or multi-institutional studies on this topic. Although there was increased operative time to insert two plates, there was no difference in overall complications.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Dual Versus Single-Plate Fixation of Midshaft Clavicular Fractures: A Retrospective Comparative Study

Background

Implant-related symptoms are the most common reason for reoperation after open reduction and internal fixation (ORIF) of midshaft clavicular fractures. Dual mini-fragment plate fixation is a relatively new solution that may decrease implant prominence while maintaining fixation strength and function. There are minimal published data comparing reoperation rates and clinical outcomes between single, superior-plate constructs and dual mini-fragment plate constructs in the fixation of midshaft clavicular fractures. We hypothesized that reducing plate size with the use of dual mini-fragment plating compared with standard, 3.5-mm, superior plating would minimize implant symptoms and the corresponding need for reoperation while still providing sufficient fixation to allow fracture-healing and return to function.

Methods

We retrospectively reviewed the cases of 44 consecutive patients who underwent ORIF of displaced midshaft clavicular fractures utilizing either a single, 3.5-mm, superior plate construct (21 patients) or a dual, 2.7-mm and 2.4-mm, plate construct (23 patients). Outcomes at a minimum of 2 years were assessed. Primary outcome measures included reoperation for any reason and the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, patient self-report section.

Results

There was a 100% union rate in both groups. None (0%) of the 23 patients who received the dual (2.7-mm and 2.4-mm) plate construct and 6 (29%) of the 21 patients who received the single (3.5-mm) plate construct underwent reoperation for implant-related symptoms. Using a Fisher exact test, the rate of reoperation was compared between the groups, and the difference was found to be significant (p = 0.008). Using an unpaired t test, the difference in mean ASES scores was not significant (p = 0.138) between the dual-plate group (98 of 100) and the single superior plate group (96 of 100) with retained implants.

Conclusions

In our comparative retrospective series, dual fixation utilizing a 2.7-mm superior plate and a 2.4-mm anterior plate for the treatment of displaced midshaft clavicular fractures was associated with a significantly lower rate of reoperation when compared with single, 3.5-mm, superior plate fixation.

Level of Evidence

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

Safety and efficacy of using 2.4/2.4 mm and 2.0/2.4 mm dual mini-fragment plate combinations for fixation of displaced diaphyseal clavicle fractures

PURPOSE

The purpose of this study was to evaluate the safety and efficacy of using lower profile 2.4/2.4 mm and 2.0/2.4 mm dual mini-fragment plate constructs for fixation of diaphyseal clavicle fractures.

METHODS

This was a retrospective case series of all displaced diaphyseal clavicle fractures treated with 2.4/2.4 and 2.0/2.4 dual mini-fragment plate constructs at a single level-one trauma center. Postoperative complications and fracture healing rates were recorded. A subset of patients with long-term follow up was used to determine the rate of reoperation for symptomatic implant removal.

RESULTS

All 36 identified fractures healed without loss of reduction or implant failure. There was one superficial infection and no deep infections or cases of wound dehiscence. Twenty patients from the entire cohort had longer-term follow up available to assess the reoperation rate for symptomatic implant removal. Two patients (10%) underwent symptomatic implant removal, and one patient with retained implants was planning on future removal due to soft-tissue irritation; this combined to a projected reoperation rate of 15% for symptomatic implant removal.

CONCLUSION

Dual mini-fragment plating of diaphyseal clavicle fractures, using 2.4/2.4 mm and 2.0/2.4 mm plate combinations, creates a lower profile construct that reliably maintains fracture reduction to healing, and has a low rate of reoperation for symptomatic implant removal.