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

Functional outcomes and complications of plate fixation for midshaft clavicle fractures by type and location: a systematic review and meta-analysis

Background

Various plate types are used in the surgical treatment of displaced midshaft clavicle fractures. These plates can be positioned in different locations on the clavicle, although no studies to date have elucidated optimal plate type and location of fixation. This systematic review compares the functional outcomes and complications in the management of displaced midshaft clavicle fractures using plate fixation by stratifying by both plate type and location.

Methods

A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted to identify all papers reporting functional outcomes, union rates, and/or complications using plates for the management of midshaft clavicle fractures. Multiple databases and trial registries were searched from inception until March 2022. A meta-analysis was conducted for functional outcomes and type of complication, stratified by plate type (locking, compression, or reconstruction) and location (superior or anteroinferior). Pooled estimates of functional outcome scores and incidence of complications were calculated using a random effects model. Risk of bias and quality were assessed using the risk of bias version 2 and ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tools. The confidence in estimates were rated and described according to the recommendations of the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) working group.

Results

Forty-five studies were included in the systematic review and 43 were included in the meta-analysis. Depending on plate type and location, pooled Constant-Murley Scores ranged from 89.23 to 93.48 at 12 months. Nonunion rates were 3% (95% confidence interval [CI] 1-6) for superior locking plates (GRADE Low). Rates of any complication (nonunion, hardware failure, hardware irritation, wound dehiscence, keloid, superficial infection, deep infection, delayed union, malunion, and/or persistent pain) by plate type and location ranged from 3% to 17% (GRADE Very Low to Moderate). Superior compression plates had the highest incidence of any complications (17% [95% CI 5-44], GRADE Very Low), while anterior inferior compression plates had the lowest incidence of any complication (3% [95% CI 0-15], GRADE Very Low). Hardware irritation was the most reported individual complication for superior locking plates and superior compression plates, 11% (95% CI 7-17, GRADE Low) and 11% (95% CI 3-33, GRADE Very Low), respectively.

Conclusion

Although most studies were of low quality, studies reporting functional outcomes generally showed good functional results and similar incidence of any complication regardless of plate type and location. There is no evidence of a plate and location combination to optimize patient functional outcomes or complications. We were unable to reliably evaluate union rates or individual complications for most plate types stratified by location.

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.

Clinical Outcomes of Double Mini-Plating Compared with a Single Superior Plating in Midshaft Clavicular Fractures: A Randomized Clinical Trial Study

Background

In the current study, we aimed to assess the clinical outcomes of the double-plating method using 2.7 mm compression plates compared with the single superior 3.5 mm compression plating method in displaced midshaft fractures of the clavicle.

Materials and Methods

Thirty patients with midshaft fractures of the clavicle were randomly assigned into two groups. In group A, 15 patients were fixed by a double-plating technique using two 2.7 mm compression plates on the superior and anteroinferior sides of the bone. The fractures in group B were fixed by a superior plating technique using a single 3.5 mm compression plate. Intraoperative bleeding measurement, length of surgical incision, duration of procedure time, and functional scores were assessed post-surgically through one-year follow-ups.

Results

There was no significant difference between groups in terms of surgery time. Device failure was not found among all recruited patients. Incision length and device prominence complaint were significantly different between groups (P value = 0.02, P value = 0.03). Mean ± standard deviation intraoperative bleeding rate was 88.67 ± 29.96 milliliter in the double-plating group and 108.67 ± 41.72 milliliter in the other group, which was not different between these two groups (P value = 0.14). There were no signs of non-union either in radiographies or clinically.

Conclusion

Double mini-plating of diaphyseal clavicular fractures could result in a smaller surgical incision and a lower rate of prominence without affecting fixation stability and clinical outcomes in comparison with single superior 3.5 mm plates.

Dual Mini-Fragment Plate Fixation of Midshaft Clavicle Fractures Reduces Risk of Reoperation Compared With Single-Plate Fixation Techniques

BACKGROUND

Recent studies have highlighted dual plating as a method of reducing high rates of postoperative complication after operative management of displaced midshaft clavicular fractures. However, few studies have reliably characterized reoperation rates and magnitude of risk reduction achieved when using dual versus anterior and superior single-plate techniques.

HYPOTHESIS

There would be lower rates of reoperation among patients who underwent open reduction and internal fixation (ORIF) of displaced midshaft clavicular fractures via dual plating.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This was a retrospective analysis of patients who underwent ORIF for a displaced midshaft clavicular fracture between 2010 and 2021 at a level 1 trauma center with a minimum 12-month follow-up. Patients were separated into 3 cohorts based on fixation type: (1) orthogonal dual mini-fragment plate fixation, (2) superior plate fixation, and (3) anterior plate fixation. Data on patient characteristics, fracture pattern, and reoperations were documented. All-cause reoperation rates and hazard ratio (HR) estimates of dual, superior, and anterior plating were calculated using a multivariate multilevel mixed-effects parametric survival model. Significant confounders including high-risk fracture morphology and smoking status were controlled for in the final model.

RESULTS

A final cohort of 256 patients was identified with mean follow-up of 4.9 ± 3.8 years. In total, 101 patients underwent superior plating, 92 underwent anterior plating, and 63 underwent dual plating. Overall, 31 reoperations took place (18 in superior, 12 in anterior, 1 in dual plating) among 22 patients. Major contributors to reoperation included symptomatic hardware (n = 11), nonunion (n = 8), deep infection (n = 7), and wound dehiscence (n = 2). Superior plating revealed the highest reoperation rate of 0.031 per person-years, followed by anterior plating with 0.026 per person-years and dual plating with 0.005 per person-years. Overall, single plating (either anterior or superior placement) had a nearly 8-fold greater risk of reoperation than dual plating (HR, 7.62; 95% CI, 1.02-56.82; P = .048). Further broken down by technique, superior plating had an 8-fold greater risk of reoperation than dual plating (HR, 8.36; 95% CI, 1.10-63.86; P = .041), but anterior plating did not demonstrate a statistically significant difference compared with dual plating (HR, 6.79; 95% CI, 0.87-52.90; P = .068).

CONCLUSION

Dual-plate fixation represents an excellent treatment for displaced midshaft clavicular fractures, with low rates of nonunion and reoperation. When compared with single locked superior or anterior plate fixation, dual mini-fragment plate fixation has a nearly 8-fold lower risk of reoperation.

Low rate of secondary surgery and implant removal following superior, precontoured plating of midshaft clavicle fractures

Background

Surgical fixation of midshaft clavicle fractures with a single 3.5 mm superior clavicular plate has been associated with a high rate of hardware removal due to symptomatic hardware. Because of this, dual-plating techniques with lower-profile implants have been proposed. However, dual-plating systems have disadvantages, including increased cost and increased surgical morbidity. The aim of this study was to define the rate of symptomatic hardware removal for all midshaft clavicle fractures.

Methods

We retrospectively reviewed information on all patients from 2014 to 2018 at a single level 1 trauma institution with surgeries performed by two fellowship-trained orthopedic trauma surgeons. Documented removal of hardware and the reason for removal were recorded. We then contacted all patients at their listed telephone number to confirm the hardware was still in place and to administer patient outcome questionnaires. If patients did not answer, attempts were made to contact them multiple times on multiple days. Those who were not reached but had documented hardware removal were included in the total number of patients with hardware removal.

Results

The search revealed 158 patients, of whom 89 (61.8%) were included in the study. Average follow up was 4.09 years (range 2.02-6.50 years). Five patients (5.56%) underwent hardware removal. Removal was for symptomatic or irritating hardware in two of these patients (2.22%). Average abbreviated Disability of Arm, Shoulder, and Hand score was 6.27, and average American Society of Shoulder and Elbow Surgeons shoulder score was 93.6.

Conclusion

In our series, the rate of symptomatic hardware removal was 2.22%, well below reported removal rates. Hardware removal rates for prominent symptomatic superior clavicular plates may be significantly lower than previously reported, and these fractures may be adequately treated with a single, superior plate.

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.

Low profile dual plating for mid-shaft clavicle fractures: a meta-analysis and systematic review of observational studies

INTRODUCTION

Low profile dual plate fixation using two mini fragment plates (< 2.7 mm thickness) is a relatively new technique and alternative to single plating for treating midshaft clavicle fractures. To date, no meta-analysis has been performed comparing these two techniques. Therefore, a systematic review and meta-analysis of observational studies and randomized clinical trials was performed comparing single plating to low profile dual plating for midshaft clavicle fractures.

METHODS

PubMed/Medline/Embase/CENTRAL/CINAHL were searched for both randomized clinical trials (RCT) and observational studies comparing both treatments. Effect estimates were pooled across studies using random effects models. The primary outcome is overall complication rate and re-intervention rate. Secondary outcomes include healing, operation duration and functional scores.

RESULTS

Low profile dual plating has favourable outcomes regarding overall complication rate (8.1% vs. 22.5%, OR 0.3, 95% CI 0.2-0.7, I² = 16%, p = 0.007) and re-intervention rate (6.1% vs. 16.1%, OR 0.3, 95% CI 0.1-0.9, I² = 25%, p = 0.02). The largest contributing factor behind these differences was the high incidence of implant related complaints in the single plating group (4.7% vs. 11.6%, OR 0.4, 95% CI 0.2-0.9, I² = 0%, p = 0.02). The use of low profile dual plating does not have a detrimental effect on healing with union being attained in 99% compared to 97.4% in the single plating group (OR 1.8, 95% CI 0.3-10.7, I = 0%, p = 0.5). Data on operating time and functional results is limited.

CONCLUSION

This meta-analysis shows that dual plating low profile plates for midshaft clavicle fractures is a safe procedure attaining the same union rates seen in patients treated with single plating. In addition, it seems to have a lower overall complication and re-intervention rate, mostly driven by the lower incidence of implant related complaints. Low profile dual plating, however, is a fairly new technique and should be further explored in respect to more differentiated endpoints to test whether these first findings are valid.

LEVEL OF EVIDENCE

III.

Biomechanical Evaluation of Different Plate Configurations for Midshaft Clavicle Fracture Fixation: Single Plating Compared with Dual Mini-Fragment Plating

Background:

Dual-plate constructs have become an increasingly common fixation technique for midshaft clavicle fractures and typically involve the use of mini-fragment plates. The goal of this technique is to reduce plate prominence and implant irritation. However, limited biomechanical data exist for these lower-profile constructs. The study aim was to compare dual mini-fragment orthogonal plating with small-fragment clavicle plates for biomechanical noninferiority and to determine if an optimal plate configuration could be identified using a cadaveric model.

Methods:

Twenty-four cadaveric clavicles were randomized to 1 of 6 groups, stratified by computed tomography-based bone mineral content (BMC): precontoured superior or anterior fixation using a single 3.5-mm Locking Compression Plate (LCP), and 4 different dual-plating constructs utilizing 2.4-mm and 2.7-mm Adaptation plates or LCPs. An inferior butterfly fracture was created. Axial, torsional, and bending (anterior and superior surface loading) stiffnesses were determined through nondestructive cyclic testing, followed by a load-to-failure test in 3-point superior surface bending.

Results:

For axial stiffness, the 2 dual-plate constructs with a superior 2.4-mm and anterior 2.7-mm plate (either Adaptation or LCP) were significantly stiffer than the other 4 constructs (p = 0.021 and p = 0.034). For both superior and anterior bending, the superior 2.4-mm and anterior 2.7-mm plate constructs were significantly stiffer when compared with the 3.5-mm superior plate (p = 0.043). No significant differences were found in torsional stiffness or load to failure between the different constructs.

Conclusions:

Dual plating using mini-fragment plates is biomechanically superior for the fixation of midshaft clavicle fractures when compared with a single, superior, 3.5-mm plate and has biomechanical properties similar to those of a 3.5-mm plate placed anteriorly. With the exception of axial stiffness, no significant differences were found when different dual-plating constructs were compared with each other.

Clinical Relevance:

This study validates the use of dual plating for midshaft clavicle fractures.

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.

Single versus dual orthogonal plating for comminuted midshaft clavicle fractures: a biomechanics study

BACKGROUND

Dual orthogonal plating of clavicle fractures may provide greater stiffness and strength than unilateral plate constructs and allow the use of lower-profile plates. We aim to biomechanically compare three clavicle plating constructs in a comminuted clavicle fracture model.

METHOD

Fifteen clavicle sawbones were osteotomised, simulating a comminuted midshaft fracture and allocated to either: group 1, single superior plate (3.5 mm superior plate); group 2, combination plating (3.5 mm superior plate, 2.8 mm anterior plate) and group 3, dual mini-plates (two 2.8-mm orthogonal mini-plates). Specimens were biomechanically tested under torsion and cantilever bending. Construct stiffness (Nm/degree) and load to failure (Nm) were measured.

RESULTS

Group 2 had higher torsional (0.70 vs. 0.60 Nm/deg, p = 0.017) and cantilever bending stiffness (0.61 vs. 0.51 Nm/deg, p = 0.025) than group 1. Group 3 had lower cantilever bending stiffness (0.39 vs. 0.51 Nm/deg, p < 0.004) and load to failure (40.87 vs. 54.84 Nm, p < 0.01) than group 1. All dual plate constructs that catastrophically failed did so from fracture at the lateral ends of the plates. Single plate constructs failed due to plate bending.

CONCLUSION

Dual orthogonal fixation with mini-plates demonstrated lower stiffness and strength than traditional superior plating. The addition of an anterior mini-plate to a traditional superior plating improved construct stiffness and may have a role in patients seeking early return to activity.

LEVEL OF EVIDENCE

Basic science biomechanical study.