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Thurston D, Jordan RW, Thangarajah T, Haque A, Woodmass J, D'Alessandro P, Malik SS. Are displaced distal clavicle fractures associated with inferior clinical outcomes following nonoperative management? A systematic review. J Shoulder Elbow Surg 2024:S1058-2746(24)00057-0. [PMID: 38281678 DOI: 10.1016/j.jse.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 11/23/2023] [Accepted: 12/04/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Management of displaced distal clavicle fractures remains a topic of discussion because of notoriously high nonunion rates, but there is little documented in the literature as to what effect this may have on patient-reported function. The aim of this systematic review was to look at nonoperative management following displaced distal clavicle fractures to determine union rates, complications, and patient-reported outcome measures. METHODS A review of the online databases MEDLINE and Embase was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Clinical studies that included a cohort of nonoperatively managed displaced distal clavicle fractures and reported on union rate, complications, and patient-reported functional scores were included. RESULTS Eleven studies were eligible for inclusion (2 randomized controlled trials, 1 prospective noncomparative cohort study, 5 retrospective comparative cohort studies, and 3 case series) with a total of 779 patients included in this review. Average union rate was 63.2% (22.2%-94.4%) in nonoperatively managed patients, compared with 96.3% (87.9%-100%) in operatively managed patients. The Constant-Murley score and Disabilities of the Arm, Shoulder, and Hand questionnaire were the most frequently used outcome measure tools. No study demonstrated any significant difference in any outcome measure when comparing nonoperative with operative treatment. Complication rate (including nonunion) in nonoperatively managed patients was 45.1%, with 11.1% requiring delayed surgery. Average complication rate in the operatively managed groups was 41.2%, with 40.1% requiring a second operation. CONCLUSION Nonoperative management of displaced distal clavicle fractures results in higher nonunion rates, but shoulder function remains excellent, and risk of complications and delayed surgery are low. Decision making must take into account patient factors and expectations to provide high-quality, individualized care.
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Affiliation(s)
- Daniel Thurston
- The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, United Kingdom.
| | - Robert W Jordan
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Tanujan Thangarajah
- University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Aziz Haque
- University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | | | - Peter D'Alessandro
- Orthopaedic Research Foundation of Western Australia, Perth, Australia; Discipline of Surgery, Medical School, University of Western Australia, Perth, Australia
| | - Shahbaz S Malik
- Worcestershire Acute Hospitals NHS Trust, Worcester, United Kingdom
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von Rüden C, Rehme-Röhrl J, Augat P, Friederichs J, Hackl S, Stuby F, Trapp O. Evidence on treatment of clavicle fractures. Injury 2023; 54 Suppl 5:110818. [PMID: 37217399 DOI: 10.1016/j.injury.2023.05.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/24/2023]
Abstract
Depending on the severity of the injury and the involvement of the soft tissue envelope, clavicle fractures can be treated operatively or non-operatively. In the past, displaced fractures of the clavicle shaft in adults have been treated non-operatively. However, the rate of nonunion following non-operative treatment seems to be higher than previously reported. In addition, publications reporting better functional outcomes following operative treatment are increasing. In recent years this has led to a paradigm shift towards an increase of operative fracture treatment. The aim of this review article was to summarize the currently available evidence on the treatment of clavicle fractures. Classifications, indications, and treatment options for different fracture patterns of the medial, midshaft, and lateral clavicles are presented and discussed.
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Affiliation(s)
- Christian von Rüden
- Department of Trauma Surgery, Orthopaedics and Hand Surgery, Weiden Medical Center, Weiden/ Oberpfalz, Germany; Department of Trauma Surgery, BG Unfallklinik Murnau, Murnau, Germany; Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria.
| | - Julia Rehme-Röhrl
- Department of Trauma Surgery, BG Unfallklinik Murnau, Murnau, Germany
| | - Peter Augat
- Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria; Institute for Biomechanics, BG Unfallklinik Murnau, Murnau, Germany
| | - Jan Friederichs
- Department of Trauma Surgery, BG Unfallklinik Murnau, Murnau, Germany
| | - Simon Hackl
- Department of Trauma Surgery, BG Unfallklinik Murnau, Murnau, Germany; Institute for Biomechanics, Paracelsus Medical University, Salzburg, Austria
| | - Fabian Stuby
- Department of Trauma Surgery, BG Unfallklinik Murnau, Murnau, Germany
| | - Oliver Trapp
- Department of Trauma Surgery, BG Unfallklinik Murnau, Murnau, Germany
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Open coraco-clavicular ligament reconstruction (CCLR) in treatment of displaced distal clavicle fractures has low complication rate and excellent union rate: a systematic review. Arch Orthop Trauma Surg 2023; 143:1459-1477. [PMID: 35178594 DOI: 10.1007/s00402-022-04384-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 02/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND It is well established that non-operative treatment of displaced distal clavicle fractures (DDCF) leads to a high non-union rate. A number of open surgical treatments in the past have shown good to excellent outcomes including shoulder function and union rate. Despite this there is no consensus on the outcome of open coraco-clavicular ligament reconstruction (CCLR). The aim of this systematic review was to assess the union rate, complications and shoulder function of open CCLR techniques in the treatment of DDCF. PATIENTS AND METHODS A review of the online databases MEDLINE and Embase was conducted on 1 January 2021 according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies reporting union rate, complications and shoulder function were included. The studies were appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool. RESULTS The search strategy identified 18 studies eligible for inclusion with a total of 330 patients. These included 12 retrospective case series and 5 nonrandomized retrospective comparative studies and one RCT. All but one study reported on shoulder function, while all the studies reported on union rate and complications. The overall shoulder function was good to excellent using Constant-Murley score. The overall union rate was 97.6% and complication rate was 7.6%. CONCLUSION Open CCLR for displaced distal clavicle fractures that have a disruption of CC ligament, is a reliable treatment with excellent union rate and good to excellent shoulder functional scores. LEVEL OF EVIDENCE IV; Systematic review.
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Wang X, Fang X, Qi B, Xiao W, Pan Z, Xie Z. Comparing the Efficacy of Anatomical Locked Plate Fixation with Coracoclavicular Ligament Augmentation to Hook Plate Fixation in Treating Distal Clavicle Fractures. Orthop Surg 2022; 14:3358-3366. [PMID: 36419319 PMCID: PMC9732613 DOI: 10.1111/os.13612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 10/19/2022] [Accepted: 11/04/2022] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Hook plate fixation is the traditional method for treating distal clavicle fractures. However, in recent years, locked plate applications have emerged as a promising treatment method. This study aimed to compare the short- and mid-term clinical efficacy of anatomical locked plate fixation with coracoclavicular ligament augmentation using anchor nails to that of hook plate fixation in treating distal clavicle fractures. METHODS This was a retrospective single-center cohort study investigating patients with distal clavicle fractures treated between January 2016 and February 2019 in Zhongnan Hospital of Wuhan University. Fifty-nine eligible patients who underwent either anatomical locked plate fixation with coracoclavicular ligament augmentation using anchor nails (LPF&CLA group; 20 patients) or clavicle hook plate fixation (CHPF group; 39 patients) were included. The visual analog scale (VAS) and Constant-Murley shoulder scores were used to assess shoulder function. In addition, the coracoclavicular distance between the affected and unaffected shoulders (ΔCC distance) was measured to assess the reduction. Patients were followed up at 3 months, 6 months, and 1 year postoperatively. The comparisons between the two groups were made using Student's t-test, chi-square test, or Fisher's exact test, if appropriate. RESULTS Preoperative VAS scores were similar in both groups. At 3- and 6-month follow-up, the VAS score was significantly higher in the CHPF group than in the LPF&CLA group. In contrast, the Constant-Murley shoulder score was significantly lower in the CHPF group than in the LPF&CLA group. When the hook plates were removed, there was no statistical difference in both VAS (0.2 ± 0.4 in LPF&CLA group vs. 0.5 ± 0.5 in CHPF group, p = 0.05) and Constant-Murley shoulder (96.1 ± 3.1 in LPF&CLA group vs. 93.8 ± 5.2 in CHPF group, p = 0.08) scores at the last follow-up. Postoperatively, the ΔCC distance was 2.37 ± 1.93 mm in the LPF&CLA group and -1.56 ± 1.34 mm in the CHPF group. One year after surgery, ΔCC distance increased to 3.96 ± 1.17 mm in the LPF&CLA group and to -0.89 ± 1.39 mm in the CHPF group. CONCLUSION For distal clavicle fractures in which the coracoclavicular ligament is disrupted, anatomical locked plate fixation with coracoclavicular ligament augmentation achieved better functional recovery and less pain than hook plate fixation at the 6-month follow-up. However, the hook plate provided better reduction throughout the follow-up period and shoulder pain could be relieved using removal surgery. Therefore, locked plates with coracoclavicular ligament augmentation favors post-surgery pain relief while harvesting similar functional outcomes to hook plate fixation.
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Affiliation(s)
- Xin Wang
- Department of Orthopaedics Trauma and MicrosurgeryZhongnan Hospital of Wuhan UniversityWuhanHubeiChina,Clinical Research Center for Microsurgical Orthopaedics of Hubei ProvinceZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
| | - Xue Fang
- Department of Orthopaedics Trauma and MicrosurgeryZhongnan Hospital of Wuhan UniversityWuhanHubeiChina,Clinical Research Center for Microsurgical Orthopaedics of Hubei ProvinceZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
| | - Baiwen Qi
- Department of Orthopaedics Trauma and MicrosurgeryZhongnan Hospital of Wuhan UniversityWuhanHubeiChina,Clinical Research Center for Microsurgical Orthopaedics of Hubei ProvinceZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
| | - Weidong Xiao
- Department of Orthopaedics Trauma and MicrosurgeryZhongnan Hospital of Wuhan UniversityWuhanHubeiChina,Clinical Research Center for Microsurgical Orthopaedics of Hubei ProvinceZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
| | - Zhenyu Pan
- Department of Orthopaedics Trauma and MicrosurgeryZhongnan Hospital of Wuhan UniversityWuhanHubeiChina,Clinical Research Center for Microsurgical Orthopaedics of Hubei ProvinceZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
| | - Zhe Xie
- Department of Orthopaedics Trauma and MicrosurgeryZhongnan Hospital of Wuhan UniversityWuhanHubeiChina,Clinical Research Center for Microsurgical Orthopaedics of Hubei ProvinceZhongnan Hospital of Wuhan UniversityWuhanHubeiChina
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Elrih M, Quinlan J. Hook Plate Versus Distal Locking Plate for the Fixation of Unstable Distal Clavicle Injuries, Outcomes and Complications: A Meta-Analysis. Cureus 2022; 14:e30806. [PMID: 36381853 PMCID: PMC9642879 DOI: 10.7759/cureus.30806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
Numerous interventions are advised for the surgical management of distal clavicle fractures. Hook plate (HP) and distal locking plate (DLP) are among the commonly used techniques; nonetheless, no single procedure is deemed to be the benchmark treatment. Thus, the aim of the study is to conduct a comparative analysis, hopefully, to recommend the superior method between the two operations. PubMed, Embase via Ovid and Web of science were electronically searched between January 2000 and to date for studies directly comparing HP to DLP. Comparative retrospective/prospective and randomized studies were incorporated. Constant-Murley score “CMS” at a minimum of 12 months, pain visual analogue scale “VAS”, coracoclavicular distance “CCD” and reported complications were analysed. Review manager software was used for the statistical analyses. The total number of patients was 523; 274 (52.3%) with HP and 249 (47.6%) with DLP, 81 of which were associated with CC reconstruction. The mean follow up was 38.7 and 37.03 months for HP and DLP, respectively. CMS leaned towards the DLP group with no statistically significant difference (P=0.06). VAS was in favour of the DLP with again no statistically significant difference (P=0.12). In terms of CCD, the comparison favoured the HP with a lesser CCD postoperatively and a statistically significant difference (P<0.05). Complications were significantly higher in the HP group (P<0.0001). Contrary to our hypothesis, though HP did show a better radiological outcome; nonetheless, DLP did demonstrate a better functional result with a lesser rate of complications and the ability to retain the implant avoiding a second surgery.
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Katayama Y, Takegami Y, Tokutake K, Okui N, Sakai T, Takahashi H, Imagama S. Comparison of functional outcome and complications of locking plate versus coracoclavicular fixation in the treatment of unstable distal clavicle fractures: the multicenter, propensity-matched TRON study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03358-0. [PMID: 35969305 DOI: 10.1007/s00590-022-03358-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 08/08/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE This multicenter, retrospective study aimed to compare clinical outcomes and complications between locking plate fixation and new coracoclavicular (CC) fixation for patients with unstable distal clavicle fracture. METHODS We included 142 patients in this TRON study. The mean follow-up was 15.5 (6-31) months. The patients were divided into two groups: the locking plate group (Group L) and CC fixation group (Group C). To adjust for baseline differences between the groups, a propensity score algorithm was used to match two groups in a 1:1 ratio. After matching, we compared operation time and the University of California Los Angeles (UCLA) shoulder score at 3 and 6 months postoperatively and at last follow-up as clinical outcomes and the rate of complications. RESULTS After matching, 20 cases from each group remained. Operation time was shorter in Group C (75 [22, 111] vs. 100 [38, 120] min; P = 0.023). At 3 months postoperatively, UCLA score in Group C was better, but no significant differences between the groups were found at 6 months and last follow-up after surgery. The rate of complications was not significantly different between the groups. CONCLUSION CC fixation might be equivalent to locking plate fixation in clinical outcome, and the operation time is shorter than that required for locking plate fixation.
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Affiliation(s)
- Yujiro Katayama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Yasuhiko Takegami
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Katsuhiro Tokutake
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuyuki Okui
- Department of Orthopedic Surgery, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Tadahiro Sakai
- Department of Orthopedic Surgery, TOYOTA Memorial Hospital, Toyota, Japan
| | - Hiroshi Takahashi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Teimouri M, Ravanbod H, Farrokhzad A, Sabaghi J, Mirghaderi SP. Comparison of hook plate versus T-plate in the treatment of Neer type II distal clavicle fractures: a prospective matched comparative cohort study. J Orthop Surg Res 2022; 17:369. [PMID: 35907856 PMCID: PMC9338617 DOI: 10.1186/s13018-022-03261-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background This study aimed to compare the clinical and radiological outcomes of distal clavicle fracture fixation with a hook plate versus the standard non-locking T-plate for unstable Neer type II fractures.
Methods A prospective matched cohort study including two groups of hook plates and T-plates fixation was conducted in our two tertiary trauma centers. Patients with distal clavicle fractures Neer type II were assessed for union and the Constant-Murley score (CMS) at 1-, 3-, and 6-month follow-ups. Inadequate radiographic consolidation > 6 months after surgery was defined as non-union. Subscales of CMSpain, CMSactivities of daily living, CMSrange of motion (ROM), and CMSstrength were also compared between groups. According to recommendations, the implant was removed after union confirmation in the hook plate at a planned second surgery. Results Sixty consecutive patients were enrolled: 30 in the T-plate group and 30 in the hook plate group. CMS showed similar functional outcomes for T-plates and hook plates at all follow-ups (Month 6: 92.0 vs. 91.7, P = 0.45). However, on the month 1 follow-up, the T-plate group scored higher than the hook plate group for ROM and pain (CMSpain = 13.0 vs. 12.3, P = 0.03; CMSROM = 35.2 vs. 33.2, P = 0.002). Despite this, Pain, ROM, and other CMS domains were comparable between groups (P > 0.05). The mean time to union was 2.5 + 1.4 months for the T-plate group and 2.3 + 1.6 months for the hook plate group (P = 0.44). There was one fixation failure in each group and one periprosthetic fracture in the hook plate group (two revisions for the hook plates and one for T-plates, P = 1.00). Non-union and other complications were not observed. Conclusion Both surgical approaches resulted in full recovery and good function. However, in the hook plate group ROM and pain scores were lower at 1 month. Standard non-locking T-plates are a viable alternative to hook plates with low cost and promising outcomes for treating displaced distal clavicle fractures.
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Affiliation(s)
- Mehdi Teimouri
- Department of Orthopedic Surgery, Ayatollah Kashani Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hadi Ravanbod
- Department of Orthopedic Surgery, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amirhosein Farrokhzad
- Department of Orthopedic Surgery, Ayatollah Kashani Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Jamal Sabaghi
- Department of Orthopedic Surgery, Ayatollah Kashani Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Seyed Peyman Mirghaderi
- Joint Reconstruction Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. .,Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences, Tehran, Iran.
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