Treatment of distal clavicle nonunion with and without bone grafting

Osteosynthesis using scorpion plate for nonunion of distal clavicle fracture with small distal bone fragment: A case report

Distal clavicle nonunion is a relatively common complication of unstable, displaced distal clavicle fractures; however, its standard surgical procedure has not been fully established. We describe a case of symptomatic nonunion of a distal clavicle fracture with a very small distal bone fragment that was treated with a scorpion plate. A 63-year-old man presented with left shoulder pain after a bicycle fall 5 months earlier. Plain radiographs and computed tomography revealed atrophic nonunion of the distal clavicle with a small distal bone fragment measuring 12 mm in length. Shoulder pain interfered with his work and daily life; therefore, we scheduled surgery. After releasing the nonunion site, cancellous bone was grafted from the iliac crest. We placed a scorpion plate with two grasping arms that fixed the distal clavicular fragment without straddling the acromioclavicular joint. One year postoperatively, his pain subsided, and bone union was confirmed. Our case presents a surgical procedure for treating the nonunion of distal clavicle fractures using a scorpion plate and an autologous bone graft. This procedure is especially beneficial for cases with small distal bone fragments, because the grasping arms of the scorpion plate allow secure fixation of the distal bone fragment and bone graft without further fragmentation.

Biomechanical analysis of plating techniques for unstable lateral clavicle fractures with coracoclavicular ligament disruption (Neer type IIB)

BACKGROUND

Neer type IIB lateral clavicle fractures are inherently unstable fractures with associated disruption of the coracoclavicular (CC) ligaments. Because of the high rate of nonunion and malunion, surgical fixation is recommended; however, no consensus has been reached regarding the optimal fixation method. A new plating technique using a superior lateral locking plate with anteroposterior (AP) locking screws, resulting in orthogonal fixation in the lateral fragment, has been designed to enhance stability and reduce implant failure. The purpose of this study was to biomechanically compare 3 different clavicle plating constructs within a fresh frozen human cadaveric shoulder model.

METHODS

Twenty-four fresh frozen cadaveric shoulders were randomized into 3 groups (n = 8 specimens): group 1, lateral locking plate only (Medartis Aptus Superior Lateral Plate); group 2, lateral locking plate with CC stabilization (No. 2 FiberWire); and group 3, lateral locking plate with 2 AP locking screws stabilizing the lateral fragment. All specimens were subject to cyclic loading of 70 N for 500 cycles. Data were analyzed for gap formation after cyclic loading, construct stiffness, and ultimate load to failure, defined by a marked decrease in the load displacement curve.

RESULTS

After 500 cycles, there was no statistically significant difference between the 3 groups in gap formation (P = .179). No specimen (0/24) failed during cyclic loading. Ultimate load to failure was significantly higher in group 3 compared to group 1 (286 N vs. 167 N; P = .022), but not to group 2 (286 N vs. 246 N; P = .604). There were no statistically significant differences in stiffness (group 1: 504 N/mm; group 2: 564 N/mm; group 3: 512 N/mm; P = .712). Peri-implant fracture was the primary mode of failure for all 3 groups, with group 3 demonstrating the lowest rate of peri-implant fractures (group 1: 6/8; group 2: 7/8; group 3: 4/8; P = .243).

CONCLUSION

Biomechanical evaluation of the clavicle plating techniques showed effective fixation across all specimens at 500 cycles. The lateral locking plate with orthogonal AP locking screw fixation in the lateral fragment demonstrated the greatest ultimate failure load, followed by the lateral locking plate with CC stabilization. This new plating technique showed compatible stiffness and gap formation when compared to conventional lateral locking plates as well as plates with CC fixation. The use of orthogonal screw fixation in the distal fragment may negate against the need for CC stabilization in these types of fractures, thus minimizing surgical dissection around the coracoid and potential complications.

Functional outcomes and complications following combined locking plate and tunneled suspensory device fixation of lateral-end clavicle nonunions

BACKGROUND

Lateral-end clavicle fractures have a high rate of nonunion that can lead to ongoing pain and loss of shoulder function. The operative techniques used to manage such nonunions vary, and data on postoperative functional outcomes and complications are limited, with no consensus on the optimal surgical treatment. Our goal was to present the outcomes and complications of a new indication for combined locking plate and tunneled suspensory device fixation in the operative management of lateral-end clavicle fracture nonunions.

METHODS

A consecutive series of 38 patients (mean age, 46 years; age range, 24-76 years) with symptomatic lateral-end clavicle nonunions underwent operative treatment using a new technique of anatomic locking plate combined with open reduction and tunneled suspensory device fixation between March 2011 and September 2019. Patients were assessed at a minimum of 1-year postoperative follow-up for patient-reported outcomes, range of motion, and complications.

RESULTS

All patients (N = 38) achieved bony union after operative treatment. Functional outcomes were available for 34 patients. The mean Oxford Shoulder Score was 44 (standard error of the mean [SEM], 0.7), and the mean EQ-5D-3L index score was 0.784 (SEM, 0.033). Mean forward flexion was 176° (SEM, 3°); mean extension, 53° (SEM, 3°); mean combined abduction, 171° (SEM, 4°); mean internal rotation, 57° (SEM, 2°); and mean external rotation, 83° (SEM, 4°). In 2 patients (5.3%), metalwork (plate) removal was performed owing to plate prominence.

CONCLUSIONS

Nonunion of lateral-end clavicle fractures can be effectively managed by combined plate and open reduction-tunneled suspensory device fixation. Excellent union rates and functional outcomes, as well as low complication rates, can be expected. The most significant complication of this technique is subsequent metalwork removal.

Stand-alone coracoclavicular suture repair achieves very good results in unstable distal clavicle fractures at a minimum follow-up of 1 year

BACKGROUND

The treatment of unstable (Neer type IIB and V) extra-articular distal clavicle fractures remains challenging, especially when encountering a small lateral fragment which does not allow for sufficient screw purchase. It was the purpose of this study to present the clinical and radiologic outcome of a consecutive series of patients treated by a stand-alone coracoclavicular stabilization using a so-called cow-hitch technique with a suture anchor.

METHODS

Nineteen patients were treated with a specific surgical technique for distal clavicle fractures (11 left, 8 right) with either rupture or bony avulsion of the coracoclavicular ligaments. Fourteen patients were examined in our outpatient clinic for the purpose of this study after a mean follow-up of 5 years (1-12.2 years). The examination included scoring according to Constant Murley score (CMS), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), the Subjective Shoulder Value (SSV), and follow-up radiographs. Two additional patients were amenable to a telephone interview.

RESULTS

All patients reported very good subjective results, with a mean SSV of 92% and a mean ASES score of 96%. The CMS resulted in average absolute values of 92 points. Fractures consolidated in 95% of cases. One patient developed an asymptomatic pseudarthrosis. The coracoclavicular distance was restored from 21 mm preoperatively to 11 mm at the final follow-up and finally showed an average side-to-side difference of +1.8 mm. Sports activities were fully resumed after an average of 4.7 months.

CONCLUSION

The coracoclavicular stand-alone cow-hitch suture repair for unstable distal clavicle fractures is a minimally invasive fixation technique without prominent hardware that allows for an anatomic reduction and stable fixation with a low complication and high bony union rate. Both radiographic and clinical long-term results are very satisfactory.

Treatment of distal clavicle fracture of Neer type II with locking plate in combination with titanium cable under the guide

To observe and compare the curative effect of a locking plate plus titanium cable under the Guide device and clavicular hook plate in the treatment of Neer type II distal clavicle fractures. A prospective cohort study was conducted to analyse the clinical data of 36 patients with distal clavicle fractures from January 2016 to January 2019. The results were analysed. According to the random number method, the patients were divided into two groups: the titanium cable group (fixed with a titanium cable in combination with a locking plate) and hook plate group (fixed with a clavicular hook plate only). Under the guidance of a special device (for which a patent was obtained), in the titanium cable group, the coracoclavicular ligament was fixed with tension reduction, and then the distal clavicular fracture was fixed with a locking plate. In the hook plate group, the distal clavicle fracture was fixed with a hook plate. The incision length, operation time, bleeding volume and VAS score before, 1 week after and 1 year after the operation were compared between the two groups. The effect of the operation was evaluated by the Constant-Murley score before and 1 year after the operation. X-ray films were taken 2 days, 3 months, half a year and 1 year after the operation to observe the reduction and healing of fractures. At the same time, complications were recorded. The amount of bleeding was the same in the two groups. The operation time in the hook plate group was relatively short, and the difference was statistically significant (P < 0.05). The VAS score in the titanium cable group was significantly lower than that in the hook plate group one year after the operation. The Constant-Murley score in the titanium cable group and hook plate group was significantly higher 1 year after the operation. The number of postoperative complications in the titanium cable group was significantly lower than that in the hook plate group. The treatment of Neer type II distal clavicle fractures with a titanium cable plus a locking plate has a good curative effect, few complications and good postoperative recovery and thus is worth popularizing.

Autologous tendon graft for non-union distal clavicle fracture in a patient with chronic kidney disease

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Autologous tendon grafting in distal clavicle non-union fracture can be an option of treatment.

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In a poor environment with impaired bone healing, biological support, such as autologous tendon graft, to maintain fracture reduction may be necessary.

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This case shown an outcome with the use of autologous semitendinosus graft for distal clavicle nonunion in CKD patients.

Background

Fracture of distal-end accounts for 20% of all clavicle fracture. In the situation of impaired bone healing environment such as chronic kidney disease (CKD), nonunion rates after surgery might increase. In the case where bone healing is unexpected, biological healing with tendon graft could be an alternative method to maintain bone reduction.

Presentation of case

A 62-year old male with a history of end-stage CKD presented to the hospital with pain, wound, and deformity on the right shoulder. The patient have had surgery in the past 4 months and resulted in a non-union fracture of the distal third right clavicle. The patient underwent implant removal and continued with coracoclavicular ligament reconstruction with autologous tendon grafts of semitendinosus tendon and mini-plate augmentation.

Discussion

The Distal clavicle has a high rate of delayed and nonunion even without the presence of comorbidity. A compromised bone quality frequently leads to failed osteosynthesis in patients with end-stage renal failure. In the advanced stages of kidney disease, problems with a renal clearance of phosphate and low 1ɑ-hydroxylase levels resulting in increased serum phosphate levels and low serum calcium levels. Given these circumstances, we considered the idea to maintain fracture reduction by biologic soft tissue healing of the graft to replace the coracoclavicular ligaments as we can not rely on normal bone strength and healing capacity.

Conclusion

In the situation where bone healing is unexpected, biological healing with tendon graft may be necessary. The use of autologous tendon graft and mini-plate suture augmentation could help to maintain bone reduction in such environment.

Plate osteosynthesis for mid-shaft clavicle fractures: An update

INTRODUCTION

Over the last few years, treatment of mid-shaft clavicle fractures seems to have shifted from conservative to surgical. Our study reports the results of plate osteosynthesis of mid-shaft clavicle fractures and compares them with literature.

MATERIALS AND METHODS

A retrospective cohort study was conducted on 32 patients with mid-shaft clavicle fractures treated with plate and screws between January 2009 and December 2014. All the patients followed the same post-operative rehabilitation program with radiographic and clinical evaluation (DASH score and Constant score) at a minimum follow-up of 24 months.

RESULTS

All the patients healed clinically and radiographically, without deformities or non-unions, with complete and early functional recovery and return to their pre-injury sport activities. At one year follow-up the mean Constant Score was 93.8 (SD 4.8) and the mean DASH score was 42 (SD 5.0).

CONCLUSIONS

Osteosynthesis with plate and screws of mid-shaft clavicle fractures allows not only restoration of the anatomy, but also early recovery of shoulder function. For this reason, such surgical treatment should always be considered when facing this particular fracture group, also in accordance with recent literature.