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Frane N, Watzig B, Vohra A, Deeyor S, Hui C, McKee M, Dehghan N. Immediate Weight-bearing Through Walker or Crutches After Surgical Fixation of Clavicle Fractures in Patients With Lower Extremity Fractures: A Retrospective Cohort Study. J Orthop Trauma 2024; 38:227-233. [PMID: 38251900 DOI: 10.1097/bot.0000000000002773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 01/10/2024] [Indexed: 01/23/2024]
Abstract
OBJECTIVES To assess the safety of immediate upper extremity weight-bearing as tolerated (WBAT) rehabilitation protocol after clavicle fracture open reduction internal fixation (ORIF). METHODS DESIGN Retrospective cohort study. SETTING Three Level 1 trauma centers. PATIENTS SELECTION CRITERIA Patients older than 18 years who had ORIF of mid-shaft clavicle fractures and lower extremity fractures who were allowed immediate WBAT on their affected upper extremity through use of a walker or crutches were included. All clavicles were fixed with either precontoured clavicular plates or locking compression plates. Included patients were those who had clinical/radiographic follow-up until fracture union, nonunion, or construct failure. OUTCOME MEASURES AND COMPARISONS WBAT patients were matched in a one-to-one fashion to a cohort with isolated clavicle fractures who were treated non-weight-bearing (NWB) postoperatively on their affected upper extremity. Matching was done based on age, sex, and temporality of fixation. After matching, treatment and control groups were compared to determine differences in possible confounding variables that could influence the primary outcome, including patient demographics, fracture classification, cortices of fixation, and construct type. All patients were assessed to verify conformity with weight-bearing recommendation. Primary outcome was early hardware failure (HWF) with or without revision surgery. Secondary outcomes included postoperative infections and union of fracture. RESULTS Thirty-nine patients were included in the WBAT cohort; there were no significant differences with the matched NWB cohort based on patient demographics. Both the WBAT and the NWB cohorts had 2.5% chance of acute HWF that required surgical intervention ( P = 1.0). Additionally, there was no difference in overall HWF ( P = 0.49). All patients despite weight-bearing status including those who required revision ORIF for acute HWF had union of their fracture ( P = 1.0). CONCLUSIONS Our data would support that immediate weight-bearing after clavicle fracture fixation in patients with concomitant lower extremity trauma does not lead to an increase in HWF or impact ultimate union. This challenges the dogma of prolonged postoperative weight-bearing restrictions and allow for earlier rehabilitation. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nicholas Frane
- NorthStar Trauma Network, Allina Orthopaedics, Minneapolis, MN
| | - Benjamin Watzig
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ; and
| | - Arjun Vohra
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ; and
| | - Sorka Deeyor
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ; and
| | - Clayton Hui
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ; and
| | - Michael McKee
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ; and
| | - Niloofar Dehghan
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ; and
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Pastor T, Zderic I, Berk T, Souleiman F, Vögelin E, Beeres FJP, Gueorguiev B, Pastor T. New generation of superior single plating vs. low-profile dual minifragment plating in diaphyseal clavicle fractures: a biomechanical comparative study. J Shoulder Elbow Surg 2024; 33:409-416. [PMID: 37748530 DOI: 10.1016/j.jse.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/31/2023] [Accepted: 08/06/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Recently, a new generation of superior clavicle plates was developed featuring the variable-angle locking technology for enhanced screw positioning and a less prominent and optimized plate-to-bone fit design. On the other hand, minifragment plates in dual plating mode have demonstrated promising clinical results. The aim of the current study was to compare the biomechanical competence of single superior plating using the new-generation plate vs. dual plating using low-profile minifragment plates. METHODS Sixteen paired human cadaveric clavicles were pairwise assigned to 2 groups for instrumentation with either a superior 2.7-mm variable-angle locking compression plate (group 1), or with one 2.5-mm anterior combined with one 2.0-mm superior matrix mandible plate (group 2). An unstable clavicle shaft fracture (AO/OTA 15.2C) was simulated by means of a 5-mm osteotomy gap. Specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with bidirectional torsion around the shaft axis, and monitored via motion tracking. RESULTS Initial construct stiffness was significantly higher in group 2 (9.28 ± 4.40 N/mm) compared to group 1 (3.68 ± 1.08 N/mm), P = .003. The amplitudes of interfragmentary motions in terms of axial and shear displacement, fracture gap opening and torsion, over the course of 12,500 cycles were significantly higher in group 1 compared to group 2, P ≤ .038. Cycles to 2 mm shear displacement were significantly lower in group 1 (22,792 ± 4346) compared to group 2 (27,437 ± 1877), P = .047. CONCLUSION From a biomechanical perspective, low-profile 2.5/2.0-mm dual plates could be considered as a useful alternative for diaphyseal clavicle fracture fixation, especially in less common unstable fracture configurations.
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Affiliation(s)
- Tatjana Pastor
- AO Research Institute Davos, Davos, Switzerland; Department for Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | - Till Berk
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Firas Souleiman
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Esther Vögelin
- Department for Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Frank J P Beeres
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | | | - Torsten Pastor
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland.
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Charles SJC, Kumar P, Reddy RP, Cong T, Chen S, Mittwede P, Moloney G, Siska P, Lin A. Dual Versus Single Plate Fixation of Displaced Midshaft Clavicle Fractures: A Cost-Effectiveness Analysis. J Bone Joint Surg Am 2023; 105:1886-1896. [PMID: 37967070 DOI: 10.2106/jbjs.23.00338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
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.
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Affiliation(s)
- Shaquille J-C Charles
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Praveen Kumar
- Public Health Dynamics Laboratory, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rajiv P Reddy
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ting Cong
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Stephen Chen
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Peter Mittwede
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gele Moloney
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Peter Siska
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Albert Lin
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Jafari Kafiabadi M, Sabaghzadeh A, Barazandeh Rad S, Karami A, Sadighi M, Biglari F. Clinical Outcomes of Double Mini-Plating Compared with a Single Superior Plating in Midshaft Clavicular Fractures: A Randomized Clinical Trial Study. Adv Biomed Res 2023; 12:265. [PMID: 38192890 PMCID: PMC10772796 DOI: 10.4103/abr.abr_221_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/30/2023] [Accepted: 10/01/2023] [Indexed: 01/10/2024] Open
Abstract
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.
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Affiliation(s)
- Meisam Jafari Kafiabadi
- Department of Orthopedic Surgery, Clinical Research Development Unit of Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Sabaghzadeh
- Department of Orthopedic Surgery, Clinical Research Development Unit of Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saber Barazandeh Rad
- Department of Orthopedic Surgery, Clinical Research Development Unit of Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amin Karami
- Department of Orthopedic Surgery, Clinical Research Development Unit of Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Sadighi
- Department of Orthopedic Surgery, Clinical Research Development Unit of Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farsad Biglari
- Department of Orthopedic Surgery, Clinical Research Development Unit of Shohada-e Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Reddy RP, Charles S, Como M, Chen SR, Mittwede PN, Rai A, Moloney GB, Sabzevari S, Lin A. Dual Mini-Fragment Plate Fixation of Midshaft Clavicle Fractures Reduces Risk of Reoperation Compared With Single-Plate Fixation Techniques. Am J Sports Med 2023; 51:3393-3400. [PMID: 37849249 DOI: 10.1177/03635465231203010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
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.
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Affiliation(s)
- Rajiv P Reddy
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Shaquille Charles
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Matthew Como
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Stephen R Chen
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Peter N Mittwede
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Ajinkya Rai
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Gele B Moloney
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
| | - Soheil Sabzevari
- Department of Orthopaedics and Rehabilitation, Division of Sports Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Albert Lin
- Department of Orthopaedic Surgery, UPMC Freddie Fu Sports Medicine Center, Pittsburgh, Pennsylvania, USA
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Trivellas M, Wittstein J. Midshaft Clavicle Fractures: When Is Surgical Management Indicated and Which Fixation Method Should Be Used? Clin Sports Med 2023; 42:633-647. [PMID: 37716727 DOI: 10.1016/j.csm.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
For displaced midshaft clavicle fractures, operative treatment either with open reduction and plate fixation or with intramedullary fixation has been shown to provide earlier return to work and sport, improved functional outcomes, greater patient-reported satisfaction with appearance, and significantly decreased incidence of nonunion and malunion when compared with conservative treatment. Operative intervention is not without risks associated with surgery. Shared decision-making with the patient and understanding patient goals allows surgeons to recommend a management option that the patient will be comfortable with and will follow to achieve a satisfactory outcome.
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Affiliation(s)
- Myra Trivellas
- Department of Orthopaedic Surgery, Duke University School of Medicine, 3475 Erwin Road, Durham, NC 27705, USA
| | - Jocelyn Wittstein
- Department of Orthopaedic Surgery, Duke University School of Medicine, 3475 Erwin Road, Durham, NC 27705, USA.
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Tamburini LM, Mayo BC, Edgar C. Dual- Versus Single-Plate Fixation of Clavicle Fractures: Understanding the Rationale Behind both Approaches. Clin Sports Med 2023; 42:677-684. [PMID: 37716730 DOI: 10.1016/j.csm.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Clavicle fractures are a common injury resulting from a high-energy force, such as a fall onto the shoulder, motor vehicle accident, or sporting activity. Although some clavicle fractures may be treated nonoperatively, operative treatment results in higher union rates and faster return to activity. Here we discuss the operative treatment options for plating of clavicle fractures; specifically, a single plate placed either superiorly or anteriorly or two plates placed orthogonally. Because both techniques provide adequate stability, fracture and patient characteristics should guide the surgical decision making regarding single versus dual plating of clavicle fractures.
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Affiliation(s)
- Lisa M Tamburini
- Department of Orthopaedic Surgery, University of Connecticut, UConn Musculoskeletal Institute, 120 Dowling Way, Farmington, CT 06032, USA
| | - Benjamin C Mayo
- Department of Orthopaedic Surgery, University of Connecticut, UConn Musculoskeletal Institute, 120 Dowling Way, Farmington, CT 06032, USA
| | - Cory Edgar
- Department of Orthopaedic Surgery, University of Connecticut, UConn Musculoskeletal Institute, 120 Dowling Way, Farmington, CT 06032, USA.
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8
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Huang D, Hu Z, Feng W, Wang X. Dual plate has better biomechanical stability than hook plate or superior single plate for the fixation of unstable distal clavicle fractures: a finite element analysis. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04801-5. [PMID: 36763130 DOI: 10.1007/s00402-023-04801-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 01/26/2023] [Indexed: 02/11/2023]
Abstract
INTRODUCTION A variety of surgical techniques have been addressed for distal clavicle fractures, while none of these is considered to be gold standard fixation. Currently, dual plate fixation has been proposed and achieved satisfying clinical results. However, the biomechanical study about dual plate technique in treating unstable distal clavicle fractures is limited. Thus, the purpose of this study was to investigate the biomechanical properties of this technique by finite element analysis. MATERIALS AND METHODS A geometry model of distal clavicle fractures was combined with hook plate, superior single plate and dual plate, respectively, to simulate the implant fixation process. Two loading conditions and two boundary conditions were applied in the finite element models following a mesh convergence test. The stress distribution was observed, and peak von Mises stress and maximum displacement were used as indexes for analysis. RESULTS The dual plate model showed the highest clavicle stress (13.1 MPa), but lowest fixation stress (18.9 MPa) compared to the hook plate and superior single model. In regarded to stability, dual plate model exhibited a minimum displacement with only 0.099 mm. CONCLUSIONS Dual plate fixation has better biomechanical stability with lower risk of implant failure. Thus, dual plate fixation is an alternative technique for unstable distal clavicle fracture. The complication of peri-implant fracture of dual plate technique should also be cautious in clinical practice, and more clinical evidence is needed.
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Affiliation(s)
- Daoqiang Huang
- First Department of Orthopedics, Affiliated Xiaolan Hospital, Southern Medical University, No. 65 Jucheng Road, Xiaolan, Zhongshan, Guangdong, People's Republic of China
| | - Zhiqiang Hu
- First Department of Orthopedics, Affiliated Xiaolan Hospital, Southern Medical University, No. 65 Jucheng Road, Xiaolan, Zhongshan, Guangdong, People's Republic of China.,The Second School of Clinical Medicine, Southern Medical University, Zhongshan, People's Republic of China
| | - Weili Feng
- First Department of Orthopedics, Affiliated Xiaolan Hospital, Southern Medical University, No. 65 Jucheng Road, Xiaolan, Zhongshan, Guangdong, People's Republic of China
| | - Xiaoping Wang
- First Department of Orthopedics, Affiliated Xiaolan Hospital, Southern Medical University, No. 65 Jucheng Road, Xiaolan, Zhongshan, Guangdong, People's Republic of China.
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Charles SJC, Chen SR, Mittwede P, Rai A, Moloney G, Sabzevari S, Lin A. Risk factors for complications and reoperation following operative management of displaced midshaft clavicle fractures. J Shoulder Elbow Surg 2022; 31:e498-e506. [PMID: 35472574 DOI: 10.1016/j.jse.2022.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Optimal management of a displaced midshaft clavicle fracture remains controversial. This study assessed demographic factors, fracture pattern, and surgical technique as potential predictors of surgical complications. Smoking, diabetes, obesity, polytrauma, high-energy mechanism, inpatient status, transverse or comminuted fractures, and single-plating technique were hypothesized to be associated with an increased risk of complications following clavicle fracture open reduction internal fixation (ORIF). METHODS Consecutive patients with minimum 12-week follow-up from the trauma and sports medicine divisions at a single tertiary institution who presented with a midshaft clavicle fracture and underwent ORIF between 2007 and 2020 were retrospectively identified. Patient demographics, fracture pattern, plating technique, and postoperative complications were recorded. Postoperative complications were classified into major (reoperation) and minor (no reoperation) complications. Chi-squared statistics, Fisher's exact test, analysis of variance, Kruskal-Wallis test, and multivariate logistic regression modeling were utilized with a significance level set to P < .05. RESULTS One hundred ninety-eight patients (average = 39.5 ± 14.6 years) were identified with an average follow-up of 9.1 ± 10.7 months. The cohort consisted of 155 males (78.3%), 62 smokers (31.3%), and 12 diabetics (6.1%). Injury characteristics revealed 80 transverse fractures (40.4%), 87 oblique fractures (43.9%), and 31 Z-type fractures (15.7%). Seventy-nine patients (39.9%) underwent superior plating, 72 (36.4%) underwent anterior plating, and 47 (23.7%) underwent dual plating. Overall, postoperative complications occurred in 47 patients (23.7%), 29 minor (14.6%) and 18 major (9.1%). Major complications requiring reoperation were symptomatic hardware, nonunion, deep infection, wound dehiscence, and broken hardware. Minor complications consisted of sensory deficit or paresthesia beyond peri-incisional numbness, superficial infections, postoperative pain and/or stiffness, and delayed union. Smoking status (P = .008), obesity (P = .009), and transverse or Z-type fractures (P = .002) were significant prognostic factors for overall complication risk. Only manual labor was predictive of minor complications (P = .019). Transverse or Z-type fractures and single plating were predictive of major complications (P = .004 and P = .008, respectively). No reoperations occurred in patients who underwent dual plating. Smokers (P = .027) with transverse/Z-type fractures (P = .022) were at the highest risk of reoperation with single plating. CONCLUSION The overall rate of complications following ORIF of displaced midshaft clavicle fracture was 27.3%, with 9.1% requiring reoperation. Given relatively high complication rates, in instances when nonoperative vs. operative management is equivocal, nonoperative management should be strongly considered in obese patients, smokers, and patients who present with transverse or Z-type fracture. If operative management is indicated, use of dual plating may decrease reoperation rates.
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Affiliation(s)
| | - Stephen R Chen
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Peter Mittwede
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ajinkya Rai
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gele Moloney
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Soheil Sabzevari
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Albert Lin
- Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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10
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Kitzen J, Paulson K, Korley R, Duffy P, Martin CR, Schneider PS. Biomechanical Evaluation of Different Plate Configurations for Midshaft Clavicle Fracture Fixation: Single Plating Compared with Dual Mini-Fragment Plating. JB JS Open Access 2022; 7:JBJSOA-D-21-00123. [PMID: 35265785 PMCID: PMC8901219 DOI: 10.2106/jbjs.oa.21.00123] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Joep Kitzen
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Orthopaedic Surgery, Maasstad Hospital, Rotterdam, the Netherlands
| | - Kent Paulson
- McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robert Korley
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul Duffy
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - C Ryan Martin
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Prism S Schneider
- Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,McCaig Institute for Bone and Joint Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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