Surgical treatment, complications, and reimbursement among patients with clavicle fracture and acromioclavicular dislocations: a US retrospective claims database analysis

Prospective Multicenter Randomized Controlled Trial of Surgical Versus Nonsurgical Treatment for Acute Rockwood Type 3 Acromioclavicular Injury

Background

Evidence for the superiority of surgical versus nonsurgical treatment of Rockwood type 3 acromioclavicular joint (ACJ) dislocation is still lacking.

Hypothesis

It was hypothesized that surgical treatment will outperform nonsurgical treatment.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

A prospective randomized trial involving 4 study centers was performed from January 1, 2011, to March 31, 2016. A total of 85 patients with acute Rockwood type 3 ACJ dislocations were allocated randomly to receive either nonsurgical or surgical treatment. A total of 70 patients were treated as allocated, and 8 patients made an early crossover from nonsurgical to surgical treatment, leaving 47 patients treated surgically and 31 patients nonsurgically. All patients were followed up longitudinally, including clinical evaluation using the Constant score and standardized radiographic evaluation, with final follow-up after 2 years.

Results

At no follow-up time point was there a significant difference in Constant score between the surgically and nonsurgically treated patients. Radiographic analysis showed not only an inferior coracoclavicular distance at all follow-up points for surgical treatment but also a higher incidence of posttraumatic osteoarthritis and heterotopic ossifications, without any negative clinical correlation. With regard to complications, 1 patient (3%) in the nonsurgical group underwent secondary surgical ACJ stabilization. The revision rate after surgical treatment was 17% (P < .001). Neither primary horizontal instability nor younger age were associated with inferior clinical outcomes after nonsurgical treatment.

Conclusion

Surgical treatment of ACJ Rockwood type 3 injuries did not lead to superior functional outcomes. Neither younger age nor horizontal instability were associated with inferior outcomes after nonsurgical treatment. Surgical treatment led to a slower recovery and to higher complication and revision rates.

Registration

ISRCTN registry (study ID: ISRCTN92265154).

Quinolone Ear Drops and Achilles Tendon Rupture

BACKGROUND

Delayed eardrum healing has been observed in the ear opposite to the ear treated with otic quinolones (OQ) in rats. Case reports describe tendinopathies after OQ treatment, suggesting adverse systemic effects.

METHODS

We studied patients aged 19 to 64 years with diagnosis of otitis externa or media in private insurance between 2005 and 2015. We compared OQ treatment against otic neomycin, oral amoxicillin, or azithromycin. Outcomes included Achilles tendon rupture (ATR), Achilles tendinitis (AT), and all-type tendon rupture (ATTR). We applied an active comparator, new-user design with 1-year look-back and ceased follow-up at initiation of systemic steroids or oral quinolones, external injury, hospitalization, and after 35 days. We used trimmed stabilized inverse probability of treatment weights to balance comparison groups in a survival framework. Negative outcomes (clavicle fractures or sports injuries) were examined to rule out differences from varied physical activity (unmeasured confounding).

RESULTS

We examined 1 501 009 treated otitis episodes. Hazard ratios (HR) for OQ exposure associated with ATR were 4.49 (95% confidence interval [CI], 1.83-11.02), AT 1.04 (95% CI, 0.73-1.50), and ATTR 1.71 (95% CI, 1.21-2.41). Weighted risk differences (RD) per 100 000 episodes for OQ exposure were ATR 7.80 (95% CI, 0.72-14.89), AT 1.01 (95% CI, -12.80 to 14.81), and ATTR 18.57 (95% CI, 3.60-33.53). Corresponding HRs for clavicle fractures and sports injuries were HR,1.71 (95% CI, 0.55-5.27) and HR,1.45 (95% CI, 0.64-3.30), suggesting limited residual confounding.

CONCLUSIONS

OQ exposure may lead to systemic consequences. Clinicians should consider this potential risk and counsel patients accordingly. Risk factors and mechanisms for this rare, adverse effect deserve further evaluation. Mechanistic and other clinical studies are warranted to corroborate this finding.

Quantifying osteosynthesis plate prominence - mathematical definitions and case study on a clavicle plate

Hardware prominence remains a clinical challenge in focus for implant design in subcutaneous plate applications. Existing evaluation of hardware prominence relies on plate-to-bone distance at a single point or on average. A reproducible measure for plate prominence remains undefined. This study mathematically defines the plate prominence linked to the cross-sectional area change due to the plate presence on the bone. Two anatomical plate designs were fitted to 100 clavicles, and afterwards plate prominence parameters were evaluated and compared. This methodology enables the quantification of hardware prominence for different plate designs to inform the development of implants targeting low prominence.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Brachial plexus injury after clavicle fracture operation: a case report and literature review

BACKGROUND

Open reduction and internal fixation (ORIF) is the preferred choice for treating clavicle fractures. The brachial plexus injury caused by ORIF of a clavicle fracture is very rare. If it is not treated in time, the function of the brachial plexus will be challenging to recover, which will eventually lead to upper limb dysfunction and seriously affect the patient's quality of life. Our team recently used ORIF to treat a patient with a clavicle fracture, who developed brachial plexus injury symptoms after surgery.

CASE PRESENTATION

A 34-year-old female patient was admitted to the hospital for 13 h due to the right shoulder movement restriction after a fall. Due to the significant displacement of the fracture, we used ORIF to treat the fracture. The surgery went well. When the anaesthesia effect subsided 12 h after the operation, the patient developed right brachial plexus injury symptoms, decreased right upper limb muscle strength, dysfunction, and hypoesthesia. Symptomatic treatments, such as nourishing nerve and electrical stimulation, were given immediately. Sixty days after the operation, the patient's brachial plexus injury symptoms disappeared, and the function of the right upper limb returned to the preoperative state.

CONCLUSIONS

Patients with clavicle fractures usually need to undergo a careful physical examination before surgery to determine whether symptoms of brachial plexus injury have occurred. Anaesthesia puncture requires ultrasound guidance to avoid direct damage to the brachial plexus. When the fracture end is sharp, reset should be careful to prevent nerve stump stabbed. When using an electric drill to drill holes, a depth limiter should be installed in advance to prevent the drill from damaging the subclavian nerve and blood vessels. When measuring the screw depth, the measuring instrument should be close to the bone surface and sink slowly to avoid intense hooks and damage to the brachial plexus. Try to avoid unipolar electrosurgical units to prevent heat conduction from damaging nerves, and bipolar electrocoagulation should be used instead. If symptoms of brachial plexus injury occur after surgery, initial symptomatic treatment is drugs and functional exercise, and if necessary, perform surgical exploration.

Nonanatomic and Suture-Based Coracoclavicular Joint Stabilization Techniques Provide Adequate Stability at a Lower Cost of Implants in Biomechanical Studies When Compared With Anatomic Techniques: A Systematic Review and Meta-Analysis

Purpose

To compare the stability and cost of the used implants in nonanatomic and anatomic acromioclavicular joint repair/reconstruction (ACCR) techniques tested in cadaveric shoulder biomechanical studies during the last decade.

Methods

A systematic review and meta-analysis were performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and prospectively registered in PROSPERO. Two independent reviewers searched PubMed, Embase, and Virtual Health Library databases. Studies evaluating 3-direction stability under 70-N loads and load-to-failure protocols with servohydraulic testing systems were included. A meta-analysis of the mean differences of anterior, posterior, and superior direction; relative stability value in 3 directions; superior direction load-to-failure; stability/cost index; and load-to-failure/cost index was performed using a continuous random-effects model and 95% confidence interval.

Results

Eighteen articles were included. Both non-ACCR and ACCR techniques exceeded the minimum acceptable threshold of stability and load-to-failure. ACCR techniques were biomechanically better in terms of anterior stability (P = .04) and relative stability value (mean difference 64.08%, P = .015). However, supraphysiological stability and failure loads were achieved with non-ACCR techniques at a lower cost of implants. Techniques combining 2 clavicular tunnels separated by at least 10 mm, a mean of 2 sutures, and/or suture tapes had the greatest stability/cost index and load-to-failure/cost index among the included techniques (confidence interval 99%).

Conclusions

Non-ACCR and ACCR techniques exceeded the minimum acceptable threshold of stability and failure loads in controlled biomechanical testing. However, non-ACCR and techniques combining 2 clavicular tunnels separated by at least 10 mm, a mean of 2 sutures, and/or suture tapes provide supraphysiologic stability and failure loads at a lower cost of implants.

Clinical Relevance

Non-ACCR and suture-based techniques may provide more cost-effective and greater value treatment for acromioclavicular joint injury and could be considered in the surgical management of normal activity individuals and cost-sensitive populations.

The variance of clavicular surface morphology is predictable: an analysis of dependent and independent metadata variables

Background

The anatomy of the clavicle is specific and varied in reference to its topography and shape. These anatomic characteristics play an important role in the open treatment of clavicle fractures. The complex and variable topography creates challenges for implant placement, contouring, and position. Hardware prominence and irritation does influence the decision for secondary surgical intervention.

Methods

Computerized tomographic scans of 350 adult clavicles with the corresponding patients' metadata were acquired and digitized. Morphologic parameters determining the shape of the clavicle were defined and computed for each digitized bone. The extracted morphologic parameters were correlated with patient metadata to analyze the relationship between morphologic variability and patient characteristics.

Results

The morphologic parameters defining the shape, that is, the radius of the medial and lateral curves, the apparent clavicle height and width, and the clavicle bow position, correlate with the clavicle length. The clavicle length correlates with the patients' height. Gender differences in shape and form were dependent and related to individual height distribution and clavicle length. Asian populations showed a similarly predictable, but shifted, correlation between shape and clavicle length.

Conclusion

This anatomic analysis shows that the clavicle shape can be predicted through the clavicle length and patients' stature. Smaller patients have shorter and more curved clavicles, whereas taller patients have longer and less curved clavicles. This correlation will aid surgeons in fracture reduction, implant curvature selection, and in optimal adaptation of clavicle implants, and represents the basis for anatomically accurate solutions for clavicle osteosynthesis.