Anteroinferior plating of midshaft clavicular nonunions

Lateral clavicle fracture-plating options and considerations

Clavicle fractures are among the most prevalent types of fractures with numerous treatment strategies that have evolved over time. In the realm of lateral-third clavicle fracture management, several surgical methods are available, with plate and screw constructs being one of the most frequently employed options. Within this construct, numerous choices exist for fixing the fracture. This editorial provides an overview of the common plate options utilized in the management of distal third clavicle fractures underscoring the critical considerations and approaches that guide clinicians in selecting the most appropriate fixation techniques, considering the complex landscape of clavicle fractures and their challenging management.

A novel treatment of clavicular nonunion: Combination with PRP, autologous bone grafting, and internal plate fixation

BACKGROUND

Nonunion is a major concern for orthopedic surgeons, particularly nonunion of the clavicle, which can cause severe pain, loss of full range of motion, poor sleep quality, and loss of strength in the affected individuals. Platelet-rich plasma (PRP), an important biological agent, is widely used in orthopedics.

OBJECTIVE

We used a combination of three techniques - the PRP technique, autologous bone grafting technique, and internal plate fixation technique - to ensure adequate internal fixation and enable a bone growth-supportive environment at the fracture site.

METHODS

The surgical approach was applied to a patient with clavicle nonunion.

RESULTS

Based on postoperative follow-up findings and intraoperative findings at the time of re-removal of the patient's implant, the prognosis at the fracture site was considered satisfactory.

CONCLUSION

We observed that the patient treated with this method had favorable clinical outcomes, and we recommend that this technique be used in patients with long-bone nonunion.

Midshaft clavicle fractures: is anterior plating an acceptable alternative to superior plating?

PURPOSE

The purpose of this study was to determine whether anterior plating is better tolerated than superior plating for midshaft clavicle fractures.

METHODS

This was a prospective non-randomized observational cohort study following operative vs. non-operative management of clavicle fractures from 2003 to 2018 at 7 level 1 academic trauma centers in the USA. The subset of patients treated with plate and screws is the basis for this comparative study. Adults aged 18-85 with closed clavicle fractures displaced over 100% or shortened by more than 1.5 cm were eligible for enrollment. Patients were followed for 2 years following enrollment. Allowable fixation methods at the discretion of the surgeon consisted of anterior-inferior or superior plating. A total of 412 patients were enrolled. Of these, 192 patients received either superior or anterior plating for a displaced clavicle fracture with complete documented prospective research forms capturing type of plating technique. The primary outcome measure was hardware removal (HWR). Secondary outcomes were Disability of the Arm Shoulder and Hand (DASH) score and Visual Analog Pain (VAP) score, and satisfaction score (1 = high satisfaction; 5 = low satisfaction).

RESULTS

There was no difference in HWR rates (7.1% superior 9/127; 6.2% anterior 4/65, p = 0.81), VAP score (mean 1.5 SD 1.0 superior; mean 1.7 SD 0.6 anterior, p = 0.21), DASH score (mean 7.5 SD 12.4 superior; mean 5.2 SD 15.2 anterior; p = 0.18) or satisfaction score (mean 1.6 SD 1.0 superior; mean 1.7 SD 0.60 anterior, p = 0.18).

CONCLUSION

There is no difference in HWR rates or functional outcomes when using a superior vs. anterior plating technique.

Anteroinferior plating is an independent factor for decreasing symptomatic implant removal rates after plate fixation for midshaft clavicle fractures

Objectives

The factors that significantly influence the symptomatic implant removal rates after plate fixation for midshaft clavicle fractures remain controversial. The purpose of this study was to compare the symptomatic implant removal rates between 2 different types of plating technique and to evaluate independently associated factors.

Design

Retrospective cohort study.

Setting

Acute care center.

Patients/Participants

A total of 71 patients 16 years or older who were diagnosed with displaced midshaft clavicle fractures from April 2016 to March 2020.

Intervention

Thirty-nine patients were treated with superior plating (Group SP), and the remaining 32 patients were treated with anteroinferior plating (Group AIP).

Main Outcome Measurements

Symptomatic implant removal rates after plate fixation for midshaft clavicle fractures.

Results

Symptomatic implant removal rates were significantly lower in Group AIP (28.1%) than in Group SP (53.8%) (P = 0.033). Multivariate analyses showed that symptomatic implant removal rates were significantly decreased by three independent factors, namely AIP (odds ratio [OR] = 0.323) (P = 0.037), greater age (45 years or older) (OR = 0.312) (P = 0.029), and high body mass index (≥25 kg/m²) (OR = 0.117) (P = 0.034).

Conclusions

AIP significantly and independently decreased the symptomatic implant removal rate. Among the three explanatory factors showing significant difference, plating technique is the only factor that can be altered by medical institutions. Therefore, we recommend this technique for displaced midshaft clavicle fractures to reduce a second surgery such as symptomatic implant removal.

Level of Evidence

Level 3, retrospective cohort study.

Complications and Outcomes After Surgical Intervention in Clavicular Nonunion: A Systematic Review

BACKGROUND

Surgical repair of clavicle fractures is being employed more frequently, although most fractures are still treated conservatively. Both can result in nonunion. Current treatments for clavicle nonunion include open reduction with internal fixation (ORIF) plating without bone graft, ORIF plating with bone graft, and intramedullary pin fixation.

METHODS

We performed a systematic review and meta-analysis of studies reporting outcome, complication, and reoperation rates following surgical treatment for clavicle nonunion. Subgroup analysis was undertaken for outcome and complication rates between single plating and intramedullary pin fixation, bone graft use, and nonunion time length definition.

RESULTS

Fifty-three studies met inclusion criteria (1,258 clavicle nonunions). Mean clinical follow-up was 2.6 years. Seventy-two percent of nonunions were of the middle third, 1% were proximal third, 12% were distal third, and 15% were not reported. Forty-eight percent of nonunions were atrophic or oligotrophic and 17% were hypertrophic (35% not reported). Mean time to union was 13.6 weeks. Ninety-five percent of patients achieved union after the primary nonunion surgery. Overall complication rate was 17%. Single-plating fixation had significantly faster union time (15.2 vs. 19.8 weeks), lower reoperation rate (23% vs. 37%), and hardware removal rate (20% vs. 34%) than intramedullary pin fixation. Bone graft had significantly lower rates of delayed union (0.6% vs. 3.6%) but higher complication (15% vs. 8%) and reoperation rates (29% vs. 14%) than the other groups. Studies that defined nonunion after 3 months had significantly faster union times than the 6-month studies (13 vs. 16 weeks). The 3-month group had a significantly lower overall complication rate (12% vs. 25%) and hardware/fixation failure rate (3% vs. 5.5%) than the 6-month group.

CONCLUSIONS

This systematic review is the largest report of complications, reoperations, and patient outcomes of clavicle nonunions after surgical intervention in the current literature. Plating showed faster time to union and lower reoperation rates than intramedullary pin fixation. Bone graft use showed lower rates of delayed union but substantially higher rates of complications and reoperations. Reports with a definition of nonunion at 3 months showed faster union times and lower complication rates compared to reports with a definition of nonunion that was 6 months or greater. Surgery could be considered at 3 months post-injury in cases of symptomatic non-united clavicle fracture, and plating results in reliable outcomes. Adjuvant bone grafting requires further study to determine its value and risk/benefit ratio.

LEVEL OF EVIDENCE

Level IV, Systematic Review. See Instructions for Authors for a complete description of levels of evidence.

Treatment of a Recalcitrant Non-union of the Clavicle

Background

Plate fixation is the treatment of choice for a midshaft clavicle non-union. Those non-unions that require >1 surgical procedure to heal are termed recalcitrant non-union. Regardless of the number of previously failed procedures, our surgical strategy is aimed at achieving an optimal mechanical and biological environment to facilitate healing.

Materials and methods

We performed a retrospective analysis of 14 patients with a recalcitrant clavicle non-union treated with open reduction and plate fixation combined with graft augmentation when indicated. Healing rates after index surgery were analysed. All patients were observed for at least 12 months.

Results

All patients healed at a mean time of 193.2 days (range 90-390). Five of the 14 patients had at least one positive surprise culture, for which they received antibiotic treatment. At the latest follow-up, no patient reported pain or discomfort. Mean disability of the arm, shoulder and hand (DASH) score was 16.3 points (range 0-40), indicating only mild residual impairment. A possible link was found between the time between injury and definitive surgery and the time to healing [Pearson correlation 0.527, sig. (two-tailed) 0.000].

Conclusion

This study shows 100% bone healing and good functional outcomes after surgical revision for a recalcitrant clavicle non-union.

How to cite this article

Grewal S, Baltes TPA, Wiegerinck E, et al. Treatment of a Recalcitrant Non-union of the Clavicle. Strategies Trauma Limb Reconstr 2022;17(1):1-6.

Results of pre-contoured titanium anterior plating of midshaft clavicle fractures

BACKGROUND

Plating midshaft clavicle fractures anteriorly is gaining popularity because of low complication rates. Improvements in plate fixation constructs for midshaft clavicle fractures have unclear clinical significance. The purpose of this study was to present the early clinical and radiographic outcomes of pre-contoured titanium anterior plates for the treatment of midshaft clavicle fractures.

METHODS

Skeletally mature patients who underwent plate fixation of a midshaft clavicular fracture from 2008 to 2015 using pre-contoured titanium anterior plates were included in this retrospective investigation. The primary outcome measures were union rate and hardware removal rate. The secondary outcome measures included reoperation for all causes and mechanical implant failure.

RESULTS

A total of 26 patients were included. Complete healing occurred in 96% of patients without further surgical intervention, and all patients achieved union. Medical complications occurred in 2 patients (7.7%), consisting of cellulitis (n = 1) and chronic pain (n = 1). In 1 patient (3.8%), delayed union occurred and the use of a bone stimulator was required postoperatively to achieve union. Finally, 2 patients (7.7%) had symptomatic implants that required removal.

CONCLUSIONS

In the acute fracture setting, the anterior plating system used in this study led to a high rate of union with decreased rates of implant irritation. Only 7.7% of patients required hardware removal for symptomatic hardware, as opposed to the estimated 20%-60% reported in the literature in patients with symptomatic superior clavicle plates.

A simple surgical technique for correcting malunion after midshaft clavicle fracture

Clavicle malunion occurs in two-thirds of all clavicle fractures treated conservatively. It can lead to pain, shoulder dysfunction and cosmetic complaints. Surgical treatment of all midshaft fractures will lead to overtreatment, as not all malunions are symptomatic. In the past, several treatment modalities for correcting malunion of the clavicle have been described, and all have been successful but none have shown superiority. This article describes a new surgical technique with excising a wedge to realign the clavicle malunion.

Experiencia en fracturas de clavícula mediodiafisaria con placa de reconstrucción en posición anteroinferior en pacientes del Hospital José Carrasco Arteaga, IESS 2017 Cuenca – Ecuador

Las fracturas mediodiafisarias de clavícula corresponden del 75% al 80% de los casos de fracturas claviculares. En el contexto quirúrgico, existen dos técnicas para reparar este tipo de fracturas: la colocación de placa en posición superior y en posición anteroinferior. La primera técnica es la más usada; sin embargo, la segunda brinda una temprana recuperación, minimiza pérdida de sangre y disminuye intervenciones secundarias con reducción económica en salud. Demostrando ser más efectiva. El objetivo del presente trabajo fue evaluar las ventajas de la técnica de colocación de placa en posición anteroinferior para fractura mediodiafisaria de clavícula. Se estudiaron una serie de casos que describe las ventajas de la técnica de colocación de placa en posición anteroinferior por fractura mediodiafisaria de clavícula en el hospital José Carrasco Arteaga, entre enero a diciembre del año 2017. Analizado mediante estadística descriptiva. Se estudiaron 12 pacientes masculinos entre los 18 y 30 años, previo consentimiento informado y cumplieron con criterios de inclusión. Los datos se obtuvieron de resultados de procedimientos quirúrgicos y fueron analizados en Microsoft Excel. Todas las fracturas mediodiafisarias de clavícula se trataron con colocación de una placa de 6 a 8 orificios de 3.5mm de reconstrucción en posición anteroinferior. No se presentaron complicaciones intra ni posoperatorios. Consolidaron al mes y medio con un buen resultado funcional. La técnica de colocación de placa en posición anteroinferior ofrece el retorno temprano de la función del hombro y evita el riesgo de lesión neurovascular. Además, presenta una baja tasa de prominencia del implante.

Bilaterally Threaded, Minimal Invasive, Elastic Locking Intramedullary Nailing (ELIN) for the Treatment of Clavicle Fractures

Objective

To evaluate and present the effectiveness of this innovatively designed, elastic locking intramedullary nail (ELIN) in fixation of clavicle fractures.

Methods

The study included 38 patients from July 2014 to July 2017. All of them received intramedullary fixation treated with ELIN, 22 were males and 16 females. The mean age of the patients was 54 years. There were twenty right‐side and 18 left‐side clavicular fractures. Radiographs were taken to assess the fracture type: 21 were type A, 16 type B, and one type C. General anesthesia or cervical block was given to all patients. A small incision of 3–5 cm was given only to those who needed mini‐open reduction. The administration of ELIN and reduction of the fracture was made sure with a C arm machine. After a follow‐up of 8 to 33 months, the clinical outcomes were assessed and evaluated. The constant scores and disabilities of the arm, shoulder and hand questionnaire (DASH) were used to determine the outcomes and functional status of the patients. The study was done accordingly to the guidelines provided by the ethics committee.

Results

Mean operation time was 25.63 min. Mean follow‐up time was 16.5 months. The rate of closed reduction and open reduction was 84% and 16% respectively. There was no shortening of the clavicle. There was no breakage of the nail, though bending of the nail occurred in one patient. Superficial skin infection occurred in three patients at insertion points or the nail tip which was embedded subcutaneously. Skin erosion with nail exposure occurred in a patient with no significant infection. All the other patients had excellent shoulder function. A mini scar was observed in seven patients all the other patients had no scar. Asymmetry was observed in three patients. The mean Constant score was 98.47 and the mean DASH score was 1.55 at the last follow‐up. The implant was removed in all the patients.

Conclusion

Clavicular fractures treated with ELIN is minimally invasive, which presents a safe and novel surgical technique with less complications and a high success rate, excellent aesthetic and quick recovery after surgery. ELIN restores the micro‐dynamic stress at the fracture ends and promotes fracture healing, keeps intact the fracture hematoma and maintains the blood supply, accelerates healing and thus leads to faster osseous healing and better restoration of clavicle length.

Patient Position Is Related to the Risk of Neurovascular Injury in Clavicular Plating: A Cadaveric Study

BACKGROUND

Fixation of clavicle shaft fractures with a plate and screws can endanger the neurovascular structures if proper care is not taken. Although prior studies have looked at the risk of clavicular plates and screws (for example, length and positions) to vulnerable neurovascular structures (such as the subclavian vein, subclavian artery, and brachial plexus) in the supine position, no studies to our knowledge have compared these distances in the beach chair position.

QUESTIONS/PURPOSES

(1) In superior and anteroinferior plating of midclavicle fractures, which screw tips in a typical clavicular plating approach place the neurovascular structures at risk of injury? (2) How does patient positioning (supine or beach chair) affect the distance between the screws and the neurovascular structures?

METHODS

The clavicles of 15 fresh-frozen cadavers were dissected. A hypothetical fracture line was marked at the midpoint of each clavicle. A precontoured six-hole 3.5-mm reconstruction locking compression plate was applied to the superior surface of the clavicle by using the fracture line to position the center of the plate. The direction of the drill bits and screws through screw holes that offer the greater risk of injury to the neurovascular structures were identified, and were defined as the risky screw holes, and the distances from the screw tips to the neurovascular structures were measured according to a standard protocol with a Vernier caliper in both supine and beach chair positions. Anteroinferior plating was also assessed following the same steps. The different distances from the screw tips to the neurovascular structures in the supine position were compared with the distances in the beach chair position using an unpaired t-test.

RESULTS

The risky screw holes were the first medial and second medial screw holes. The relative distance ratios compared with the entire clavicular length for the distances from the sternoclavicular joint to the first medial and second medial screw holes were 0.46 and 0.36 in superior plating and 0.47 and 0.37 in anteroinferior plating, respectively. The riskiest screw hole for both superior and anteroinferior plates was the second medial screw hole in both the supine and beach chair positions (supine superior plating: 8.2 mm ± 3.1 mm [minimum: 1.1 mm]; beach chair anteroinferior plating: 7.6 mm ± 4.2 mm [minimum: 1.1 mm]). Patient positioning affected the distances between the riskiest screw tip and the nearest neurovascular structures, whereas in superior plating, changing from the supine position to the beach chair position increased this distance by 1.4 mm (95% CI -2.8 to -0.1; supine 8.2 ± 3.1 mm, beach chair 9.6 ± 2.1 mm; p = 0.037); by contrast, in anteroinferior plating, changing from the beach chair position to the supine position increased this distance by 5.4 mm (95% CI 3.6 to 7.4; beach chair 7.6 ± 4.2 mm, supine 13.0 ± 3.2 mm; p < 0.001).

CONCLUSIONS

The second medial screw hole places the neurovascular structures at the most risk, particularly with superior plating in the supine position and anteroinferior plating in the beach chair position.

CLINICAL RELEVANCE

The surgeon should be careful while making the first medial and second medial screw holes. Superior plating is safer to perform in the beach chair position, while anteroinferior plating is more safely performed in the supine position.

Are commercially-available precontoured anatomical clavicle plating systems offering the purported superior optimum fitting to the clavicle? A cadaveric analysis and review of literature

PURPOSE

The indication for operative treatment of displaced midshaft clavicle fractures remains controversial. However, if plate fixation is considered, implant prominence and skin irritation are the most common causes for re-operation. Low profile implants as well as closely contouring plates to the individual anatomy may reduce these complications. The aim of this study was to compare the fitting accuracy and implant prominence of 3.5mm pelvic reconstruction plates (PRP) with pre-contoured anatomical clavicle plates (PACP) for midshaft clavicle fractures.

METHODS

Three-dimensional data of the largest, median and smallest male and female clavicle of an existing database of 89 cadaveric clavicles were included for analysis. A three-dimensional model of a commercially available PACP was used for digitally positioning of the plate on the segmented clavicles. Three-dimensional printouts of each clavicle were produced and the 3.5mm reconstruction plates were manually bent and positioned by the senior author. Computed tomography scans and three-dimensional reconstructions were then obtained to digitally compare the fitting accuracy and implant prominence.

RESULTS

Pelvic reconstruction plates offered superior fitting accuracy and lower implant prominence compared to PACP. The largest difference in implant prominence was observed in large sized female clavicles and measured 3.6mm.

CONCLUSION

Both, the less costly PRP plates and commercially available PACP for midshaft fractures of the clavicle demonstrated a clinically acceptable fitting accuracy. The manually bent pelvic-reconstruction plates demonstrated reduced implant prominence with superior fitting. Hypothetically this might contribute to a reduced rate of reoperation.

LEVEL OF EVIDENCE

Level IV cadaveric study.

What is the hardware removal rate after anteroinferior plating of the clavicle? A retrospective cohort study

BACKGROUND

Plate position in the operative treatment of displaced midshaft clavicle fractures or nonunions is most often on the superior side. However, superior clavicular plating often results in complaints of plate prominence and local soft tissue irritation, necessitating hardware removal. We have used anteroinferior placement of the plate in the hope of increasing biomechanical stability and fixation and also of lowering complaints of plate prominence and soft tissue irritation. In this report, we set out to study the percentage of hardware removal in our group of patients treated with anteroinferior plating of the clavicle after long-term follow-up.

METHODS

In this retrospective review, we evaluated all patients who were surgically treated with anteroinferior plating for midshaft clavicle fracture, delayed union, or nonunion by the senior author between February 2003 and July 2015. Patients required a minimum age of 16 years at time of surgery and a follow-up of >12 months. Patients with malunion, plating on the superior aspect, or double plating were excluded.

RESULTS

The medical records of 53 patients (54 fractures) were reviewed after a mean follow-up duration of 6.4 years (range, 1.1-13.1). The mean age at follow-up was 47.8 years (range, 20.4-80.7). All fractures and nonunions healed. In only 3 cases (5.6%), hardware removal was requested by the patient because of plate prominence.

CONCLUSIONS

Anteroinferior plating of midshaft clavicle fractures, delayed unions, and nonunions resulted in low hardware removal rates in our cohort.

Anterior-Inferior Plating Results in Fewer Secondary Interventions Compared to Superior Plating for Acute Displaced Midshaft Clavicle Fractures

OBJECTIVES

To determine whether a difference in plate position for fixation of acute, displaced, midshaft clavicle fractures would affect the rate of secondary intervention.

DESIGN

Retrospective Comparative Study.

SETTING

Two academic Level 1 Regional Trauma Centers.

PATIENTS

Five hundred ten patients treated surgically for an acutely displaced midshaft clavicle fracture between 2000 and 2013 were identified and reviewed retrospectively at a minimum of 24 months follow-up (F/U). Fractures were divided into 2 cohorts, according to plate position: Anterior-Inferior (AI) or Superior (S). Exclusion criteria included age <16 years, incomplete data records, and loss to F/U. Group analysis included demographics (age, sex, body mass index), fracture characteristics (mechanism of injury, open or closed), hand dominance, ipsilateral injuries, time between injury to surgery, time to radiographic union, length of F/U, and frequency of secondary procedures.

INTERVENTION

Patients were treated either with AI or S clavicle plating at the treating surgeon's discretion.

MAIN OUTCOME MEASURES

Rate and reason for secondary intervention.

STATISTICAL ANALYSIS

Fisher exact test, t test. and odds ratio were used for statistical analysis.

RESULTS

Final analysis included 252 fractures/251 patients. One hundred eighteen (47%) were in group AI; 134 (53%) were in group S. No differences in demographics, fracture characteristics, time to surgery, time to union, or length of F/U existed between groups. Seven patients/7 fractures (5.9%) in Group AI underwent a secondary surgery whereas 30 patients/30 fractures (22.3%) in group S required a secondary surgery. An additional intervention secondary to superior plate placement was highly statistically significant (P < 0.001). Furthermore, because 80% of these subsequent interventions were a result of plate irritation with patient discomfort, the odds ratio for a second procedure was 5 times greater in those fractures treated with a superior plate.

CONCLUSIONS

This comparative analysis indicates that AI plating of midshaft clavicle fractures seems to lessen clinical irritation and results in significantly fewer secondary interventions. Considering patient satisfaction and a reduced financial burden to the health care system, we recommend routine AI plate application when open reduction internal fixation of the clavicle is indicated.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intrapleural Penetration of a Clavicle Fracture: An Indication for Operative Fixation

INTRODUCTION

Clavicle fractures are common injuries treated by orthopedic surgeons, with most injuries managed nonoperatively. Operative fixation of clavicle fractures is indicated in specific clinical scenarios such as open injuries, ipsilateral shoulder trauma, or fractures with associated neurovasculature compromise. Operative fixation is not widely accepted for closed injuries and is typically reserved for instances of failed closed treatment with resultant nonunion or delayed union. Among the complications associated with clavicle fractures, pneumothorax has not been commonly reported. We report a case of a severely displaced clavicle fracture requiring operative repair through plate fixation to achieve union of the fracture as well as resolve the pneumothorax.

CASE REPORT

A 22-year-old intoxicated male with no past medical history was admitted to the trauma bay in stable condition after being involved in a motor vehicle accident. On the primary survey, the patient was noted to be tachypneic with decreased breath sounds over his right hemithorax. Radiographic studies of his chest demonstrated a right proximal third clavicle fracture with inferior displacement with associated partial pneumothorax; the patient was also noted to have a right femoral shaft fracture. Neurovascular examinations of his extremities were normal. A chest thoracostomy tube was inserted and placed under suction. Computerized tomography studies later revealed that the fractured clavicle had penetrated the pleura and caused the partial lung collapse. The patient was initially placed in a sling and underwent intramedullary nailing of his femur on the day of presentation. Given the severe displacement of his clavicle fracture into the lung tissue resulting in pneumothorax, there was significant concern for nonunion and lack of resolution of the pneumothorax. 2 days after stabilization of his right femur fracture, the patient underwent open reduction with internal fixation of his right clavicle. Follow-up radiographs showed a healed clavicle fracture and resolved pneumothorax.

CONCLUSION

Closed clavicle fractures typically heal uneventfully. Low energy, minimally displaced clavicle fractures can be managed nonoperatively, but high energy, significantly displaced injuries may require operative repair. Specifically, if these injuries result in pneumothorax, physicians shoulder consider operative repair for both treatment of the bony defect as well resulting pneumothorax.

Anterior inferior plating versus superior plating for clavicle fracture: a meta-analysis

Background

The position of plate fixation for clavicle fracture remains controversial. Our objective was to perform a comprehensive review of the literature and quantify the surgical parameters and clinical indexes between the anterior inferior plating and superior plating for clavicle fracture.

Methods

PubMed, EMBASE, and the Cochrane Library were searched for randomized and non-randomized studies that compared the anterior inferior plating with the superior plating for clavicle fracture. The relative risk or standardized mean difference with 95% confidence interval was calculated using either a fixed- or random-effects model.

Results

Four randomized controlled trials and eight observational studies were identified to compare the surgical parameters and clinical indexes. For the surgical parameters, the anterior inferior plating group was better than the superior plating group in operation time and blood loss (P < 0.05). Furthermore, in terms of clinical indexes, the anterior inferior plating was superior to the superior plating in reducing the union time, and the two kinds of plate fixation methods were comparable in constant score, and the rate of infection, nonunion, and complications (P > 0.05).

Conclusions

Based on the current evidence, the anterior inferior plating may reduce the blood loss, the operation and union time, but no differences were observed in constant score, and the rate of infection, nonunion, and complications between the two groups. Given that some of the studies have low quality, more randomized controlled trails with high quality should be conduct to further verify the findings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1517-1) contains supplementary material, which is available to authorized users.

Plate fixation and bone grafting of distal clavicle nonunions: radiologic and functional outcomes

INTRODUCTION

The optimal treatment for distal clavicle nonunions remains unknown. Small series have reported outcomes following distal fragment excision and various fixation techniques. We present the clinical, radiographic and functional outcomes after superior plating or double (superior and anteroinferior) plating in combination with bone grafting as treatment for distal clavicle nonunions.

METHODS

We collected demographic and radiographic data from a consecutive series of ten patients with symptomatic nonunion of the distal clavicle treated since 1998. Functional outcomes were assessed, as well as the visual analogue scale (VAS) score.

RESULTS

The mean clinical follow-up was 41.4 months (range of 12-158 months). The mean radiological follow-up was 30.6 months (range of 3-158 months). All nonunions healed as demonstrated by subsidence of clinical symptoms and radiographic criteria. The average time to union was 3.7 months (range of 2-8 months). The mean The Disabilities of the Arm, Shoulder and Hand (DASH) score was 11.9 (range of 0-62.5) and mean VAS score was 0.9 at follow-up.

CONCLUSION

This study illustrates good clinical, radiologic and functional outcomes in ten patients with distal clavicle nonunion treated with superior or double (superior and anteroinferior) plating in combination with bone grafting. Double-plating can be considered an alternative to superior plating offering better resistance against the pulling effect of the arm with the use of smaller fixation plates.

Extraperiosteal Dual Plate Fixation of Acute Mid-Shaft Clavicle Fractures: A Technical Trick

Historically, surgical treatment of acute mid-shaft clavicle fractures has excellent outcomes with low rates of nonunion. More complex fracture patterns with significant comminution may limit the fixation that can be obtained with a single plate. The authors describe the surgical technique and case series of patients treated with extraperiosteal dual plating for acute mid-shaft clavicle fractures.

Anteroinferior 2.7-mm versus 3.5-mm plating of the clavicle: A biomechanical study

INTRODUCTION

Lower patient satisfaction and high rates of plate prominence has led to the use of lower profile, smaller plates in the treatment of midshaft clavicle fractures. Specifically regarding the use of 2.7mm reconstruction plates, there lacks biomechanical comparison to its more robust 3.5mm counterpart. This study was designed to compare the mechanical properties of anteroinferior plate fixation on a clavicle fracture model using either 2.7mm or 3.5mm reconstruction plates.

METHODS

Forty-eight synthetic left clavicles were divided into two groups based on the type of fixation: 3.5mm or 2.7mm pelvic reconstruction plate fixed in the anteroinferior position. Fixation was tested on AO/OTA 15B1.3 transverse midshaft fractures. Each specimen underwent the following three mechanical tests: axial compression, torsion, and four-point bending.

RESULTS

Significant differences were observed in axial (p=0.016) and torsional (p=0.00097) stiffness between the two groups. The average bending rigidity (EI) was found to be significantly lower for the 2.7-mm plates as compared to the 3.5-mm plates (p=0.03). The loading scenarios performed in the mechanical tests did not lead to failure of any implants.

CONCLUSION

While our results show clear mechanical superiority of 3.5-mm reconstruction plates over 2.7-mm plates, superior results in the clinical setting may not necessarily translate. With exceptional mechanical strength also noted for the 2.7mm plate, well above the biomechanical properties of an intact clavicle, these results may obviate the need for robust plates in general.

A hybrid approach to mid-shaft clavicle fixation

BACKGROUND

The purpose of this study was to demonstrate the strength characteristics of a hybrid uni-cortical construct for clavicle fixation. The technique reported aims to combine benefits of uni-cortical fixation with stability comparable to traditional bi-cortical fixation. The approach utilises long, oblique uni-cortical screws at the distal ends of the plate acting as surrogate bi-cortical screws. Locked uni-cortical screws positioned centrally provide bending and torsion strength to the construct. This alternative hybrid uni-cortical technique does not require far cortex screw or drill penetration required in bi-cortical fixation techniques, thus avoiding potentially catastrophic vascular and or neurologic injury. The purpose of this study was to compare the mechanical behaviour of the hybrid uni-cortical construct to standard bi-cortical fixations under both torsion and bending loads.

METHOD

Thirty osteotomized human cadaveric clavicles were randomly allocated to three surgical fixation techniques: bi-cortical locked screw fixation, bi-cortical non-locked screw fixation and hybrid uni-cortical screw fixation. Each clavicle construct was tested non-destructively under torsional loading, and then under cantilever bending to failure. Construct bending and torsional stiffness, as well as ultimate failure strength, were measured.

RESULTS

There were no significant differences between uni-cortical or bi-cortical fixation constructs in either bending stiffness or ultimate bending moment (p>0.05); however, there was a trend towards greater bending stiffness in the hybrid construct. The uni-cortical hybrid fixation technique displayed a significantly lower mean torsional stiffness value when compared with the bi-cortical locked screw fixation (mean difference: 134.4 Nmm/degrees, 95% confidence interval [32.3, 236.4], p=0.007).

CONCLUSION

A hybrid uni-cortical approach to clavicle plate fixation that may improve screw purchase and reduce risk of intra-operative vascular damage demonstrates comparable bending strength to current bi-cortical approaches.

Anteroinferior versus superior plating of clavicular fractures

BACKGROUND

Open reduction and plate fixation has gained recognition as an effective treatment for certain types of clavicular fractures. However, 88% of cases report some implant-related problems. To determine the optimal plate position, the aim of the present study was to compare implant-related irritation and proportion of plate removal in patients with clavicular fractures undergoing plate fixation by an anteroinferior or superior approach.

METHODS

Retrospectively collected data of 39 patients who underwent anteroinferior plating for displaced midshaft clavicular fractures were compared with prospectively collected data of 60 patients who were treated with superior plate fixation as part of a multicenter randomized controlled trial. Electronic medical records were reviewed for reports of complications, in particular, implant-related irritation and implant removal during follow-up. In addition, all patients were contacted in June 2014 to obtain additional information. The primary outcome parameter was implant-related irritation.

RESULTS

Univariate and multivariate regression analysis showed plate position was not significantly associated with implant-related irritation. Higher rates of asymptomatic patients with the plate still in place were observed in the anteroinferior group (46% vs 22%, P = .01). Almost an equal percentage of implant removals was seen in both groups because of implant irritation (36% vs 37%, P = .938).

CONCLUSIONS

The present study found the surgical approach of clavicular plating was not associated with implant-related irritation. Future studies are needed to determine whether there is an optimal approach for clavicle plating.

Dual mini-fragment plating for midshaft clavicle fractures: a clinical and biomechanical investigation

BACKGROUND

We sought to evaluate clinical and biomechanical outcomes of dual mini-fragment plate fixation for clavicle fractures. We hypothesized that this technique would produce an anatomical reduction with good clinical outcomes, be well tolerated by patients, and demonstrate equivalent biomechanics to single plating.

METHODS

Dual mini-fragment plating was performed for 17 isolated, displaced midshaft clavicle fractures. Functional outcomes and complications were retrospectively reviewed. A sawbones model compared dual plating biomechanics to a (1) superior 3.5-mm locking reconstruction plate, or (2) antero-inferior 3.5-mm locking reconstruction plate.

RESULTS

On biomechanical testing, with anterior loading, dual plating was significantly more rigid than single locked anterior-plating (p = 0.02) but less rigid than single locked superior-plating (p = 0.001). With superior loading, dual plating trended toward higher rigidity versus single locked superior-plating (p = 0.07) but was less rigid than single locked anterior-plating (p = 0.03). No statistically significant differences in axial loading (p = 0.27) or torsion (p = 0.23) were detected. Average patient follow-up was 16.1 months (12-38). Anatomic reduction was achieved and maintained through final healing (average 14.7 weeks). No patient underwent hardware removal. Average 1-year DASH score was 4.0 (completed in 88 %).

CONCLUSIONS

Displaced midshaft clavicle fractures can be effectively managed with dual mini-fragment plating. This technique results in high union rates and excellent clinical outcomes. Compared to single plating, dual plating is biomechanically equivalent in axial loading and torsion, yet offers better multi-planar bending stiffness despite the use of smaller plates. This technique may decrease the need for secondary surgery due to implant prominence and may aid in fracture reduction by buttressing butterfly fragments in two planes.

A biomechanical comparison of four different fixation methods for midshaft clavicle fractures

Clavicle fractures may occur in all age groups, and 70%-80% of clavicle fractures occur in the midshaft. Many methods for treating midshaft clavicular fractures have been reported and remain controversial. To provide some guidance for clinical treatment, 30 artificial polymethyl methacrylate models of the clavicle were sewn obliquely at the midshaft to simulate the most common type of clavicular fractures, and the fracture models were divided into five groups randomly and were fixed as follows: the reconstruction plates were placed at the superior position of the fracture model (R-S group), the reconstruction plates were placed at the anteroinferior position of the fracture model (R-AI group), the locking plates were placed at the superior position (L-S group), the locking plates were placed at the anteroinferior position (L-AI group); and the control models were unfixed (control group). The strain gauges were attached to the bone surface near the fracture fragments, and then, the biomechanical properties of the specimens were measured using the compression test, torsion test and three-point bending test. The results showed that plate fixation can provide a stable construct to help with fracture healing and is the preferred method in the treatment of clavicle fractures. The locking plate provides the best biomechanical stability when placed at the anteroinferior position, and this surgical method can reduce the operation time and postoperative complications; thus, it would be a better choice in clinical practice.

Clinical comparison of two different plating methods in minimally invasive plate osteosynthesis for clavicular midshaft fractures: A randomized controlled trial

AIM

The aim of this study was to compare the clinical and radiographic outcomes between two different plating methods (superior vs. anteroinferior) in minimally invasive plate osteosynthesis (MIPO) for acute displaced clavicular shaft fractures.

MATERIALS AND METHODS

A prospective, randomized controlled trial was performed in a single centre. Nineteen patients were treated with superior plating and 18 with anteroinferior plating using the MIPO technique. A 3.5-mm locking reconstruction plate was bent preoperatively and applied to either the anteroinferior or superior aspect of the clavicle through two separate incisions. The operating time, time to union, the proportional length difference, complications, and functional outcome of the shoulder joint were evaluated using the Constant score and the University of California Los Angeles (UCLA) score.

RESULTS

There was no statistically significant difference in the Constant score and UCLA score. The mean time to union was 16.8 weeks for superior plating and 17.1 weeks for anteroinferior plating (p=0.866). The average operation time was 77.2min in superior plating and 79.4min in anteroinferior plating (p=0.491). One patient in the superior plating group showed plate failure. Despite no significant difference, one patient had nonunion in the superior plating group (p>0.999).

CONCLUSIONS

From a clinical perspective, although MIPO with anteroinferior plating provides better outcomes especially in complications without statistically significant difference, both plating methods provided satisfactory clinical and radiographic outcomes.

LEVEL OF EVIDENCE

Level I, a single-centre, prospective, randomized controlled trial.

Surgical treatment of displaced midshaft clavicular fractures with precontoured plates

BACKGROUND

Plate fixation of displaced midshaft clavicular fractures has been shown to decrease nonunion, symptomatic malunion, and residual shoulder disability compared with nonoperative treatment. However hardware-related complications are a problem. The new features of the precontoured locking plates may reduce the need for hardware removal, thus maintaining the advantages of plate fixation. This study evaluated the clinical outcomes of patients with displaced midshaft clavicular fractures treated with precontoured locking plates.

MATERIALS AND METHODS

From November 2008 to December 2012, we surgically treated 72 patients with displaced midshaft clavicular fractures. We retrospectively evaluated 68 patients who underwent 68 interventions. Postoperative functional outcomes were assessed with the Constant score, the 11-item version of the Disabilities of Arm, Shoulder and Hand (QuickDASH) questionnaire, and radiographs. Pain was subjectively assessed with a visual analog scale. Complications were recorded. Patients were asked if they were able to return to their previous employment level.

RESULTS

The mean follow-up period was 23.6 ± 10.7 months. The average values of the Constant, QuickDASH, and visual analog scale scores were 97.8, 1.8, and 0.4 points, respectively. At the last follow-up, 98.5% were able to return to their regular work. Of 15 complications (22.1%) that occurred, only 3 were considered as major: 1 subclavian vein extrinsic compression, 1 nonunion, and 1 hardware loosening. Hardware removal was required in 9 patients (13.2%).

CONCLUSIONS

Satisfactory clinical results with a low rate of complications were achieved with precontoured locking plates for displaced midshaft clavicular fractures and a low rate of hardware removal compared with traditional plates.

Surgical fixation of displaced midshaft clavicle fractures: elastic intramedullary nailing versus precontoured plating

Background

This prospective comparative study was done to evaluate the effectiveness of implants of different design (titanium elastic intramedullary nail versus anatomical precontoured dynamic compression plate) in treatment of displaced midshaft clavicular fractures.

Materials and methods

Sixty-six patients between 18 and 65 years of age were included in this study. They were randomized in two groups to be treated with either elastic intramedullary nail (EIN) or plate. Clinical and radiological assessments were performed at regular intervals. Outcomes and complications of both groups over 2 years of follow-up time were compared.

Results

Length of incision, operation time, blood loss and duration of hospital stay were significantly less for the EIN group. American Shoulder and Elbow Surgeons (ASES) and Constant Shoulder scores were significantly higher (p < 0.05) in the plating group than the EIN group for the first 2 months but there was no significant difference found between the two groups regarding functional and radiological outcome at the 2-year follow-up. Significantly higher rates of refracture after implant removal (p = 0.045) in the plating group was observed. Infection and revision surgery rates were also higher in the plate group, but this difference was insignificant (p > 0.05).

Conclusions

EIN is a safe, minimally invasive surgical technique with a lower complication rate, faster return to daily activities, excellent cosmetic and comparable functional results, and can be used as an equally effective alternative to plate fixation in displaced midshaft clavicle fractures.

Level of evidence

Level 2.

Minimally invasive in the treatment of clavicle middle part fractures with locking reconstruction plate

PURPOSE

We aimed to assess the possibility and feasibilities in the treatment of clavicle midpiece fracture by minimally invasive with percutaneous locking reconstitution plate.

METHODS

Total 29 cases of patients with clavicle midpiece fractures were reviewed including 13 males and 16 females. All the patients were treated by minimally invasive with locking reconstitution plates.

RESULTS

All the patients showed satisfaction of the appearance of incision and union of all the fractures. One case suffered fixation device failure and 3 cases suffered skin irritation responses.

CONCLUSION

The minimally invasive with locking reconstruction plate is a good option for clavicle midpiece fractures treatment with good fracture healing.

Analysis of neurovascular safety between superior and anterior plating techniques of clavicle fractures

OBJECTIVES

Clavicle fractures are commonly plated as a method of fixation, with superior and anterior techniques described. Although advantages and disadvantages have been attributed to both, it is unclear if one approach provides a lower risk of neurovascular injury. The aim of this study was to compare the potential for neurovascular injury between these 2 plate locations in a cadaveric model.

METHODS

Seventeen adult fresh frozen cadavers underwent bilateral dissections exposing the clavicle and underlying neurovasculature. After taking baseline anatomical measurements, a superior and anterior clavicle plate was applied, removed and measurements were taken from the nearest screw exit site to the underlying subclavian vein/artery and brachial plexus. The differences between superior and anterior measurements were compared based on proximity with the neurovasculature.

RESULTS

Distance to the vessels were unobtainable in 6 specimens (35%) plated with the anterior technique due to the trajectory of the screws projecting cephalad to the vessels. In the remaining specimens, there was no significant difference in the distance to the subclavian vein/artery and brachial plexus in the superior plate position (9.2 ± 4.6, 12.2 ± 5.8, and 9.8 ± 5.2 mm, respectively) compared with the anterior plate position (8.3 ± 3.5, 12.2 ± 6.5, and 9.7 ± 5.3 mm, respectively). In addition, no significant difference in potential neurovascular injury with regard to body size or gender was found.

CONCLUSIONS

The majority of our specimens showed no significant difference between superior and anterior plating in regard to potential risk for injury to the underlying neurovasculature. However, there appears to be a subset of the population with a more caudal position of the neurovascular structures in which anterior plating may be potentially safer.

Open reduction and plate fixation versus nonoperative treatment for displaced midshaft clavicular fractures: a multicenter, randomized, controlled trial

BACKGROUND

There is a growing trend to treat displaced midshaft clavicular fractures with primary open reduction and plate fixation; whether such treatment results in improved patient outcomes is debatable. The aim of this multicenter, single-blinded, randomized controlled trial was to compare union rates, functional outcomes, and economic costs for displaced midshaft clavicular fractures that were treated with either primary open reduction and plate fixation or nonoperative treatment.

METHODS

In a prospective, multicenter, stratified, randomized controlled trial, 200 patients between sixteen and sixty years of age who had an acute displaced midshaft clavicular fracture were randomized to receive either primary open reduction and plate fixation or nonoperative treatment. Functional assessment was conducted at six weeks, three months, six months, and one year with use of the Disabilities of the Arm, Shoulder and Hand (DASH) and Constant scores. Union was evaluated with use of three-dimensional computed tomography. Complications were recorded, and an economic evaluation was performed.

RESULTS

The rate of nonunion was significantly reduced after open reduction and plate fixation (one nonunion) as compared with nonoperative treatment (sixteen nonunions) (relative risk = 0.07; p = 0.007). Group allocation to nonoperative treatment was independently predictive of the development of nonunion (p = 0.0001). Overall, DASH and Constant scores were significantly better after open reduction and plate fixation than after nonoperative treatment at the time of the one-year follow-up (DASH score, 3.4 versus 6.1 [p = 0.04]; Constant score, 92.0 versus 87.8 [p = 0.01]). However, when patients with nonunion were excluded from analysis, there were no significant differences in the Constant scores or DASH scores at any time point. Patients were less dissatisfied with symptoms of shoulder droop, local bump at the fracture site, and shoulder asymmetry in the open reduction and plate fixation group (p < 0.0001). The cost of treatment was significantly greater after open reduction and plate fixation (p < 0.0001).

CONCLUSIONS

Open reduction and plate fixation reduces the rate of nonunion after acute displaced midshaft clavicular fracture compared with nonoperative treatment and is associated with better functional outcomes. However, the improved outcomes appear to result from the prevention of nonunion by open reduction and plate fixation. Open reduction and plate fixation is more expensive and is associated with implant-related complications that are not seen in association with nonoperative treatment. The results of the present study do not support routine primary open reduction and plate fixation for the treatment of displaced midshaft clavicular fractures.

Superior versus anteroinferior plating of clavicle fractures

Plate fixation of displaced clavicle fractures has proven to be reliable and reproducible, leading to high union rates and a low rate of associated complications. However, the decision of whether to place the plate superiorly or anteroinferiorly on the clavicle has remained controversial. The authors performed a retrospective review on a consecutive series of patients who underwent plate fixation for a displaced midshaft clavicle fracture at a Level I urban trauma center. A review of surgical records identified 138 patients with a displaced midshaft clavicle fracture requiring operative stabilization. A total of 105 patients who met the inclusion criteria were included in the analysis. Both superior and anteroinferior techniques resulted in a similar time to radiographic union (12.6±4.8 vs 11.3±5.2 weeks, respectively) and identical union rates (95%). At final follow-up, patient-reported implant prominence was nearly double in patients with a retained superior plate (54% vs 29%, respectively; P=.04). No significant difference existed in mean visual analog scale score at a mean of 2.77 years postoperatively, although a significant difference existed in the Oxford Shoulder Score questionnaire, with a mean score of 41.4 in the superior group and 44.4 in the anteroinferior group (P=.008). Implant removal occurred more frequently after superior plating but was not significant. Both superior and anteroinferior clavicle plating are safe treatment methods for displaced clavicle fractures. Superior plating leads to an increased rate of patient-reported implant prominence and may prompt more requests for implant removal.

Results of anterior-inferior 2.7-mm dynamic compression plate fixation of midshaft clavicular fractures

OBJECTIVES

To evaluate the outcome of operatively treated unstable displaced diaphyseal clavicle fractures with anterior-inferior 2.7-mm dynamic compression plate (DCP) fixation.

DESIGN

Retrospective review of clavicle fractures.

SETTING

Level-1 trauma teaching center.

PATIENTS/PARTICIPANTS

One hundred twenty-nine clavicle fractures.

INTERVENTION

An anterior-inferior approach to clavicle fractures was used with the application of a 2.7-mm DCPs.

MAIN OUTCOME MEASUREMENT

Radiographic assessment of healing and complication rates.

RESULTS

One hundred twenty-five fractures healed (97%). Postoperative complications included 1 superficial wound problem, 3 deep wound problems, 5 nonunions, and 4 prominent implants requiring removal in 3.

CONCLUSIONS

Anterior-inferior placement of 2.7-mm DCPs seems safe and is associated with minimal complications.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Anteroinferior 2.7-mm versus 3.5-mm plating for AO/OTA type B clavicle fractures: a comparative cohort clinical outcomes study

OBJECTIVES

To compare the Disability of the Arm, Shoulder, and Hand (DASH) and Constant scores, time to union, rate of union, patient cosmetic satisfaction rate, and the need for secondary procedures between 2.7- and 3.5-mm anteroinferior plating for Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA) type B clavicle fractures.

DESIGN

Retrospective, comparative cohort clinical outcomes study.

SETTING

Level I university trauma center. PATIENTS/PARTICIPATION: Thirty-seven patients with an AO/OTA type B clavicle fracture who underwent open reduction internal fixation with either a 2.7- or 3.5-mm reconstruction plate placed in the anterior-inferior position. The main outcome comparisons included DASH score, Constant score, time to union, rate of union, rate of hardware failure, cosmetic satisfaction, and secondary procedure.

MAIN OUTCOME MEASUREMENT

DASH score, constant score, time to union, rate of union, cosmetic satisfaction, secondary procedure.

RESULTS

At 1-year follow-up, analysis yielded no significant differences in DASH scores (P = 0.26) and Constant Shoulder scores (P = 0.79) between the 2 cohorts. There were no statistically significant differences in the time to union (P = 0.86) and the rate of union (P = 0.49). Although the 2.7-mm cohort had a lower reoperation rate, it was not statistically significant (P = 0.11). However, the 2.7-mm cohort did demonstrate a significantly higher rate of cosmetically acceptable reconstruction (P = 0.003).

CONCLUSIONS

Compared with 3.5-mm anterior-inferior plating, 2.7-mm anteroinferior plating for AO/OTA type B clavicle fractures leads to significantly higher rates of cosmetic acceptability while reducing the need for a secondary procedure and achieving excellent clinical outcomes as measured by the DASH and Constant scores. There were no differences between the 2.7 and 3.5 cohorts in time to union or in union rate.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Minimally invasive plate osteosynthesis using anterior-inferior plating of clavicular midshaft fractures

INTRODUCTION

This study evaluated the clinical and radiological outcomes of acute displaced clavicular midshaft fractures treated with minimally invasive plate osteosynthesis (MIPO).

MATERIALS AND METHODS

Fifteen patients with acute displaced clavicular midshaft fractures underwent MIPO. A locking reconstruction plate was applied on the anterior aspect of the clavicle through two small incisions. Functional outcomes were assessed using range of shoulder motion and University of California Los Angeles (UCLA) shoulder score. Radiological evaluation included time to union, fracture healing, and clavicular length difference measured as proportional length difference with the unaffected side.

RESULTS

All fractures healed within a mean of 15.1 weeks postoperatively. The mean proportional length difference was 0.66 ± 2.2% compared with the unaffected arm. Shoulder motion recovered to pre-injury activity level in all patients. The UCLA shoulder scores showed excellent results in 13 patients and good results in two patients. Nonunion and implant failures were not found in any patients. One patient complained of temporary hypoesthesia around the lateral clavicle area.

CONCLUSIONS

MIPO using anterior-inferior plating for acute displaced clavicular midshaft fractures provided satisfactory clinical outcomes without serious complications and could be an effective alternative option to conventional operative treatments.

Anatomical reduction for treatment of displaced midshaft clavicular fractures: Knowles pinning vs. reconstruction plating

The purpose of this study was to compare Knowles pinning and fixation with cerclage wires vs reconstruction plating and fixation with extraplate wires for the treatment of displaced midshaft clavicular fractures, with anatomical reduction serving as the objective. In this retrospective study, the records of 103 consecutive patients with complete follow-up data (minimum 12 months follow-up) treated operatively for displaced midshaft clavicular fractures between 1997 and 2009 by a single surgeon were reviewed. A total of 53 patients (mean age, 35.2±14.5 years) received Knowles pinning and 50 patients (mean age, 39.9±14.8 years) received reconstruction plating. No differences were observed between the groups with respect to type of fracture, union rate (88.7% vs. 94.0%, respectively; P=.439), and surgical complication rate (13.2% vs. 10.0%, respectively; P=.761). Wound length was significantly shorter in the Knowles pinning group (5.3±0.9 cm vs. 8.4±0.5 cm, respectively; P<.001) and implant-related complications, symptomatic hardware (P<.001), visible implant (P<.001), and palpable implant (P<.015) were significantly higher in the reconstruction plating than in the pinning group. Anatomical reduction is the ultimate objective of anatomical and functional restoration when surgical intervention is indicated, and patient compliance is the major prerequisite for surgical treatment. For treatment of displaced midshaft clavicle fractures, both Knowles pinning with cerclage wires and reconstruction plating with extraplate wires provide rigid fixation and perfect union.

Superior versus anteroinferior plating of the clavicle: a finite element study

OBJECTIVES

Fixation plate positioning remains controversial in clavicle fracture reconstruction. Biomechanical studies favor a superior plate placement and clinical series report very low mechanical complications for anteroinferior plate placement. To clarify this apparent discrepancy, a biomechanical finite element analysis of the deformation mode, stress patterns, and peak stresses involved with superior and anteroinferior clavicle plate fixation was performed.

METHODS

Finite element models of the superior and anteroinferior reconstructions were built and the results were compared with those of the intact clavicle when loaded in axial compression and cantilever bending.

RESULTS

Superior plate placement was less likely to fail in axial compression but the anteroinferior plate placement was less likely to fail in cantilever bending. For all placements and loading modes, the region near the fracture gap experienced the highest stresses and was consequently critical for the behavior of the whole construct. The anteroinferior placement led to a deformation mode similar to the intact clavicle in both loading configurations, whereas the deformation mode with the superior placement was non-physiological.

CONCLUSIONS

Anterorinferior plating is generally preferable, because it induces deformation modes similar to the intact clavicle and is less likely to fail during normal physiological loading (cantilever bending). Superior placement of the reconstruction plate may be recommended for a patient with a high risk of shoulder impacts (axial compression). Design improvements in the bridging area of the plate and special attention to obtain a good fixation around the fracture could reduce plate failures and provide a stiffer construct.

Anatomic relationships after instrumentation of the midshaft clavicle with 3.5-mm reconstruction plating: an anatomic study

OBJECTIVES

To examine the anatomic relationships of the major neurovascular structures at the midshaft clavicle region as they pertain to plate osteosynthesis in the treatment of midshaft clavicle fractures.

METHODS

Fifteen fresh cadaveric specimens were dissected at the clavicle region. The shortest distances from the midshaft clavicular fracture lines to the subclavian artery and vein and brachial plexus were measured with a digital caliper with the limb in anatomic position and at 90° of abduction. The mean and range distance values were recorded. The clavicles were then instrumented with eight-hole, 3.5-mm reconstruction plates and screws (Synthes, Paoli PA) placed in superior and anteroinferior positions. The shortest distances from the screw tips to the neurovascular structures were measured at variable plate positions, fracture zones, and limb positions. The incidence of screw tip contact was reported.

RESULTS

In 20% (three of 15) of the specimens, screw tip contact with a major neurovascular structure occurred. In these three specimens, two screw tip contacts occurred with the plate in a superior position and two occurred with the plate in an anteroinferior position. In one specimen, screw tip contact occurred with both plate positions. Limb abduction to 90° consistently increased the distance of the neurovascular structures from the clavicle. There was no observable trend in screw contact frequency in respect to limb position or fracture zone.

CONCLUSION

Caution must be exercised when instrumenting midshaft clavicle fractures regardless of chosen plate position. Limb abduction to 90° provides an added measure of safety during clavicle instrumentation.

Reconstruction plate versus minimal invasive retrograde titanium elastic nail fixation for displaced midclavicular fractures

Background

Nonoperative management of midshaft clavicle fractures (MSCFs) is standard; however, it is now generally accepted that displaced midshaft clavicle fractures benefit from internal fixation. Plating and intramedullary fixation have become the accepted methods of fixation. The purpose of this study was to see if one method of fixation of clavicle fractures has a lower complication rate and higher union rate than the other.

Materials and methods

Between December 2003 and September 2008, 38 patients were treated randomly by either plating (plate group) or retrograde nailing (RTEN group). Primary outcome measures included functional Constant scores, radiological union rate and union time. Clinical and radiological assessments were performed at the 6th week and the 3rd, 6th and 12th month postoperatively. Secondary outcome measures included the perioperative data (mean surgery time, blood loss, wound size, and hospital stay), and the complication rates.

Results

Similar results were found between the two groups regarding functional and radiological outcome after the 12th week (P > 0.05). However, earlier union and functional recovery were obtained at the 6th week for the RTEN group (P < 0.05). The rate of complications was significantly higher (15.8%) in the plate group compared with the RTEN group (0%; P > 0.05). In the plate group, significantly higher values were obtained for the perioperative data (P < 0.001).

Conclusion

Both techniques are equally effective at treating displaced midclavicular fractures, and give better function and fewer complications than nonoperative treatment. The RTEN technique has more advantages and lower complications than plating, making its use more favorable. It is recommended for athletes and young active individuals, and can be used as an alternative to conservative treatment or plate fixation.

[Locking, multidimensional plate osteosynthesis of midshaft clavicle fracture]

BACKGROUND

The goal of this consecutive, retrospective clinical follow-up study was to analyse the quality of treatment with a multidimensional, anatomical locking plate osteosynthesis after comminuted clavicle shaft fracture (Robinson 2B).

PATIENTS AND METHODS

Of 38 operated patients, 35 were examined after locking plate osteosynthesis, with a median follow-up of 32 months (11-65). Four patients had suffered a 2B1 Robinson fracture and 31 patients a 2B2 Robinson fracture. The clinical and functional results were determined based on the standard clinical examination of the shoulder, the Constant and DASH scores, an analogue visual scale and a patient survey.

RESULTS

The clinical examination yielded a mean DASH score of 1.25, a mean Constant score of 98 and a mean VAS score on the visual analogue scale of 0.4 (with a range of 0-6). Neither nonunion nor implant failure was observed. We did, however, have one case of infection of the soft tissue.

CONCLUSION

The treatment of comminuted shaft fractures of the clavicle by means of a multidimensional locking plate is a safe treatment option that includes early functional postoperative care with free range of motion.

The comminuted midshaft clavicle fracture: a biomechanical evaluation of plating methods

BACKGROUND

The optimal plate location and fixation method for midshaft fractures of the clavicle remains undetermined. The objective of this study was to develop a realistic biomechanical model with which to compare superior with inferior-medial plate placement, and the failure resistance of locked and against non-locked constructs.

METHODS

We estimated implant loads for operated patients in early rehabilitation utilising 3-D mathematical model of the shoulder. During simulation of upper limb motion associated with eating, the fracture opened in an inferior and frontal direction. The peak X, Y, and Z loads from the simulation were reproduced using a materials testing machine. A one centimetre transverse osteectomy was created at the midshaft of forty composite clavicles. Each specimen was then fixed with either (1) non-locked superior plating (n=10), (2) locked superior plating (n=10), (3) non-locked inferior-medial plating (n=10), or (4) locked inferior-medial plating (n=10). Specimens were loaded at 20 N/s in four-point bending for 50 cycles to the peak X, Y, Z moment obtained from the computational model (-3.50, 2.46, and -1.00 N m), then loaded to failure at 20 N/s.

FINDINGS

Inferior-medial unlocked plates were significantly stiffer than superior locked plates (P=0.046).

INTERPRETATION

Operative fixation of midshaft clavicle fractures is controversial, though becoming more widely accepted. Few biomechanical data are available to assist surgical decision-making. Inferior plates may be better equipped to resist the in vivo loads experienced by the clavicle during early rehabilitation after internal fixation, particularly during the shoulder flexion motions associated with eating.

Superior versus anteroinferior plating of the clavicle revisited: a mechanical study

OBJECTIVES

This study was designed to compare bone-implant stiffness of two fixation techniques on a sawbone model of a clavicle fracture.

METHODS

Twenty-four preosteotomized synthetic left clavicles (Sawbones Worldwide, Vashon, WA) were divided into four groups based on type of fixation: standard 3.5-mm pelvic reconstruction plate in the superior position; standard 3.5-mm pelvic reconstruction plate in an anteroinferior position; 3.5-mm locking pelvic reconstruction plate in a superior position; and a 3.5-mm locking pelvic reconstruction plate in an anteroinferior position. Three nondestructive cyclic mechanical tests were performed in random order: axial, torsion, and four-point bend.

RESULTS

No significant difference was found in axial (P = 0.61) or torsional stiffness (internal rotation, P = 0.46 or external rotation, P = 0.49) among all groups. No significant difference occurred in bending rigidity (four-point bending test) with type of plate (P = 0.41), but when the plate was placed anteroinferiorly, bending rigidity was significantly higher (P < 0.001) than in the superior position.

CONCLUSION

Placing the plate anteroinferiorly on the clavicle provides a more stable construct in terms of bending rigidity with no detriment in axial and torsional stiffness compared with placing the plate superiorly. We believe that anteroinferior plating is preferred as a result of the increase in bending rigidity together with other advantages, including avoidance of neurovascular compromise, the use of longer screws, and decreased hardware prominence.

Malunion after midshaft clavicle fractures in adults

This is an overview of the current literature on malunion after midshaft clavicle fracture. Anatomy, trauma mechanism, classification, incidence, symptoms, prevention, and treatment options are all discussed. The conclusion is that clavicle malunion is a distinct clinical entity that can be treated successfully.

Treatment of midshaft clavicular delayed and non-unions with anteroinferior locking compression plating

INTRODUCTION

Pain and impaired shoulder function are the predominant symptoms of midshaft clavicle non-unions. Obtaining consolidation and improvement of shoulder function is often successfully achieved with osteosynthesis and bone grafting. Most data in the literature pertain to plate osteosynthesis, placing the plate on the subcutaneous superior aspect of the clavicle. Although union rates are generally high, most patients require hardware removal as the plate is prominent under the skin causing pain and cosmetic problems.

MATERIALS AND METHODS

In the current retrospective study, we followed a cohort of 21 consecutive cases (20 patients) with a midshaft clavicular delayed or non-union, treated with anteroinferior plating using a 3.5 mm locking compression plate (LCP) for a mean of 30 months.

RESULTS

We operated on 10 males and 10 females with a mean age of 48.2 years (range 16-65). There was one early plate failure that needed revision. Two patients required hardware removal because of prominence of the plate. All but two patients were satisfied with the final cosmetic result. The average DASH score at follow up was 22.8.

DISCUSSION AND CONCLUSIONS

Anteroinferior plating with a 3.5 mm LCP is a reliable and reproducible treatment of midshaft clavicular delayed and non-union regarding consolidation, function, cosmesis and reduction of second surgery.

Neurovascular risks of anteroinferior clavicular plating

Anteroinferior plating has been described for internal fixation of clavicular fractures, citing improved bicortical fixation, less hardware prominence, and safer drill trajectories compared with other plate configurations. This anatomic study defined structures at risk during anteroinferior clavicular plating. Four paired cadaveric specimens (8 clavicles) from ages 75 to 93 years were systematically dissected. Using the screw paths associated with an anteroinferior plate (anteroinferior to superoposterior), the distance from the posterior clavicle cortex to the nearest vital structure was measured at 5 different positions along the clavicle. In the medial half of the clavicle, the subclavian artery is in closest proximity to the clavicle, measuring, on average, 22.95 mm and 15.10 mm at point A and B. At the lateral three-fifths point of the clavicle (point C), the brachial plexus is 12.76 mm from the posterior clavicle and is more at risk than the subclavian artery. Lateral to the three-fifth point of the clavicle, there were no vital structures that could be injured by overdrilling. Our results suggest that more care should be observed with placement of screws in the medial half of the clavicle where subclavian artery damage is more likely.

Anterior-inferior plating of middle-third fractures of the clavicle

INTRODUCTION

Various techniques have been reported for the treatment of middle-third clavicle (collar bone) fractures. This prospective study was conducted to evaluate the results of anterior-inferior plating using a 3.5-mm reconstruction plate for the treatment of middle-third clavicle fractures.

PATIENTS AND METHODS

Twenty-six patients with middle-third clavicle fractures were treated with anterior-inferior plating. The indications for surgery included complete displacement, severe comminution, and marked shortening of the clavicle (>2 cm).

RESULTS

The mean time to union was 14 weeks (range 8-20 weeks). At the time of latest follow-up, all of the patients had returned to their pre-injury activity level. The plates were removed in ten patients after the fractures healed. No patients required plate removal due to implant-related problems.

CONCLUSION

Anterior-inferior plating is an effective treatment modality for middle-third clavicle fractures, with few complications and early return of shoulder function. The procedure provides stable fixation, avoids risk to vital structures below the clavicle, and is associated with a low rate of implant-prominence problems.

Anteroinferior plating of midshaft clavicle nonunions and fractures

OBJECTIVE

Anatomic reconstruction of clavicle with limited dissection and biomechanically optimal osteosynthesis. Anteroinferior plate placement to minimize patient's discomfort and need for implant removal.

INDICATIONS

Midshaft clavicle nonunions. Midshaft clavicle fractures. Clavicle malunions for which osteotomy is needed.

CONTRAINDICATIONS

Infection. Compromised skin. Comorbidities causing unacceptable operative risks.

SURGICAL TECHNIQUE

Expose anteroinferior aspect of the clavicle. Remove previous implants with minimal dissection. In atrophic nonunions, remove intervening tissue. Obtain cultures. Open medullary canal using drill. Contour standard or Locking Compression (LCP) 3.5-mm pelvic reconstruction plate (Synthes, Paoli, PA, USA) on anteroinferior aspect of clavicle. Use osteotome to petal/shingle the nonunion and add bone graft. In hypertrophic nonunions, bone graft is generally not needed but excess callus should be removed to prevent impingement on neurovascular structures.

POSTOPERATIVE MANAGEMENT

Mitella for 10 days to protect wound healing. Start with early pendulum exercises. No active abduction or anteflexion of > 90 degrees or heavy lifting in first 6 weeks.

RESULTS

From December 1993 to February 2007, 52 patients (53 clavicles) were treated with anteroinferior plating of clavicle. There were 38 atrophic nonunions or delayed unions, three hypertrophic nonunions, three infected nonunions, six acute fractures, and one malunion. For two patients initial radiographs could not be located. Average age was 45 years. One patient was lost to follow-up prior to healing. The others were followed up after an average of 35 months. All had consolidation at an average of 3 months (range 2-7 months). Two patients underwent removal of a lag screw that was placed from superior to inferior, whereas three patients underwent plate removal.

Vertical fragment in adult midshaft clavicle fractures: an indicator for surgical intervention

This article describes a retrospective cohort study that investigated whether adult midshaft clavicle fractures possessing the radiological sign of a butterfly vertical fragment demonstrate a higher rate of early and delayed surgical intervention when compared to adult midshaft clavicle fractures with no vertical fragment sign. The radiographs of 134 adult midshaft clavicle fractures were divided into 2 cohorts: those with a vertical fragment radiological sign and those without. Within each cohort, the number of cases that underwent early surgical intervention and that underwent delayed surgical intervention was noted. The vertical fragment group displayed a rate for early surgical intervention, all for skin tenting, of 8.5%, whereas the no vertical fragment group's rate was 1.1%; this proved to be significantly different (P=.0464). Furthermore, the vertical fragment group displayed a rate for delayed surgical intervention for symptomatic nonunion of 12.8%, whereas the no vertical fragment group's rate was 5.7%. Despite being twice as likely for the vertical fragment group to have undergone delayed surgical intervention, this did not prove to be statistically significant (P=.0965). This study revealed that midshaft fractures with the radiological sign of an interfragmentary vertical fragment are significantly more likely to require early surgical intervention due to skin tenting. Furthermore, these fractures are twice as likely to go into symptomatic nonunion, and in this area we may be able to improve current management by considering early surgical intervention.

Reconstruction plates for stabilization of mid-shaft clavicle fractures: differences between nonlocked and locked plates in two different positions

Reconstruction plates permit contouring to the irregular anatomic shape of the clavicle. This study evaluated the biomechanical stability of locking and nonlocking clavicle reconstruction plates for treating midshaft, transverse fractures, comparing anterior-inferior to superior plate position. Twenty-four synthetic clavicles with mid-shaft fractures were repaired with either a locking or nonlocking clavicle reconstruction plate in either the anterior-inferior or superior plate position (n = 6/group). Repaired constructs were tested in axial compression, axial torsion, and cantilever bending failure. In compression, anterior-inferior plates were significantly stiffer than superior plates and locked plates stiffer than nonlocked. In torsion, anterior-inferior plates were stiffer, with a significant interaction term that favored anterior-inferior locked and superior nonlocked plates. In cantilever bending, superior plates had a significantly higher bending failure load and stiffness. Anterior-inferior plates failed at a significantly lower load ( approximately 40 N or approximately 4 kg), which could potentially occur in the postoperative period.