Modification of the Ilizarov external fixator for aseptic hypertrophic nonunion of the clavicle: an option for treatment

Intercalary Tricortical Iliac Crest Graft for Treatment of Midclavicle Nonunion With Bone Loss: Two Case Reports and Review of Literature

Several articles support the use of cancellous iliac crest bone grafting in the treatment of clavicle nonunion; however, there is very little literature on the use of tricortical iliac crest grafts in the setting of clavicle nonunion with bone loss. When it has been studied, tricortical grafting has been shown to produce radiologically confirmed union in the clavicle, leaving patients satisfied with the ultimate outcome. We present two cases of clavicle fracture nonunion successfully treated with tricortical interposition bone grafting. In the first case, a 45-year-old female presented with an atrophic left midshaft clavicle fracture nonunion with failed hardware that had undergone two previous attempts at fixation without achieving union. She was treated with a structural interposition iliac crest bone graft with plate fixation and regained full painless function of the arm with radiographic fracture union. In the second case, a 50-year-old male presented after a left midshaft clavicle fracture that had undergone acute stabilization, followed by revision for nonunion that was unsuccessful, resulting in persistent nonunion with bone loss. He was treated with a tricortical iliac crest bone graft and plate fixation. Cultures from the time of surgery did grow Staphylococcus epidermidis and Propionibacterium acnes, and he was treated with intravenous vancomycin for six weeks. The patient's clavicle went on to union and he regained full, painless function by his six-month follow-up visit. These cases demonstrate the use of tricortical interposition bone grafting with compression plating as a viable option for rare instances in which previous surgical intervention has failed to progress a midshaft clavicle fracture to union.

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.

The treatment of the atrophic clavicular nonunion by double-plate fixation with autogenous cancellous bone graft: a prospective study

Background

The objective of this study is to assess prospectively the effectiveness of double-plate fixation combined with autogenous cancellous bone graft in the treatment for the atrophic clavicular nonunion.

Methods

Between February 2013 and November 2017, a total of 12 patients with atrophic clavicular nonunion (mean age, 40.4 ± 9.0 years, range, 27–60 years) were treated by double-plate fixation with autogenous cancellous bone graft in our institute. The Constant Score System was used to evaluate the preoperative and final outcomes. The Short Form-36 (SF-36) outcome questionnaire was used to assess the final clinical results.

Results

All patients were followed-up, with the average follow-up of 34.7 ± 6.7 months (range, 24–48 months). The healing rate was 100% in our study. The mean time of bony union was 9 weeks (range, 8–10 weeks). One patient had a postoperative superficial infection, and the patient was cured by oral antibiotics and wound dressing. No implant-related complications (plate-screw loosening or breakage) were observed postoperatively. No vascular injury, neural impairment, or thoracic outlet syndrome was discovered preoperatively or postoperatively. There is a statistical significance between the preoperative and the postoperative constant scores (P < 0.05). All the patients were satisfied with their final clinical results by SF-36 outcome questionnaire. Average scores of the physical function and bodily pain components of the SF-36 were 94.2 ± 7.3 and 92.5 ± 5.8, respectively.

Conclusion

Our results presented that double-plate fixation with autogenous cancellous bone graft is an effective treatment for atrophic clavicular nonunion, especially for those with a significant bone defect.

Treatment of diaphyseal clavicular nonunion with special emphasis on microsurgery

Diaphyseal fractures of the clavicle had until recently the reputation to always heal with abundant callus formation, except if operated, due to a reported high rate of nonunion after plate fixation by older series. The reason would be that the bone has only periosteal vascularization, easily destroyed by periosteal stripping for implant apposition. Bone autograft and external fixation has been reported as the best technique to heal a nonunited clavicle nonunion. Are these classical considerations still valid nowadays? The purposes of this article focusing only on diaphyseal clavicular fractures are to review the vascularization of the bone, the rate of nonunion after nonoperative treatment, the indications and techniques of osteosynthesis, and the treatment possibilities of an established nonunion. This article will not deal with the specific problems of the lateral clavicular fractures, which are equivalent to acromio-clavicular fracture-dislocations, nor of medial fractures, close to the sterno-clavicular joint.

Complications in leg lengthening using an Ilizarov external fixator and intramedullary alignment in children: comparative study during a fourteen-year period

BACKGROUND

The purpose of this retrospective study was to evaluate the complications associated with leg lengthening in children treated with the Ilizarov external fixator (IEF) and compare them between two groups of patients: one group was treated using an IEF alone and the other group was treated using an IEF in association with intramedullary alignment (IA).

PATIENTS AND METHODS

The study was performed at the University Children's Hospital in Belgrade, Serbia during a fourteen-year period (from 2000 to 2014). Complications occurred in 73 paediatric patients who underwent the leg lengthening procedure. Complications were classified according to the Caton classification and compared between two groups. Group I comprised 39 patients who underwent the limb lengthening procedure using IEF alone. Group II consisted of 34 patients who were treated with the combination of IEF and IA using two Kirschner wires (K-wires) or Titanium Elastic Nails (TEN). The duration of hospital treatment was also compared between the two groups and the impact of the type of IA on the occurrence of complications was assessed.

RESULTS

There was a high rate of complications in patients treated using an IEF compared with those treated using the combination of IEF and IA, but there was no statistically significant difference between the two groups. There was a statistically significant difference in the duration of initial hospitalisation between the two groups, particularly when comparing TEN usage in IA. A comparison of the group of patients treated using an IEF in association with K-wires and patients treated using IEF and TEN showed there was no statistically significant difference in complication rate and duration of initial hospitalisation.

CONCLUSION

IA has multiple advantages as a method of treatment of leg length inequality. The major effect of applying IA in association with a circular IEF is significantly reduced complication rate and duration of initial hospitalisation, particularly when using TEN as a method of IA. This method of treatment also decreases hospital costs.

Use of the clavicular part of the pectoralis major in treatment of failed revision osteosynthesis of the clavicle

BACKGROUND

Symptomatic atrophic nonunion after multiple clavicle osteosynthesis can be difficult to treat. The aim of this study was to evaluate the results of a transfer of the clavicular part of the pectoralis major muscle as augmentation of osteosynthesis of these nonunions.

MATERIALS AND METHODS

A retrospective study included all patients who were treated between 2001 and 2010 (minimum 2-year follow-up). The indications for primary surgery, the number of operations, and the indication for a pectoralis major transfer were evaluated. Time of radiologic consolidation and postoperative complications were assessed. Clinical evaluation was performed with preoperative and postoperative satisfaction ratings and Constant-Murley scores.

RESULTS

The study included 11 patients. The indications for a primary osteosynthesis were acute displaced fractures (7), delayed union (2), nonunion (1), and malunion (1). On average, 3.7 procedures were performed (range, 2-6) before the tendon transfer. At revision, there were 2 patients with infection and 9 without infection. Of the 11 clavicles, 10 showed radiologic consolidation after a mean time of 10 weeks (6-20 weeks). The mean follow-up was 62 months (24-132 months). The mean Constant-Murley score increased from 37 (24-55) preoperatively to 59 (43-98), and the satisfaction rating increased from 2 (1-3) to 7 (2-10). Complications included nonunion (1), hardware removal (2), hardware irritation (4), and donor site pain (1).

CONCLUSION

The use of the clavicular part of the pectoralis major transfer as an augmentation in revision for symptomatic atrophic nonunion after multiple clavicle osteosynthesis showed good radiologic and acceptable clinical results.

Management of clavicle nonunion and malunion

BACKGROUND

Clavicle fractures are common injuries of the shoulder girdle and occasionally result in nonunion or symptomatic malunion. When present, these chronic injuries can result in considerable shoulder dysfunction. A number of surgical techniques have been described for the management of these injuries. Current literature suggests that supplemental bone grafting may not be necessary in all cases but should be considered in the setting of atrophic nonunion. However, optimal treatment is controversial, as discussed in the literature. This article highlights the current treatment options based on the existing literature and describes our preferred techniques.

METHODS

We carried out a comprehensive review of the PubMed and Medline databases using multiple keywords (eg, clavicle fracture, clavicle nonunion, and clavicle malunion) to identify the relevant literature regarding this topic. Reference lists of the relevant articles were reviewed for additional important articles.

CONCLUSION

Nonunion and malunion of the clavicle remain challenging problems. Reliable bony union and improved shoulder function can be expected with thoughtful surgical planning, appropriate implant choice, and meticulous surgical technique.

Biomechanical comparison of fixation techniques in midshaft clavicular fractures

OBJECTIVES

The purpose of this study is to evaluate the biomechanical properties and the stability among a locking clavicle plate (LCP), a dynamic compression plate (DCP) and an external fixator (Ex-fix) in an unstable displaced clavicle fracture model under torsional and three-point bending loading.

MATERIALS AND METHODS

Forty-eight human adult formalin-fixed clavicles were paired according to their bone mineral density homogeneously into three groups: LCP, DCP, and Ex-fix. Each specimen was osteotomized at the midshaft. Torsional and three-point bending forces were performed for 1000 cycles with stiffness recorded at 10 cycles (initial) and then at 100-cycle intervals thereafter. Initial stiffness, failure loads, and the percentage of initial stiffness at the various intervals were compared using analysis of variance.

RESULTS

The mean initial stiffness values (Nmm/deg) for torsion were 703.2 (LCP), 448.1 (DCP), and 365.2 (Ex-fix). The mean failure moments (Nmm) for torsion were 7671.7 (LCP), 4370.3 (DCP), and 2999.7 (Ex-fix). The mean initial stiffness (Nmm) for bending were 32.6 (LCP), 23.4 (DCP), and 20.6 (Ex-fix). The mean failure loads (N) for bending were 213.2 (LCP), 131.1 (DCP), and 102.7 (Ex-fix). For both torsion and bending, an overall significant difference among the three constructs in terms of failure loads and also a significant difference between the locking plate and the other two models only in terms of initial stiffness was seen. For torsion and bending, at all cyclic intervals, there was a significant difference between the locking plate and the other two models. After 700 cycles, a significant difference was also detected between the DCP and Ex-fix in torsion, but no difference was found between these groups at any cyclic interval in bending.

CONCLUSIONS

The locking plate is significantly more stable than DCP and Ex-fix under torsional and bending cyclic loading in a displaced fracture clavicle model.

Bilateral clavicle fracture external fixation

Fractures of the middle third of the clavicle are frequent and their conservative treatment ends in bone union in nearly 95% of cases. Surgical treatment is unanimously indicated with open fractures or in cases of cutaneous damage, neurovascular complications, and impaction of the shoulder stump syndromes. We report herein a case of bilateral fractures of the clavicle that required double stabilization with an external fixator following major cutaneous damage appearing after the initial conservative management. The intraoperative discovery of Propionibacterium acnes infection and bone union obtained within the classical time frame, with a satisfactory functional result, all retrospectively proved the soundness of this indication.

Intraoperative distraction in the upper extremity

Intraoperative distraction aids in the restoration of length, facilitates reduction, assists in maintaining rotational alignment, and provides a temporary stable platform for definitive fixation of acute fractures, malunions, and nonunions. This technique has been described at length in the lower extremity; however, there is a paucity of literature regarding its use in the upper extremity. Distraction is the application of tension across a fracture site. Proximal and distal fixation may be achieved in several ways, with common instrumentation including the use of an external fixator set. Intraoperative distraction may be invaluable in the treatment of displaced fractures of the upper extremity. The objective of this paper was to detail the technique of intraoperative distraction in the surgical treatment of fractures of the clavicle, humerus, radius, and ulna.

Nonunion of the clavicle treated with plate fixation: a review of forty-seven consecutive cases

Forty-seven consecutive patients underwent superior plating for clavicular nonunion between 1995 and 2005. This retrospective analysis was performed to assess the efficacy of plate fixation and the need for iliac crest bone grafting. Forty-three patients were treated with pelvic reconstruction plates and four with straight dynamic compression plates. Of the patients, 30 were treated with local bone graft only, 14 with demineralized bone matrix, and 3 with distant autogenous bone graft. Of the fractures, 93% united after a single operation. Of the patients, 69% returned the Disabilities of the Arm, Shoulder and Hand questionnaire. The mean Disabilities of the Arm, Shoulder and Hand score was 14.6 (range, 0-53). Plate prominence or sensitivity resulted in removal in 20% of cases. We believe that superiorly applied plate fixation is effective for the treatment of clavicular nonunion. Distant autogenous bone graft is not necessary in most cases to obtain union.