Precontoured Locking Compression Plate with Titanium Alloy Cable System: In Treatment of Neer Type IIb Distal Clavicle Fracture

A new classification system for distal clavicle fractures: based on fracture location and ligament integrity

INTRODUCTION

Although various classification systems have been introduced for the description of distal clavicle fractures, there is no consensus on the best classification system that is helpful in determining treatment and prognosis. The objective of this study was to establish a new classification system for distal clavicle fractures and to verify the reliability of the new classification system by evaluating the inter- and intraobserver agreement.

MATERIALS AND METHODS

A total of 1075 consecutive patients with distal clavicle fractures were selected from five university-affiliated hospitals between 2012 and 2022. The distal fragment size (DFS), the coracoclavicular distance (CCD) and the acromioclavicular distance (ACD) were measured on anteroposterior radiographs of each acromioclavicular joint. Twenty independent investigators evaluated 1075 radiographs of distal clavicle fractures, completing the fracture typing according to the new classification system and selecting a treatment choice for each case. This procedure was repeated 3 months later. Fleiss κ values were calculated to estimate the inter- and intraobserver agreement.

RESULTS

The new classification categorizes distal clavicle fractures into three types based on the relationship between fracture location and ligament footprints. Type I fractures occur distal to the coracoclavicular (CC) ligaments with or without ligament injury. Type II fractures occur CC ligament attachment regions with ligament injury Type III fractures occur proximal to the CC ligaments without ligament injury. Several subtypes (types IA, IB, IC, ID, IIA, IIB, IIC, IID, and IIE) were further introduced according to fracture displacement and ligament integrity. The inter- and intraobserver reliability of our new classification system was substantial (κ = 0.622 vs. 0.678). Inter- and intraobserver reliability for treatment choice was perfect (κ = 0.846 vs. 0.882).

CONCLUSIONS

The new classification system which takes into account fracture location and ligament integrity brought few disputes in category division and treatment selection.

Canceling Notch Improves the Mechanical Safety of Clavicle Locking Plate: A 3D Finite Element Study

OBJECTIVE

Implant failure is a disastrous complication of the operative treatment of midshaft clavicle fractures, and improving the osteosynthesis plate is a strategy for preventing this. We aimed to investigate whether canceling the notch and adding screw-hole inserts enhanced the mechanical properties of the plate.

METHODS

A clavicle model was generated based on the CT images of six adult volunteers (age range, 20-40 years; three males and three females; height range 160-175) using dedicated software, and a midshaft fracture model was created. The domestically made seven-hole locking plate commonly used for midshaft clavicle fractures was simulated (Model I); modifications were made to the plate (Model II). Using 3D finite element analysis, we simulated the fracture construct under three different load conditions-downward cantilever bending, axial compression, and axial torsion-and compared the stress distribution.

RESULTS

We found that under axial compression, Model II experienced its maximum stress on the plate at 551.9MPa, which was less than that in Model I (790.4 MPa). Moreover, a greater stress concentration at the fracture site was observed under axial torsion, despite the maximum stress of both the models being similar.

CONCLUSION

Canceling the notch and filling the screw holes near the fracture can ameliorate stress concentration on the internal fixation construct and enhance its reliability under axial compression. This improvement has substantial effects on the mechanical properties of implants and potentially prevents implant failure. Modern osteosynthesis anatomical implants need to be improved.

A Novel and Open Classification Emphasizing on Osteoligamentous Complex for Distal Clavicle Fractures

OBJECTIVE

Current X-ray-based classification methods cannot describe all distal clavicle fracture (DCF) patterns, especially the osteoligamentous injury pattern of DCFs. We aimed to develop a novel classification based on the osteoligamentous injury pattern of the DCFs and investigated its reliability.

METHODS

All DCFs from January 2017 to January 2022 were respectively screened and 45 cases (mean age 20-78; male 31, female 14) met the including criteria and were enrolled. Based on their Zanca view X-ray radiograph and three-dimensional CT construction images, we analyzed the osteoligamentous injury pattern of each case, particularly the acromioclavicular (AC) and coracoclavicular ligaments and their bone attachment. Then we developed a novel classification method, five types in total, sorting all DCFs according to their lesion manifestations of osteoligamentous complex. Also, we investigated the inter- and intra-observer reliability using kappa value.

RESULTS

A novel classification method for DCF was developed, manifesting the avulsion or rupture of conoid and trapezoid ligaments, and involvement of AC joint. Forty-five cases of DCFs were included in this study. Among them, 11 (24.4%) were Type 1 fracture, three (6.7%) cases were Type 2, six cases (13.3%) were Type 3, 21 (46.7%) were Type 4, four (8.9%) were Type 5. Kappa values for inter-observer agreement were 0.57 after first evaluation and 0.61 after second evaluation. Intra-observer agreement was 0.72 for experienced shoulder specialist and 0.63 for radiologist.

CONCLUSION

This new classification method is reliable to use, supplementary to current classification systems, and emphasizes on the osteoligamentous complex injury when opting for the treatment.

Outcomes, Union Rate, and Complications After Operative and Nonoperative Treatments of Neer Type II Distal Clavicle Fractures: A Systematic Review and Meta-analysis of 2284 Patients

BACKGROUND

As nonoperative treatment of Neer type II distal clavicle fractures is associated with nonunion rates up to 33%, operative treatment is frequently advocated. However, evidence is lacking regarding which operative treatment to perform and whether this is superior to nonoperative treatment in terms of functional outcome and complication rate.

PURPOSE

(1) To evaluate which surgical technique in the treatment of Neer type II distal clavicle fractures is optimal with regard to patient-reported outcomes and union and complication rates. (2) To review nonoperatively treated patients.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the literature and meta-analysis were performed on January 27, 2021, in PubMed, Embase, CENTRAL, CINAHL/EBSCO, Web of Science/Clarivate Analytics, and SPORTDiscus/EBSCO. The search included all studies regarding nonoperative and operative treatment of Neer type II distal clavicle fractures with a minimum of 20 patients and follow-up of 12 months. The primary and secondary outcomes were patient-reported outcome measures at 12 months and union, complication, and revision rates.

RESULTS

A total of 59 articles were included involving 2284 patients. Coracoclavicular fixation, hook plate, transacromial pins, alternative plate, tension band wire/K-wire, a combination of surgical techniques, and a nonoperative group were described. Hook plates showed lower Constant-Murley scores as compared with coracoclavicular fixation (standard mean difference, -0.77; 95% CI, -1.26 to -0.28; P = .002). However, no significant difference was seen when the hook plate was compared with the locking plate and tension band wire/K-wire groups, and no significant difference in union rate was seen among all operative treatment groups. Operatively treated patients had significantly higher union rates than patients treated nonoperatively (standard mean difference: 0.05; 95% CI, 0.01 to 0.37; P = .004).

CONCLUSION

Patients treated with hook plates showed significantly lower Constant-Murley scores and higher complication and revision rates as compared with those treated with coracoclavicular fixation, without differences in union rate. Higher Constant-Murley scores were seen in those patients with supplemental coracoclavicular fixation when using locking. Nonoperatively treated patients showed good functional outcome despite the 31% nonunion rate, although future studies are necessary to substantiate this conclusion. When using a locking plate, additional craniocaudal fixation showed significant better functional outcome.

What is the optimal surgical treatment for Neer type IIB (IIC) distal clavicle fractures? A systematic review and meta-analysis

Background

The purpose of the present study was to systematically review the current treatment strategies for the treatment of Neer type IIB distal clavicle fractures in terms of functional outcome and complication rates and to examine the most appropriate surgical method by comparing all the available surgical techniques and implants.

Methods

We performed a systematic review of the existing literature (2000–2021) in accordance with the PRISMA statement. We searched PubMed, Scopus, Web of Science, Research Gate and Google Scholar using the general terms ‘distal AND clavicle AND fracture’ to capture as many reports as possible. The MINORS tool was used to assess the risk of bias of the nonrandomized studies. We categorized the reported surgical techniques into four main types: open or arthroscopic coracoclavicular (CC) stabilization, locking plate fixation with or without CC augmentation, hook plate fixation and acromioclavicular joint (ACJ) transfixation. We reported findings for two main outcomes: clinical results and complication rates categorized into major and minor.

Results

Our database search yielded a total of 630 records; 34 studies were appropriate for qualitative analysis. There were 790 patients, with a mean age of 40.1 years, a female percentage of 37% and a mean follow-up period of 29.3 months. In total, 132 patients received a hook plate, 252 received a locking plate, 368 received CC stabilization and 41 received transacromial transfixation. All studies were retrospective and had fair MINORS scores. Locking plate, CC stabilization and ACJ transfixation showed similar clinical results but were much better than hook plate fixation; CC augmentation did not significantly improve the outcome of locking plate fixation. The rate of major complications was similar among groups; hook plate and AC joint transfixation had the worst rates of minor complications. Open CC techniques were slightly better than arthroscopic techniques.

Conclusions

The present systematic review for the optimal fixation method for Neer type IIB fractures of the distal clavicle showed similar major complication rates among techniques; the hook plate technique demonstrated inferior clinical results to other techniques. Open CC stabilization and locking plate fixation without CC augmentation seem to be the best available treatment options.

Using a modified J-shaped Y-knot all-suture anchor to pass a suture under the coracoid process in coracoclavicular stabilization

Introduction

The distal clavicle fracture is a common shoulder injury. There are several treatment methods which can achieve good outcomes, of which coracoclavicular (CC) stabilization is one of the most popular surgical options. In CC stabilization, the step of passing a suture under the coracoid base is the most difficult step because the standard surgical tool is not designed for passing a suture under the coracoid process. To solve this problem, there are commercial tools for use in this step but all of them are expensive, and thus of limited availability in developing or low-resource settings. We propose a modified J-shaped Y-knot all-suture anchor for use in passing a suture under the coracoid process.

Case presentation

A 45-year-old Thai male who had a left distal clavicle fracture was scheduled for CC stabilization. We modified a sterile Y-knot all-suture anchor to loop underneath the coracoid base which was easy to use and can design individually.

Discussion

In CC stabilization, there are many specialized commercial tools specially designed to easily pass the suture under the coracoid base but they are very expensive. The surgeon can use this technique to modify J-shaped Y-knot all-suture anchor for use in CC stabilization, recycling a Y-knot all-suture anchor normally discarded after use.

Conclusion

A modified J-shaped Y-knot all-suture anchor can use in passing a suture under the coracoid process.

•

The step of passing a suture under the coracoid base is the most difficult step.

•

A Y-knot suture anchor is easy to modify for use in passing a suture under the coracoid process.

•

A modified J-shaped Y-knot suture anchor can re-sterile to use in cases of coracoclavicular stabilization.

•

A modified J-shaped Y-knot suture can adjust according to the shape of the individual coracoid process in each patient.

[Effectiveness analysis of Endobutton plate combined with high-strength suture Nice knot fixation in the treatment of distal clavicle fractures]

OBJECTIVE

To investigate the effectiveness of Endobutton plate coracoclavicular fixation combined with fracture site high-strength suture Nice knot cerclage fixation in the treatment of distal clavicle fracture with coracoclavicular ligament injury.

METHODS

The clinical data of 33 cases of distal clavicular fracture with coracoclavicular ligament injury treated by Endobutton coracoclavicular plate fixation between January 2017 and December 2020 were analyzed retrospectively. According to the fixation methods of fracture site, they were divided into two groups: the high-strength suture Nice knot fixation group (study group, 16 cases) and the transacromial Kirschner wire fixation group (control group, 17 cases). There was no significant difference between the two groups in common data such as age, gender, injury side, cause of injury, Craig type, combined injury, time from injury to operation, and preoperative visual analogue scale (VAS) score and Constant-Murley score ( P>0.05). Postoperative fracture healing and complications were observed, and the increase rate of coracoclavicular space on the affected side was calculated at last follow-up. VAS score was used to evaluate shoulder pain before operation, at 1 week, 1 month, 3 months after operation, and at last follow-up. The shoulder function was evaluated according to Constant-Murley shoulder score before operation, at 1 month, 3 months after operation, and at last follow-up.

RESULTS

The operations were successfully completed in both groups without severe complications such as vascular nerve injury and coracoid fracture. In the control group, 1 case (5.9%) had slight pin tract infection and 1 case (5.9%) had Kirschner wire displacement; there was no obvious complication in the study group. The patients in both groups were followed up 9-36 months (mean, 22.9 months). The fracture healing time of the study group and the control group were (12.56±0.73) weeks and (13.59±0.87) weeks, respectively, and the difference was significant ( t=-3.661, P=0.001). At last follow-up, the increase rates of coracoclavicular space on the affected side of the study group and the control group were 8.88%±1.19% and 8.55%±1.07%, respectively, showing no significant difference ( t=0.837, P=0.409). The postoperative VAS score and Constant-Murley score of the two groups significantly improved when compared with those before operation, and the two scores gradually improved with the extension of time after operation ( P<0.05). Except that the VAS score at 1 week and 1 month after operation and the Constant-Murley score at 1 month after operation in the study group were significantly better than those in the control group ( P<0.05), there was no significant difference between the two groups at other time points after operation ( P>0.05).

CONCLUSION

For oblique fracture or combined with butterfly fracture in the distal clavicle fracture with coracoclavicular ligament injury, the fracture site high-strength suture Nice knot fixation is a good supplement to the Endobutton plate coracoclavicular fixation. It can stabilize the fracture end, reduce the complications of Kirschner wire fixation, and is more conducive to fracture healing. The effectiveness is satisfactory.