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Langenhan R, Probst A, Bushuven S, Bushuven S, Trifunovic-Koenig M. Postoperative recreational sports and subjective shoulder function: a comprehensive analysis following intramedullary stabilization of displaced midshaft clavicular fractures. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05319-0. [PMID: 38703216 DOI: 10.1007/s00402-024-05319-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 04/05/2024] [Indexed: 05/06/2024]
Abstract
Introduction Sports-related outcomes and the role of recreational sports activities for shoulder function after intramedullary stabilization (IMS) of displaced midshaft clavicular fractures (DMCFs) in the general population are not well known. In this study, we aimed to determine the sport-related outcomes (return-to-sports [RTS] rate, type of sports, time until RTS, and intensity) and to explore the role of sports after IMS of DMCFs. Materials and Methods This single-center, retrospective, cohort study included patients who underwent IMS of DMCFs between 2009 and 2022 at a Level II trauma center in Germany, experienced no major complications, and had completed at least 1 year of follow-up. Propensity score matching was conducted to obtain a balanced sample of patients who did not engage (cases) and engaged (controls) in postoperative sports activities by adjusting for age and fracture complexity. Groups were compared to assess the impact of regular sports activities on subjective shoulder functioning at follow-up, as evaluated using the Disabilities of the Arm, Shoulder, and Hand and Oxford Shoulder Score (OSS) questionnaires, after controlling for the patient- (i.e., sex and smoking) and treatment- (i.e., surgery duration and physical therapy) factors. Results Among the 199 patients included, the RTS rate was 97.5%, and 160 patients practiced regular postoperative activity, mostly in the same sport and intensity. In the matched cohort (39 cases and 39 controls), practicing regular sports activities postoperatively was the only independent factor associated with a higher OSS in the multiple regression analysis (unstandardized regression coefficient = 2.40; Bias-corrected and accelerated 95% confidence interval [0.28, 4.69]). Conclusions The sport-related outcomes after IMS of DMCFs in our cohort were comparable to those achieved after plate osteosynthesis, and IMS reported in the literature. Recreational sports activities benefitted subjective shoulder function, thereby encouraging further research and potentially influencing management policies. Level of evidence Grade IV - a retrospective observational cohort study.
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Affiliation(s)
- Ronny Langenhan
- Department of Orthopedic Surgery, Hegau-Bodensee-Klinikum Singen, Health Care Association District of Constance (GLKN), Virchowstrasse 10, D-78224, Singen, Germany.
| | - Axel Probst
- Department of Orthopedic Surgery, Hegau-Bodensee-Klinikum Singen, Health Care Association District of Constance (GLKN), Virchowstrasse 10, D-78224, Singen, Germany
| | - Stefan Bushuven
- Health Care Association District of Constance (GLKN), Institute for Infection Control and Infection Prevention, Hegau-Jugendwerk Gailingen, Kapellenstrasse 31, D-78262, Gailingen, Germany
- Training Center for Emergency Medicine (NOTIS e.V.), Breite Strasse 7, D-78234, Engen, Germany
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center-University of Freiburg, Hugstetterstrasse 55, D-79106, Freiburg, Germany
| | - Stefanie Bushuven
- Department of Orthopedic Surgery, Hegau-Bodensee-Klinikum Singen, Health Care Association District of Constance (GLKN), Virchowstrasse 10, D-78224, Singen, Germany
- Department of Neurorehabilitation, Health Care Association District of Constance (GLKN), Hegau-Jugendwerk Gailingen, Kapellenstrasse 31, D-78262, Gailingen, Germany
| | - Milena Trifunovic-Koenig
- Training Center for Emergency Medicine (NOTIS e.V.), Breite Strasse 7, D-78234, Engen, Germany
- Wiesbaden Institute for Healthcare Economics and Patient Safety, Wiesbaden Business School, Rhein-Main University of Applied Sciences, Kurt-Schumacher-Ring 18, D-65197, Wiesbaden, Germany
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Kamaci S, Bess L, Glogovac G, Colosimo AJ. Plate osteosynthesis of midshaft clavicle fractures in adolescent contact sports athletes - adolescent clavicle fracture. J Pediatr Orthop B 2022; 31:1-6. [PMID: 32991374 DOI: 10.1097/bpb.0000000000000810] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Surgical treatment of mid-shaft clavicle fractures via anatomical plates in adult athletes is documented to be safe and effective. Functional and cosmetic outcomes in adolescent contact sports athletes have not been well documented. Adolescent athletes (age 11-19) surgically treated for mid-shaft clavicle fractures between 1 May 2011 and 30 October 2017 were included in this study. Twenty-one adolescent athletes with a mean follow-up of 44 months were reviewed. Retrospective chart reviews were performed. Functional and cosmetic outcomes, return to sports time/rate were analyzed using Nottingham Clavicle Scores and a 'Custom Questionnaire'. Return of function and healing, evidenced on radiographs, was achieved in all 21 patients. All patients returned back to competitive sports. The mean time to return back to training was 45.9 ± 16 (24-76) days. Sixteen (76.1%) of the patients reported Nottingham Clavicle Scores with a mean score of 91.7 (85-98). In the Custom Questionnaire, 16 patients who participated in the phone interview were satisfied with the cosmetic outcomes. The most common complaint was implant prominence and irritation in 6 (40%) patients, subsequently requiring implant removal in 3 (18.8%). Surgical fixation of mid-shaft clavicle fractures can lead to excellent union and cosmetic outcomes and a rapid return to sports in adolescent contact sport athletes. However, one should consider the outcomes of implant-related complaints and the possibility of implant removal surgery in the future.
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Affiliation(s)
- Saygin Kamaci
- Division of Sports Medicine, Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Department of Orthopaedic Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Laura Bess
- Division of Sports Medicine, Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Georgina Glogovac
- Division of Sports Medicine, Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Angelo J Colosimo
- Division of Sports Medicine, Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Park JS, Ko SH, Hong TH, Ryu DJ, Kwon DG, Kim MK, Jeon YS. Plate fixation versus titanium elastic nailing in midshaft clavicle fractures based on fracture classifications. J Orthop Surg (Hong Kong) 2021; 28:2309499020972204. [PMID: 33258399 DOI: 10.1177/2309499020972204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The best strategy for implant selection in midshaft clavicular fractures (MCF) remains controversial. The present study aims to determine the optimal strategy for implant selection by comparing plate and Titanium Elastic Nail (TEN) with respect to outcomes and related complications and analyze the results based on fracture patterns. METHODS A total of 97 patients with MCF who underwent plate (48 patients) or TEN (49 patients) fixation were retrospectively reviewed. Both groups were divided into three subgroups by fracture type using the AO Foundation/Orthopaedic Trauma Association classification: simple fracture (type A), wedge fracture (type B), and multi-fragmentary fracture (type C). The observed outcome measures were bone union rate, related complications, functional scores, and patient satisfaction score. These outcomes were analyzed based on the fracture classification. RESULTS Both groups demonstrated excellent union rates (p = 0.495) and similar functional scores (p > 0.05). Visual analog scale (VAS) for satisfaction was better in TEN than plate fixation (p < 0.001). In type A and B subgroups, there were no significant difference in functional scores between plate and TEN fixation (p > 0.05). In type C subgroup, however, both VAS for pain and DASH score in TEN fixation were significantly worse than in plate fixation at 2 and 6 weeks postoperatively (p < 0.05). The incidences of clavicle shortening and skin irritation are higher especially in type C subgroup of TEN fixation (p < 0.05). CONCLUSION Patient satisfaction of TEN fixation was higher than that of plate fixation, but TEN fixation had a higher incidence of early postoperative pain and migration in type C fractures. Therefore, type A and B fractures can successfully be treated with plate or TEN fixation, but type C fractures should be treated with plate fixation.
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Affiliation(s)
- Jun Sung Park
- Department of Orthopaedic Surgery,65745Inha University Hospital, Incheon, Republic of Korea
| | - Sang Hyun Ko
- Department of Orthopaedic Surgery,65745Inha University Hospital, Incheon, Republic of Korea
| | - Taek Ho Hong
- Department of Orthopaedic Surgery,65745Inha University Hospital, Incheon, Republic of Korea
| | - Dong Jin Ryu
- Department of Orthopaedic Surgery,65745Inha University Hospital, Incheon, Republic of Korea
| | - Dae Gyu Kwon
- Department of Orthopaedic Surgery,65745Inha University Hospital, Incheon, Republic of Korea
| | - Myung-Ku Kim
- Department of Orthopaedic Surgery,65745Inha University Hospital, Incheon, Republic of Korea
| | - Yoon Sang Jeon
- Department of Orthopaedic Surgery,65745Inha University Hospital, Incheon, Republic of Korea
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Hoogervorst P, van Dam T, Verdonschot N, Hannink G. Functional outcomes and complications of intramedullary fixation devices for Midshaft clavicle fractures: a systematic review and meta-analysis. BMC Musculoskelet Disord 2020; 21:395. [PMID: 32571362 PMCID: PMC7310279 DOI: 10.1186/s12891-020-03256-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 03/31/2020] [Indexed: 02/05/2023] Open
Abstract
Background An alternative to the current gold standard in operative treatment of displaced midshaft clavicle fractures (DMCF) using plate osteosynthesis, is internal fixation by means of intramedullary fixation devices. These devices differ considerably in their specifications and characteristics and an evaluation of their clinical results is warranted. The aim of this systematic review is to generate an overview of functional outcomes and complications in the management of DMCF per available intramedullary device. Methods A systematic review was conducted to identify all papers reporting functional outcomes, union rates and/or complications using an intramedullary fixation device for the management of midshaft clavicle fractures. Multiple databases and trial registries were searched from inception until February 2020. Meta-analysis was conducted based on functional outcomes and type of complication per type of intramedullary fixation device. Pooled estimates of functional outcomes scores and incidence of complications were calculated using a random effects model. Risk of bias and quality was assessed using the Cochrane risk of bias and ROBINS-I tools. The confidence in estimates were rated and described according to the recommendations of the GRADE working group. Results Sixty-seven studies were included in this systematic review. The majority of studies report on the use of Titanium Elastic Nails (TEN). At 12 months follow up the Titanium Elastic Nail and Sonoma CRx report an average Constant-Murley score of 94.4 (95%CI 93–95) and 94.0 (95%CI 92–95) respectively (GRADE High). The most common reported complications after intramedullary fixation are implant-related and implant-specific. For the TEN, hardware irritation and protrusion, telescoping or migration, with a reported pooled incidence 20% (95%CI 14–26) and 12% (95%CI 8–18), are most common (GRADE Moderate). For the Rockwood/Hagie Pin, hardware irritation is identified as the most common complication with 22% (95%CI 13–35) (GRADE Low). The most common complication for the Sonoma CRx was cosmetic dissatisfaction in 6% (95%CI 2–17) of cases (GRADE Very low). Conclusion Although most studies were of low quality, good functional results and union rates irrespective of the type of device are found. However, there are clear device-related and device-specific complications for each. The results of this systematic review and meta-analysis can help guide surgeons in choosing the appropriate operative strategy, implant and informing their patient. Level of Evidence IV
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Affiliation(s)
- Paul Hoogervorst
- Department of Orthopedic Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands. .,Department of Orthopedic Surgery, University of Minnesota, 2450 Riverside Avenue South, Suite R200, Minneapolis, MN, 55454, USA.
| | | | - Nico Verdonschot
- Department of Orthopedic Surgery, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.,Department of Biomechanical Engineering, University of Twente, Enschede, The Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud University Medical Center Nijmegen, Enschede, The Netherlands
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Pieske O, Bauer M, Schröder C, Michaelis I, Massen F, Wallmichrath J, Suero EM, Greiner A. Development and biomechanical evaluation of a new biodegradable intramedullary implant for osteosynthesis of midshaft fractures of small hollow bones. Technol Health Care 2020; 28:185-192. [PMID: 32224535 DOI: 10.3233/thc-191597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Up to date there is no intramedullary, biodegradable osteosynthesis commercially available to treat non-comminuted midshaft fractures of small hollow bones applying not only a stable osteosynthesis but an additional axial compression to the fracture site. OBJECTIVE AND METHODS Therefore we (1) designed different implant profiles and simulated the inner tension/volume using CAD. (2) Thereafter we manufactured a prototype with the best volume/tension-ratio using 70:30 poly-(L-lactide-co-D, L-lactide) (PLLA/PDLLA) and poly-ε-caprolactone (PCL) by injection moulding. Both materials are resorbable, licensed for medical use and show a slow degradation over at least one year. (3) The implants were tested in a universal testing machine (Zwick/RoellZ010) using a 3-point-bending-setup. (4) We compared the implants with different types of commercially available Ti6Al4V 6-hole 2, 3 mm-plates including interlocking systems (Leibinger Set, Stryker) (each group n= 6) using a 4-point-bending-test-setup with artificial metacarpal bones (Sawbones®). RESULTS The 3-point-bending-test-results showed that mean failure-force of PCL-tubes was 57.94 ± 4.28 N whereas the PLLA/PDLLA-tubes had an approximately four-fold higher value of 227.24 ± 1.87 N (p< 0.001). Additionally, the 4-point-bending-test-results showed that the maximum load of PLLA/PDLLA tubes (61.97 ± 3.58 N) was significantly higher than the strongest 6-hole metacarpal plate (22.81 ± 0.76 N) (p< 0.001). CONCLUSION The study showed that the new type of biodegradable, intramedullary tension-osteosynthesis made of PLLA/PDLLA is even more stable than common plate osteosynthesis in a small-hallow-bone-model. Further in vivo investigation should be performed to evaluate the surgical technique and long-term healing process of the bone and biodegradation process of the implant.
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Affiliation(s)
- Oliver Pieske
- Department of Trauma Surgery, Evangelic Hostpital Oldenburg, 26122 Oldenburg, Germany
| | - Maximilian Bauer
- Department of General Trauma and Reconstructive Surgery, University Hospital of Munich, 81377 Munich, Germany
| | - Christian Schröder
- Laboratory for Biomechanics and Experimental Orthopaedics, University Hospital of Munich, 81377 Munich, Germany
| | - Ina Michaelis
- Institute of Plastics Processing, RWTH Aachen, 52062 Aachen, Germany
| | - Felix Massen
- Department of General Trauma and Reconstructive Surgery, University Hospital of Munich, 81377 Munich, Germany
| | - Jens Wallmichrath
- Deparment of Dermatology, University Hospital of Munich, 80337 Munich, Germany
| | - Eduardo M Suero
- Department of General Trauma and Reconstructive Surgery, University Hospital of Munich, 81377 Munich, Germany
| | - Axel Greiner
- Department of General Trauma and Reconstructive Surgery, University Hospital of Munich, 81377 Munich, Germany
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Cheah JW, Goodman JZ, Dang AC. Clavicle Fracture Malunion Treated with an Osteotomy Guided by a Three-Dimensional-Printed Model: A Case Report. JBJS Case Connect 2019; 8:e98. [PMID: 30540607 DOI: 10.2106/jbjs.cc.17.00304] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE This case report describes the management of a chronic and symptomatic clavicle malunion with use of a 3-dimensional (3D)-printed model during the preoperative surgical planning. CONCLUSION The use of 3D printing has many applications in the medical field. Constant improvement in the quality of 3D printing has contributed to its increased use in a variety of surgeries. In our patient, 3D printing was used to generate a surface model of the clavicle fracture malunion and the "mirrored" contralateral healthy clavicle to plan an intraoperative osteotomy, which optimized the relative position of the osteotomy segments and hardware fixation.
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Affiliation(s)
- Jonathan W Cheah
- Department of Orthopaedic Surgery, University of California, San Francisco Medical Center, San Francisco, California
| | - Jeremy Z Goodman
- Department of Orthopaedic Surgery, University of California, San Francisco Medical Center, San Francisco, California
| | - Alexis C Dang
- Department of Orthopaedic Surgery, University of California, San Francisco Medical Center, San Francisco, California.,San Francisco Veterans Affairs Medical Center, San Francisco, California
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Displaced Clavicle Fractures in Cyclists: Return to Athletic Activity After Anteroinferior Plate Fixation. Clin J Sport Med 2019; 29:465-469. [PMID: 31688176 DOI: 10.1097/jsm.0000000000000552] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND One of the most commonly observed injuries in cycling is fracture of the clavicle. Nevertheless, there is limited literature available on clinical outcomes after plate fixation of clavicle fractures in cyclists, rehabilitation protocols, and the time to return to sports. PURPOSE The aim of this study was to evaluate the functional outcome, complications, and return to athletic activity at short-term follow-up after surgical repair. STUDY DESIGN Case series. METHODS Between January 2008 and October 2014, all professional and recreational cyclists presenting with a new clavicle fracture at the emergency department were prospectively recorded. All patients had an anteroinferior plate fixation, variable angle locking compression plate (DePuySynthes). Patients were seen at 2, 6, and 24 weeks at the outpatient clinic to gather Disability of the Arm, Shoulder, and Hand (DASH) and Constant shoulder questionnaires and radiographs were made. Cyclists were allowed to resume outside training 1 week after surgery. RESULTS Ten professional cyclists and 15 recreational cyclists were included. All (25/25) patients returned to cycling after plate fixation. Mean Constant scores and mean DASH scores of 96.8 ± 4.1 and 5.1 ± 5.5 at 6 weeks and 99.1 ± 1.5 and 2.9 ± 4.6 at 24 weeks were measured. There were 3 complications: 1 patient developed a nonunion, there was 1 wound infection requiring antibiotics, and in 1 patient, a refracture occurred. CONCLUSION Plate fixation for cyclists with displaced clavicle fractures was successful in terms of fast return to previous level of athletic activity. It is a valuable and safe option for athletes in cycling.
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8
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Bilateral Midshaft Clavicular Fracture with Unilateral Acromioclavicular Dislocation: A Case Report. Trauma Mon 2018. [DOI: 10.5812/traumamon.57811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Oppermann J, Ettmann L, Meyer C, Ries C, Stein G, Spies CK, Müller LP, Faymonville C. [Analysis of the accuracy of fit of five anatomically precontoured clavicle plate systems]. Unfallchirurg 2017; 121:475-482. [PMID: 29098302 DOI: 10.1007/s00113-017-0433-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND A common method in surgical treatment of midshaft clavicular fractures is the clavicle plating system. In addition to traditional osteosynthetic devices, anatomically preformed plate systems also exist. Advantages are described in greater accuracy of fit and less irritation of surrounding soft tissues. The purpose of this study was to compare the anatomical fit of five different precontoured clavicle plating systems. MATERIAL AND METHODS The anatomical fit of five different types of anatomical precontoured clavicle plates, 3 times VariaxSystem® (Stryker, Kalamazoo, MI), Meves® Plate (Ulrich medical Ulm, Germany) and LCP clavicle plate (Synthes, Bettlach, Switzerland) were investigated in 20 embalmed human cadaveric clavicles. An imprint of the space between the well-positioned plate and the clavicle was obtained using a silicone mass and the silicone imprint was digitally measured. Additionally, the anatomical fit was evaluated by three investigators following a standardized protocol (+2 to -2 points at lateral, midshaft and medial clavicle portions). RESULTS The first three ranks went to the Stryker Variax-plates. They showed the least distance (Stryker 628027: 7‑hole 1.44 mm, low curvature 0.93 mm-2.36 mm, 2. Stryker 628028: 8‑hole low curvature 1.68 mm, 1.03 mm-2.4 mm and 3. Stryker 628128: 8‑hole high curvature 1.87 mm, range 1.09 mm-3.1 mm) The evaluation of the anatomical fit by the investigators was in agreement with the measurement results. CONCLUSION Although there was no complete congruency between the plates and the clavicle, all clavicle plates investigated in this study presented a reasonable anatomical shape. The 7‑hole VariAx Stryker plate with slight curvature showed the best anatomical fit. A low profile and optimized anatomical precontouring can minimize irritation of the surrounding soft tissues and should be considered in plate design and implant choice.
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Affiliation(s)
- Johannes Oppermann
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln (AöR), Universität zu Köln, Kerpener Straße 62, 50937, Köln, Deutschland. .,Cologne Center for Musculoskeletal Biomechanics, Medizinische Fakultät, Universität zu Köln, Köln, Deutschland.
| | - Linda Ettmann
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln (AöR), Universität zu Köln, Kerpener Straße 62, 50937, Köln, Deutschland
| | - Carolin Meyer
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln (AöR), Universität zu Köln, Kerpener Straße 62, 50937, Köln, Deutschland
| | - Christian Ries
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln (AöR), Universität zu Köln, Kerpener Straße 62, 50937, Köln, Deutschland
| | - Gregor Stein
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln (AöR), Universität zu Köln, Kerpener Straße 62, 50937, Köln, Deutschland
| | - Christian Karl Spies
- Handchirurgie, Vulpius Klinik, Vulpiusstraße 27, 74906, Bad Rappenau, Deutschland
| | - Lars Peter Müller
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln (AöR), Universität zu Köln, Kerpener Straße 62, 50937, Köln, Deutschland.,Cologne Center for Musculoskeletal Biomechanics, Medizinische Fakultät, Universität zu Köln, Köln, Deutschland
| | - Christoph Faymonville
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln (AöR), Universität zu Köln, Kerpener Straße 62, 50937, Köln, Deutschland
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Govindasamy R, Kasirajan S, Meleppuram JJ, Thonikadavath F. Estudo retrospectivo de haste intramedular estável elástica de titânio em fraturas deslocadas do terço médio da clavícula. Rev Bras Ortop 2017. [DOI: 10.1016/j.rbo.2016.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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End cap versus no end cap in intramedullary nailing for displaced midshaft clavicle fractures: influence on implant-related irritation. Eur J Trauma Emerg Surg 2017; 44:119-124. [PMID: 28314896 DOI: 10.1007/s00068-017-0784-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 03/10/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Implant-related irritation at the entry site is a known disadvantage of intramedullary nailing for clavicle fractures. The purpose of this study was to compare implant-related irritation rates of intramedullary nailing with or without an end cap for displaced midshaft clavicle fractures. METHODS Two cohorts of patients treated with intramedullary nailing with or without an end cap were matched and compared. Primary outcome was patient-reported implant-related irritation. Secondary outcome parameters were complications. RESULTS A total of 34 patients with an end cap were matched with 68 patients without an end cap. There was no difference in implant-related irritation (41 versus 53%, P = 0.26). Significantly more minor revisions were observed in the group without an end cap (15 versus 0%, P = 0.03). For complications requiring major revision surgery, significantly more implant failures were observed in the end cap group (12 versus 2%, P = 0.04). Regardless of their treatment, patients with complex fractures (AO/OTA B2-B3) reported significantly more medial irritation compared to patients with simple fractures (AO/OTA B1)(P = 0.02). CONCLUSION The use of an end cap after intramedullary nailing for displaced midshaft clavicle fractures did not result in lower patient-reported irritation rates. Although less minor revisions were observed, more major revisions were reported in the end cap group. Based on the results of this study, no end caps should be used after intramedullary nailing for displaced midshaft clavicle fractures. However, careful selection of simple fractures might be effective in reducing implant-related problems after intramedullary nailing.
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Govindasamy R, Kasirajan S, Meleppuram JJ, Thonikadavath F. A retrospective study of titanium elastic stable intramedullary nailing in displaced mid-shaft clavicle fractures. Rev Bras Ortop 2016; 52:270-277. [PMID: 28702383 PMCID: PMC5496991 DOI: 10.1016/j.rboe.2016.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 07/21/2016] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The aim of this study is to analyze the functional outcome following titanium elastic stable intra-medullary nailing (ESIN) for displaced mid-shaft clavicular fractures (DMCF). METHODS A retrospective study of 60 patients between March 2009 and March 2015 was conducted. Patients were selected based on the inclusion criteria. Six patients were lost during follow up. Out of the remaining 54 patients, there were 39 males and 15 females. The mean age was 30.6 years. The functional outcome was analyzed using the Constant score, rate of bone union, complication, and earliest time of return to work. RESULTS All fractures united well, with an average time of 7.5 weeks. Follow-up period ranged between 12 months and 18 months (average, 14 months). 24 out of 54 patients had closed nailing, while 30 had minimal open reduction. The average size of ESIN was 2 mm (range, 1.5-3 mm). The average Constant score was 97.8 (range, 95-99). There were no major complications, but minor complications occurred, viz. skin irritation in 15 patients, temporary paresthesia in five patients, and three patients who developed superficial infections. One case had implant migration and perforation at the lateral cortex, and one case had delayed union. There were few implant-related problems, as the authors used a standard protocol to remove it after radiological union. All patients returned to work within 10 weeks of the post-operative period. CONCLUSION ESIN is a safe, minimally invasive, engenders rapid healing with good cosmesis, and provides an excellent functional outcome in terms of patient satisfaction, with fewer complications.
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Affiliation(s)
- Rajesh Govindasamy
- Vinayaka Missions Medical College and Hospital, Department of Orthopaedics, Pondy, India
| | - Saravanan Kasirajan
- Vinayaka Missions Medical College and Hospital, Department of Orthopaedics, Pondy, India
| | | | - Fawas Thonikadavath
- Vinayaka Missions Medical College and Hospital, Department of Orthopaedics, Pondy, India
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13
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Robertson GAJ, Wood AM. Return to sport following clavicle fractures: a systematic review. Br Med Bull 2016; 119:111-28. [PMID: 27554280 DOI: 10.1093/bmb/ldw029] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2016] [Indexed: 12/19/2022]
Abstract
INTRODUCTION This review aims to provide information on the return rates and return times to sport following clavicle fractures. SOURCES OF DATA A systematic search of Medline, EMBASE, CINAHAL, Cochrane, Web of Science, PEDro, SPORTDiscus, Scopus and Google Scholar was performed using the keywords 'clavicle', 'clavicular', 'fractures', 'athletes', 'sports', 'non-operative', 'conservative', 'operative', 'return to sport'. AREAS OF AGREEMENT Twenty-three studies were included: 10 reported on mid-shaft fractures, 14 on lateral fractures. The management principles for athletic patients were to attempt non-operative management for undisplaced fractures to undertake operative intervention for displaced lateral fractures and to recommend operative intervention for displaced mid-shaft fractures. AREAS OF CONTROVERSY The optimal surgical modality for mid-shaft and lateral clavicle fractures. GROWING POINTS Operative management of displaced mid-shaft fractures offers improved return rates and times to sport compared to non-operative management. Suture fixation and non-acromio-clavicular joint (ACJ)-spanning plate fixation of displaced lateral fractures show promising results. AREAS TIMELY FOR DEVELOPING RESEARCH Future prospective studies should aim to establish the optimal treatment modalities for clavicle fractures.
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Affiliation(s)
- G A J Robertson
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK.
| | - A M Wood
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
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Eden L, Ziegler D, Gilbert F, Fehske K, Fenwick A, Meffert RH. Significant pain reduction and improved functional outcome after surgery for displaced midshaft clavicular fractures. J Orthop Surg Res 2015; 10:190. [PMID: 26704994 PMCID: PMC4691016 DOI: 10.1186/s13018-015-0336-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 12/09/2015] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Displaced midshaft clavicular fractures can be treated conservatively as well as operatively by titan elastic nail (TEN) or plate fixation. This survey was performed to evaluate the clinical results of each treatment method and elaborate advantages or possible complications of each modality. METHODS Between 2008 and 2013, 102 patients were prospectively included in our study-37 patients for conservative treatment with a rucksack bandage for 4 to 6 weeks, 41 patients for plate osteosynthesis, and 24 for intramedullary stabilization with TEN. Disabilities of the Arm, Shoulder and Hand (DASH), Constant Murley Score (CMS), and visual analog scale (VAS) for pain and function as well as time of invalidity were recorded over a 1-year period. RESULTS The clinical data collected reveals that all three different therapies lead to good or excellent clinical results after 1 year. However, one can observe advantages of operative treatment in comparison to conservative therapy in some characteristics. CONCLUSION Our data shows that there are several indications where operative treatment has advantages compared to conservative treatment. In special fracture types (Robinson 2B1), TEN gives the best results. Plate fixation is extraordinarily sufficient in pain reduction within the first 5 weeks and indicated in more-part fractures (Robinson 2B2). Nevertheless, conservative treatment is always a good and promising way to treat clavicular fractures, so that individual indications and thorough patient informative talks are inevitable.
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Affiliation(s)
- Lars Eden
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, Julius Maximilian University, Oberduerrbacher Straße 6, 97080, Wuerzburg, Germany.
| | - Dirk Ziegler
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, Julius Maximilian University, Oberduerrbacher Straße 6, 97080, Wuerzburg, Germany.
| | - Fabian Gilbert
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, Julius Maximilian University, Oberduerrbacher Straße 6, 97080, Wuerzburg, Germany.
| | - Kai Fehske
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, Julius Maximilian University, Oberduerrbacher Straße 6, 97080, Wuerzburg, Germany.
| | - Annabel Fenwick
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, Julius Maximilian University, Oberduerrbacher Straße 6, 97080, Wuerzburg, Germany.
| | - Rainer H Meffert
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, Julius Maximilian University, Oberduerrbacher Straße 6, 97080, Wuerzburg, Germany.
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Dual mini-fragment plating for midshaft clavicle fractures: a clinical and biomechanical investigation. Arch Orthop Trauma Surg 2015; 135:1655-62. [PMID: 26377733 DOI: 10.1007/s00402-015-2329-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Indexed: 02/09/2023]
Abstract
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.
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Fanter NJ, Kenny RM, Baker CL, Baker CL. Surgical treatment of clavicle fractures in the adolescent athlete. Sports Health 2015; 7:137-41. [PMID: 25984259 PMCID: PMC4332647 DOI: 10.1177/1941738114566381] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
CONTEXT Current literature has clearly shown that the indications for surgical treatment of clavicle fractures in adults are expanding. Although clavicle fractures in children and adolescents have traditionally been treated nonoperatively, surgical treatment of displaced clavicle fractures may be indicated for adolescent athletes. EVIDENCE ACQUISITION A review of relevant articles published between 1970 and 2013 was completed using MEDLINE and the terms clavicle fracture and adolescent athlete. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 3. RESULTS Excellent outcomes and rapid return to competition can be achieved with surgical management of displaced clavicle fractures in the adolescent athlete with high functional demands similar to those of their adult counterparts. Complications include hardware irritation, screw loosening, pin migration, peri-incisional numbness, and refracture. Athletes and families must be counseled regarding complications and potential need for secondary surgery to remove hardware. CONCLUSION The adolescent athlete with a displaced, shortened, or comminuted clavicle fracture presents a unique, controversial dilemma for the surgeon. Earlier return to competition can be achieved with surgical management to restore length and alignment and may prevent malunion, nonunion, and poor outcomes.
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Affiliation(s)
- Nathan J Fanter
- The Hughston Foundation, Columbus, Georgia ; Hinsdale Orthopaedics, Hinsdale, Illinois
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Ranalletta M, Rossi LA, Piuzzi NS, Bertona A, Bongiovanni SL, Maignon G. Return to sports after plate fixation of displaced midshaft clavicular fractures in athletes. Am J Sports Med 2015; 43:565-9. [PMID: 25492034 DOI: 10.1177/0363546514559913] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent prospective randomized trials support primary plate fixation of displaced midshaft clavicle fractures. However, the safety and efficacy of this practice have not been well documented in athletes, nor has the time to return-to-sport. PURPOSE To analyze the time to return-to-sport, functional outcomes, and complications in a group of athletes with displaced midshaft clavicle fractures treated using precontoured locking plates. STUDY DESIGN Case series; Level of evidence, 4. METHODS A total of 54 athletes with displaced midshaft clavicle fractures were treated with plate fixation between November 1, 2008, and December 31, 2012. The mean follow-up time was 22.4 months. Patients completed a questionnaire focused on the time to return-to-sport and treatment course. Functional outcomes were assessed with the Constant score and short version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. Pain was evaluated with the visual analog scale (VAS). Radiographs were reviewed to identify radiographic union time, malunion, and nonunion. RESULTS Of the 54 patients, 53 returned to sports after open reduction and internal fixation of their fracture; 94% returned to the same level. The mean time to return-to-sport was 68 days (range, 5-180 days). Nine (16.6%) of the cases returned to sports before 6 weeks after surgery, 40 (74%) returned between 6 and 12 weeks, and 5 patients (9.2%) returned 12 weeks after surgery. The mean Constant score was 94.1 ± 5.2 (range, 78-100), and the mean QuickDASH score was 0.4 ± 4.7 (range, 0-7.1). The mean VAS pain score during follow-up was 0.29 ± 1.0 (range, 0-5). Three major complications occurred: 1 extrinsic compression of the subclavian vein, 1 nonunion, and 1 hardware loosening. Hardware removal was necessary in 5 patients (9.3%). CONCLUSION Plate fixation of displaced clavicle fractures in athletes is a safe procedure resulting in excellent functional outcomes, with an early return to the same level of sports in the majority of patients.
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Affiliation(s)
- Maximiliano Ranalletta
- Institute of Orthopedics "Carlos E. Ottolenghi," Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Luciano A Rossi
- Institute of Orthopedics "Carlos E. Ottolenghi," Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Nicolás S Piuzzi
- Institute of Orthopedics "Carlos E. Ottolenghi," Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Agustin Bertona
- Institute of Orthopedics "Carlos E. Ottolenghi," Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Santiago L Bongiovanni
- Institute of Orthopedics "Carlos E. Ottolenghi," Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Gaston Maignon
- Institute of Orthopedics "Carlos E. Ottolenghi," Italian Hospital of Buenos Aires, Buenos Aires, Argentina
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Lu CC, Liu PC, Huang SH, Hsieh CH, Tien YC, Chien SH. Complications and technical pitfalls of titanium elastic nail fixation for midclavicular fractures. Orthopedics 2014; 37:e377-83. [PMID: 24762844 DOI: 10.3928/01477447-20140401-60] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 11/08/2013] [Indexed: 02/03/2023]
Abstract
Intramedullary titanium elastic nails have been reported to fix displaced midclavicular fractures with excellent functional outcomes and minor complications. This study reports and analyzes the complications and technical pitfalls associated with titanium elastic nail fixation of displaced midclavicular fractures and describes how to prevent these problems. The authors operated on 27 patients (17 men, 10 women; mean age, 45.8 years; range, 16.5-66.9 years) with marked displaced midclavicular fractures using intramedullary titanium elastic nail fixation. The mean Constant score and Disability of the Arm, Shoulder, and Hand score were 93.58 (range, 66.5-100) and 6.22 (range, 0-35), respectively. The mean length difference compared with the contralateral clavicle was a shortening of 0.3 cm (range, -1.5 to 1 cm). Eight patients (30%) had different levels of difficulty at the medial entry point. Clavicular length shortening of more than 1 cm occurred in 5 patients (19%), and all of these patients experienced medial nail tip prominence/protrusion. One patient had 1-cm lengthening of the injured clavicle caused by distraction of the fracture site during titanium elastic nail insertion. Iatrogenic perforation of the posterolateral cortex occurred in 3 patients. Initial misplaced nail insertion occurred in 1 woman who underwent revision with the mini-open method. In 2 patients it was impossible to remove the full nail under general anesthesia. In conclusion, high patient satisfaction and functional outcomes were achieved after titanium elastic nail fixation of displaced midclavicular fractures. However, some complications and technical pitfalls must be considered before titanium elastic nails are used to fix displaced midclavicular fractures.
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Meisterling SW, Cain EL, Fleisig GS, Hartzell JL, Dugas JR. Return to athletic activity after plate fixation of displaced midshaft clavicle fractures. Am J Sports Med 2013; 41:2632-6. [PMID: 23982401 DOI: 10.1177/0363546513501494] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Recent data support primary plate fixation of displaced midshaft clavicle fractures. The safety and efficacy of this practice have not been well documented in athletes. HYPOTHESIS Plate fixation of clavicle fractures in athletes is a safe and effective procedure, resulting in a reliable and timely return to play. STUDY DESIGN Case series; Level of evidence, 4. METHODS A total of 29 patients with displaced midshaft clavicle fractures from athletic activity were treated with plate fixation between January 1, 2003 and December 31, 2008, including 1 patient treated for each clavicle for separate injuries. All 29 patients were contacted for follow-up. At a mean follow-up of 21 months, patients completed a questionnaire focused on the time to return to athletics and treatment course. Patients also completed the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire. Radiographs were reviewed to identify fracture comminution, displacement, shortening, and angulation; radiographic union time; and malunion. RESULTS All of the patients (30/30 cases) returned to sports after open reduction internal fixation of their fracture. The mean time to return to play was 83 days with a range of 13 to 277 days. Seven (23%) of the cases returned to athletics at ≤6 weeks after surgery, and a total of 20 patients (67%) returned at ≤12 weeks after surgery. All patients (100%) were satisfied with their treatment. The QuickDASH scores revealed almost perfect recovery (mean score, 0.8 of 100). Four minor complications were identified. No patient had a refracture, plate fracture, loss of fixation, nonunion, malunion, or deep wound infection. CONCLUSION Plate fixation of displaced clavicle fractures in athletes is a safe procedure, resulting in a high satisfaction rating and minimal disability to the upper extremity. An early return (<6 weeks) to sports is possible after this treatment; however, the time to return is highly variable.
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Affiliation(s)
- Steven W Meisterling
- Glenn S. Fleisig, American Sports Medicine Institute, 833 St Vincent's Drive, Suite 100, Birmingham, AL 35205.
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20
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Titanium elastic nails, open reduction internal fixation and non-operative management for middle third clavicle fractures: a comparative study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2013; 24:323-9. [PMID: 23443744 DOI: 10.1007/s00590-013-1191-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 02/08/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To compare clinical outcomes between titanium elastic nails (TENS), open reduction internal fixation (ORIF) and non-operative treatment options at mean 30 months in Allman type 1 fractures of the clavicle. DESIGN Retrospective case matched. SETTING Tertiary Trauma Centre, UK. PATIENTS Treatment method was based on surgeon choice although there was no difference between groups in terms of age or gender. Those treated non-operatively tended to have a less severe fracture pattern. There were 25 patients treated with TENS, 24 with ORIF and 41 treated conservatively. Main outcome measurements are qDASH questionnaire, patient satisfaction question and clinical complication rate. RESULTS Patients managed with TENS had significantly better clinical outcomes than both plate fixation and non-operatively managed groups. CONCLUSIONS This study supports the use of TENS fixation of middle third clavicle fractures in significantly displaced Allman type 1 injuries.
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Kadakia AP, Rambani R, Qamar F, McCoy S, Koch L, Venkateswaran B. Titanium elastic stable intramedullary nailing of displaced midshaft clavicle fractures: A review of 38 cases. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2012. [PMID: 23204762 PMCID: PMC3507328 DOI: 10.4103/0973-6042.102557] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Clavicle fractures accounting for 3 to 5% of all adult fractures are usually treated non-operatively. There is an increasing trend toward their surgical fixation. The aim of our study was to investigate the outcome following titanium elastic stable intramedullary nailing (ESIN) for midshaft non-comminuted clavicle fractures with >20 mm shortening/displacement. MATERIALS AND METHODS A total of 38 patients, which met inclusion criteria, were reviewed retrospectively. There were 32 males and six females. The mean age was 27.6 years. The patients were assessed for clinical/radiological union and by Oxford Shoulder and QuickDASH scores. 71% patients required open reduction. RESULTS 100% union was achieved at average of 11.3 weeks. The average follow-up was 12 months. The average Oxford Shoulder and QuickDASH scores were 45.6 and 6.7, respectively. 47% patients had nail removal. One patient had lateral nail protrusion while other required its medial trimming. CONCLUSION In our hands, ESIN is safe and minimally invasive with good patient satisfaction, cosmetic appearance, and overall outcome.
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Affiliation(s)
- Anish P Kadakia
- Dewsbury and District Hospital, Dewsbury, West Yorkshire, England
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22
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Tarng YW, Yang SW, Fang YP, Hsu CJ. Surgical management of uncomplicated midshaft clavicle fractures: a comparison between titanium elastic nails and small reconstruction plates. J Shoulder Elbow Surg 2012; 21:732-40. [PMID: 22154308 DOI: 10.1016/j.jse.2011.08.065] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 08/15/2011] [Accepted: 08/28/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study compared titanium elastic nail (TEN) fixation with plate fixation in patients with uncomplicated midshaft clavicle fractures. METHODS The records of 57 patients with midshaft clavicular fractures that were operated on within 2 weeks after injury at Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan, were retrospectively analyzed. Each patient received either TENs (n = 25) or fixation with a 3.5-mm reconstruction plate (n = 32) depending on the preference of the operating surgeon. Operative parameters, postoperative pain and function scores, complications, and fracture union time were determined. RESULTS There was no difference in the fracture pattern distribution between the 2 groups, and all operations were performed without complications. Operation time, wound size, blood loss, length of hospitalization, and subjective time to pain relief were less for the TEN group than for the 3.5-mm reconstruction plate fixation group (P < .001 for all). Patients in the TEN group showed a greater range of shoulder motion and higher Constant scores than those in the plate fixation group up to 18 weeks after surgery (P < .001 for all). Fewer patients in the TEN group, 4 (16%), requested removal of the implant, as compared with 12 (37.5%) in the plate group. CONCLUSION Fixation of uncomplicated midshaft clavicle fractures with TENs provides adequate fixation and faster relief of pain and return to normal function of the affected shoulder than fixation with 3.5-mm reconstruction plates.
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Affiliation(s)
- Yih-Wen Tarng
- Department of Emergency, Kaohsiung Veterans General Hospital, Kaohsiung City, Taiwan
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Chen YF, Wei HF, Zhang C, Zeng BF, Zhang CQ, Xue JF, Xie XT, Lu Y. Retrospective comparison of titanium elastic nail (TEN) and reconstruction plate repair of displaced midshaft clavicular fractures. J Shoulder Elbow Surg 2012; 21:495-501. [PMID: 21641826 DOI: 10.1016/j.jse.2011.03.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Revised: 01/04/2011] [Accepted: 03/08/2011] [Indexed: 02/01/2023]
Abstract
BACKGROUND Titanium elastic nails (TENs) are commonly used to repair displaced midshaft clavicular fractures. Although several clinical studies have shown that the use of TENs is more effective and less invasive than traditional plate fixation, high rates of complications associated with TENs have been reported. This retrospective study compared the use of TENs with reconstruction plates in the treatment of displaced midshaft clavicular fractures. MATERIALS AND METHODS From January 2005 to July 2007, 141 patients with displaced midshaft clavicular fractures were treated with TEN or plate fixation. At 6 and 24 months postoperatively, we evaluated the patients' general health, operative complications, and functional recovery. RESULTS The mean bone union time of TEN patients was 12.4 ± 3.4 weeks, whereas that in the plate group was 14.4 ± 3.7 weeks. The time of union was significantly shorter in the TEN group than that in the plate group. There was no significant difference between these 2 groups' rates of complications such as nonunion or malunion. Shoulder function scores were significantly better in the TEN group than in the plate group at 6 months postoperatively. There was no significant difference at 24 months postoperatively. Patients were more satisfied with the cosmetic appearance and overall outcome after TEN repair than after plate fixation. CONCLUSIONS TEN fixation of displaced midshaft clavicular fractures allows for a faster functional recovery, higher patient satisfaction, and a more cosmetically satisfactory appearance than plate fixation. The complication rates of both TENs and reconstruction plates were similar.
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Affiliation(s)
- Yun-Feng Chen
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Shanghai Jiaotong University, Shanghai, China
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Frigg A, Rillmann P, Ryf C, Glaab R, Reissner L. Can complications of titanium elastic nailing with end cap for clavicular fractures be reduced? Clin Orthop Relat Res 2011; 469:3356-63. [PMID: 21409459 PMCID: PMC3210265 DOI: 10.1007/s11999-011-1845-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND We found treatment of clavicular midshaft fractures using titanium elastic nails (TENs) in combination with postoperative free ROM was associated with a complication rate of 78%. The use of end caps reduced the rate to 60%, which we still considered unacceptably high. Thus, we explored an alternative approach. QUESTIONS/PURPOSES We investigated whether (1) the complication rate could be reduced by cautious lateral advancement of the TENs, intraoperative oblique radiographs to rule out lateral perforation, and limited ROM postoperatively; (2) fluoroscopy time could be reduced; and (3) shoulder function would be reasonable. PATIENTS AND METHODS From March 2006 to December 2009, we treated 44 patients with midshaft clavicular fractures with TENs and end caps. In the first group (n = 15), the TEN was advanced laterally using an oscillating drill. The patients were permitted free ROM. In the second group (n = 29), the TEN was advanced by hand, conversion to open reduction followed two failed closed attempts and lateral perforation was checked with an intraoperative oblique radiograph. Furthermore, anteversion and abduction of the shoulder were limited to 90° for the first 6 weeks. Minimum followup was 12 months (mean, 16.7 months; range, 12-28 months). RESULTS The total complication rate was reduced from nine of 15 in the first group to five of 29 in the second group. Medial perforations ceased with the use of the end cap. Fluoroscopy time was reduced from a mean of 10 to 4 minutes by converting to open reduction after two failed closed attempts. All but three patients exhibited full shoulder ROM at three months and these three had a slight deficit of 10° to 20° in anteversion and/or abduction. At last followup, the mean American Shoulder and Elbow Surgeons score was 92 (range, 88-100) and the Disability of the Arm, Shoulder, and Hand score 1.4 (range, 0-12.5). CONCLUSIONS Cautious insertion of the TENs, intraoperative oblique radiographs, and limiting the ROM for 6 weeks postoperatively reduced the complication rate. Using TENs with end caps for midshaft clavicular fractures is minimally invasive while associated with comparable complication rates and function to plate osteosynthesis. LEVEL OF EVIDENCE Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Arno Frigg
- Department of Orthopedic and Trauma Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Paavo Rillmann
- Department of Trauma Surgery, Davos Hospital, Davos, Switzerland
| | - Christian Ryf
- Department of Trauma Surgery, Davos Hospital, Davos, Switzerland
| | - Richard Glaab
- Department of Trauma Surgery, Davos Hospital, Davos, Switzerland
| | - Lisa Reissner
- Department of Trauma Surgery, Davos Hospital, Davos, Switzerland
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Excessive complications of open intramedullary nailing of midshaft clavicle fractures with the Rockwood Clavicle Pin. Clin Orthop Relat Res 2011; 469:3364-70. [PMID: 21424833 PMCID: PMC3210273 DOI: 10.1007/s11999-011-1867-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Intramedullary clavicle fixation is a potential alternative to plate fixation. Previous studies documenting the complication rates of intramedullary clavicle fixation have demonstrated variable rates of soft tissue complications and fracture healing. QUESTIONS/PURPOSES We asked the following questions: (1) Does use of the Rockwood Clavicle Pin (DePuy Orthopaedics Inc, Warsaw, IN) predispose patients to soft tissue complications requiring additional surgery or a high infection risk? (2) Does the Rockwood Clavicle Pin provide a truly minimally invasive insertion technique and reliable fracture fixation? PATIENTS AND METHODS We retrospectively evaluated 18 patients (mean age, 31 years) who sustained a closed midshaft fracture of the clavicle treated with open intramedullary nailing with a Rockwood Clavicle Pin. We determined the incidence of complications and rate of fracture healing. RESULTS Fourteen complications occurred in 10 patients. Five patients experienced a complication with fracture healing, including three nonunions. Nine patients experienced complications relating to soft tissue, including infection, skin necrosis, or posterior pain from pin prominence. CONCLUSIONS The Rockwood Clavicle Pin remains a historically relevant method of clavicle fixation. However, due to an unacceptably high rate of nonunion, repeat operation, and soft tissue complications, we do not recommend this device for treating middiaphyseal clavicle fractures. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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De Giorgi S, Notarnicola A, Tafuri S, Solarino G, Moretti L, Moretti B. Conservative treatment of fractures of the clavicle. BMC Res Notes 2011; 4:333. [PMID: 21899777 PMCID: PMC3224586 DOI: 10.1186/1756-0500-4-333] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Accepted: 09/08/2011] [Indexed: 11/17/2022] Open
Abstract
Background In the treatment of clavicle fractures, the choice of procedure depends on the possibility of restoring the anatomical functional integrity of the shoulder. Methods We examined 71 patients (51 males and 20 females, mean age 38.9 years) who were affected by clavicle fracture sequelae. Demographic and clinical data and the site of the lesion were recorded for each partecipant. The dissatisfaction of the patient was determined by the presence of 1 or more affirmative answers on the Simple Shoulder Test. The Constant Shoulder Score was also included in the functional and clinical exams. We measured the length of the healthy clavicle and the previously fractured clavicle, and we expressed the difference in length in mm and in percentage shortening. We then examined the correlations between the shortening of the bone and the clinical and functional outcomes of the patients. Results Sixty patients had a lesion of the diaphysis, 8 patients had a lesion of the lateral third of the clavicle, and 3 patients had a lesion of the medial third of the clavicle. The mean Constant Shoulder Score was 77.9, and 51 of the 71 patients were satisfied with their treatment. Radiography showed a mean clavicle shortening of 10 mm (mean percentage 6.5%). In the 20 dissatisfied patients, the mean clavicle shortening was 15.2 mm (9.7%). In these patients, we found a highly significant association between dissatisfaction with treatment and the amount of bone shortening, (p < 0.0001), as well as with a diaphyseal location (p < 0.05) and with the female sex (p = 0.004). No other variable related to the patient, the type of treatment or the fracture characteristics correlated with the treatment outcome. Conclusions In the literature, measurements of the shortening of the bone segment following a fracture range between 15 and 23 mm, and marked shortening is correlated with the failure of conservative treatment. However, these data need to be reinterpreted in light of the physiological variability of the clavicle length, which ranges from 140 to 158 mm in the healthy population. Shortening of the bone by more than 9.7% should be the cut-off for predicting failure of conservative treatment.
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Affiliation(s)
- Silvana De Giorgi
- Department of Clinical Methodology and Medical-Surgical Technologies - Orthopaedics Section, University General Hospital, Piazza G,Cesare 11, 70124 Bari, Italy.
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Clavicle and acromioclavicular joint injuries: a review of imaging, treatment, and complications. Skeletal Radiol 2011; 40:831-42. [PMID: 20526774 DOI: 10.1007/s00256-010-0968-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 05/04/2010] [Accepted: 05/11/2010] [Indexed: 02/02/2023]
Abstract
Fractures of the clavicle account for 2.6-5% of all fractures. Clavicular fractures have traditionally been treated conservatively, however, there has recently been increased interest in surgical repair of displaced clavicular fractures, with resultant lower rates of nonunion and malunion. Treatment of acromioclavicular (AC) separation has traditionally been conservative, with surgery reserved for patients with chronic pain or significant dislocation and acute soft tissue injury. It is important for the radiologist to become familiar with the surgical techniques used to fixate these fractures as well as the post-operative appearance and potential complications.
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Smekal V, Irenberger A, Attal RE, Oberladstaetter J, Krappinger D, Kralinger F. Elastic stable intramedullary nailing is best for mid-shaft clavicular fractures without comminution: results in 60 patients. Injury 2011; 42:324-9. [PMID: 20394920 DOI: 10.1016/j.injury.2010.02.033] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Revised: 02/19/2010] [Accepted: 02/26/2010] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Elastic stable intramedullary nailing (ESIN) of displaced mid-shaft clavicular fractures is a minimally invasive technique which was reported to be an easy procedure with low complication rates, good cosmetic and functional results, restoration of clavicular length and fast return to daily activities. Recent studies, however, also report on higher complication rates and specific problems with the use of this technique. This prospective study compares ESIN with non-operative treatment of displaced mid-shaft clavicular fractures. METHODS Between December 2003 and August 2007, 120 patients volunteered to participate. Of these, 112 patients completed the study (60 in the operative and 52 in the non-operative group). Patients in the non-operative group were treated with a simple shoulder sling. In the operative group, intramedullary stabilisation was performed within 3 days of the trauma. Clavicular shortening was determined after trauma and after osseous consolidation on thorax posteroanterior radiographs as the proportional length difference between the left and right side with the uninjured side serving as a control for clavicular length (100%). Radiographic union was assessed every 4 weeks on 20 degrees cephalad anteroposterior and posteroanterior radiographs of the clavicle. Constant shoulder scores and DASH scores (DASH, disabilities of the arm, shoulder and hand) were assessed at final follow-up after 2 years. RESULTS ESIN led to faster osseous healing and better restoration of clavicular length in simple fractures. We were not able to restore clavicular length in comminuted fractures using ESIN. Functional outcome at a mean follow-up of 24 months (range: 22-27 months) was better in the operative group. Delayed union and non-union accounted for the majority of complications in the non-operative group. In the operative group, telescoping was the main complication, which occurred in complex fractures with severe post-traumatic shortening only. CONCLUSION We recommend ESIN for all simple displaced mid-shaft clavicular fractures in order to minimise the rate of delayed union, non-union and symptomatic mal-union. We also recommend ESIN in comminuted fractures with moderate (< or = 7%) post-traumatic shortening, as they will heal with moderate shortening. In comminuted fractures with severe shortening, however, we recommend plate osteosynthesis in order to provide for stability, clavicular length and endosteal blood supply.
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Affiliation(s)
- Vinzenz Smekal
- Department of Trauma Surgery and Sports Medicine, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria.
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Chen YF, Zeng BF, Chen YJ, Wang HM, Xue JF, Chai YM, Xie XT, Zhang C. Clinical outcomes of midclavicular fractures treated with titanium elastic nails. Can J Surg 2010; 53:379-384. [PMID: 21092430 PMCID: PMC2993033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2010] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND Midclavicular fractures are common clinically, accounting for about 76% of all clavicular fractures. Recent studies have revealed a previously unrecognized incidence of nonunion and malunion after conservative treatment of more severe midclavicular fractures. Our aim was to evaluate the clinical outcomes of midclavicular fractures treated with titanium elastic nails. METHODS From February 2005 to February 2007, 41 patients with displaced midclavicular fractures received open reduction and internal fixation with a titanium elastic nail inserted through the sternal end of the clavicle. We evaluated the visual analogue scale (VAS), the Constant score and the Disabilities of the Arm, Shoulder and Hand (DASH) scale to determine outcomes. RESULTS A mean follow-up of 14.5 months (range 7-24 mo) revealed radiographic fracture union in all patients with an average clinical healing time of 2.2 months. Mean subjective pain 3 days after surgery was significantly lower than the day before surgery (p < 0.001). The mean range of motion 3 days after surgery was significantly improved compared with the day before surgery (p < 0.001). The nails were removed in all patients a mean of 7.2 months (range 5.4-9.5 mo) after surgery, and no fractures recurred. The mean postoperative DASH score was 2.5 (range 0.5-8.0) and the mean postoperative Constant score was 95.2 (range 86.5-97.0). CONCLUSION Limited open reduction and internal fixation with titanium elastic nails is a safe and minimally invasive surgical procedure for the treatment of displaced midclavicular fractures in adults and achieves good functional results and high patient satisfaction.
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Affiliation(s)
| | - Bing-fang Zeng
- Correspondence to: Dr. Bing-fang Zeng, Department of Orthopaedic Surgery, Shanghai Sixth People’s Hospital, Jiaotong University, 600 Yishan Rd. Shanghai 200233, China,
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Smekal V, Deml C, Kamelger F, Dallapozza C, Krappinger D. Corrective osteotomy in symptomatic midshaft clavicular malunion using elastic stable intramedullary nails. Arch Orthop Trauma Surg 2010; 130:681-5. [PMID: 19885664 DOI: 10.1007/s00402-009-0994-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Indexed: 11/25/2022]
Abstract
INTRODUCTION It is our goal to present an alternative, less invasive surgical technique for corrective osteotomy in symptomatic midshaft clavicular malunion using elastic stable intramedullary nails (ESIN) and to present our results in a consecutive patients series. METHOD AND PATIENTS Between January 2003 and December 2006, five patients aged between 23 and 44 years presented with a symptomatic malunion after nonoperative treatment of displaced midshaft clavicular fractures. Corrective osteotomy was performed without bone grafting. RESULTS The osteotomy sites united in all patients after a mean of 4.4 months. The nails were removed in all patients after 7 months. At final follow-up, DASH and Constant Scores were significantly improved compared to preoperative values. Patients were significantly more satisfied with cosmetical appearance and overall outcome. Clavicular shortening was also significantly improved. Elastic stable intramedullary nailing leads to favourable results in corrective osteotomy of malunited midshaft clavicular fractures. CONCLUSION We therefore recommend this technique for corrective osteotomy of symptomatic midshaft clavicular malunions.
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Affiliation(s)
- Vinzenz Smekal
- Department of Trauma Surgery and Sports Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria.
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Smekal V, Oberladstaetter J, Struve P, Krappinger D. Shaft fractures of the clavicle: current concepts. Arch Orthop Trauma Surg 2009; 129:807-15. [PMID: 18989685 DOI: 10.1007/s00402-008-0775-7] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2008] [Indexed: 11/28/2022]
Abstract
Fractures of the clavicle are common and have been typically addressed to nonoperative treatment. Favorable results, which predominantly were achieved in the young and adolescents, were supposed to be usual in midshaft clavicular fractures. However, in the presence of comminution or complete displacement, especially when occurring in females or elderly patients, there is a marked risk of nonunion, malunion, and poor outcome. Thus, many authors prefer primary surgical stabilization, when risk factors add up. Plate fixation and intramedullary stabilization seem to be equally favored. Though, indications for operative management remain controversial. Further prospective randomized comparative clinical trials are necessary for a well-founded risk-benefit analysis.
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Affiliation(s)
- Vinzenz Smekal
- Department of Trauma Surgery and Sports Medicine, Innsbruck Medical University, Innsbruck, Austria.
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Frigg A, Rillmann P, Perren T, Gerber M, Ryf C. Intramedullary nailing of clavicular midshaft fractures with the titanium elastic nail: problems and complications. Am J Sports Med 2009; 37:352-9. [PMID: 19118080 DOI: 10.1177/0363546508328103] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Intramedullary nailing of clavicular midshaft fractures using the titanium elastic nail has been described as a technically easy, minimally invasive operation with few complications and an early return to competitive sports. HYPOTHESIS The results reported thus far have been positive. The titanium elastic nail is associated with multiple intraoperative and postoperative problems. STUDY DESIGN Case series; Level of evidence, 4. METHODS From April 2004 to March 2007, 34 patients at our institution were treated with intramedullary nailing. A standard titanium elastic nail was used in 19 cases and a titanium elastic nail with an end cap in 15 cases. The titanium elastic nail was inserted and advanced under fluoroscopic control. A short incision at the fracture site was made for open reduction if needed. Postoperatively, free range of motion was allowed. RESULTS In 62% of patients, open reduction was necessary independent of fracture type, flattening of the titanium elastic nail, or transverse fragments. Operating time was 44 minutes (range, 10-105 minutes) and fluoroscopy time 9 minutes (range, 2-25 minutes). In 70% of patients, problems or complications occurred (7 medial perforations, 7 lateral penetrations, 1 titanium elastic nail breakage, 1 titanium elastic nail dislocation, 7 hardware irritations). The reoperation rate was 36%. Medial migration and pain were significantly reduced by using an end cap. CONCLUSION Intramedullary nailing of clavicular midshaft fractures using the titanium elastic nail is a technically demanding operation with various complications in the postoperative phase. This study might explain why the implant has not yet achieved widespread application, despite the fact that other authors have reported good results. Amending the operative technique and postoperative treatment might improve the outcome in the future.
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Affiliation(s)
- Arno Frigg
- Department of Trauma Surgery, Davos Hospital, Davos Platz, Switzerland.
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Müller MC, Burger C, Florczyk A, Striepens N, Rangger C. [Elastic titanium nails in minimally invasive osteosynthesis for mid-clavicular fractures]. Chirurg 2007; 78:349-55. [PMID: 17151840 DOI: 10.1007/s00104-006-1284-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND In up to 31% of cases, conservative treatment of mid-clavicular fractures leads to unsatisfactory results. The aim of this study was to define the value of minimally invasive elastic stable intramedullary nailing (ESIN) of mid-clavicular fractures with titanium elastic nails. MATERIAL AND METHODS Within 5 years, ESIN was performed in 45 patients. We studied the functional results and complications. RESULTS Retrospectively we analysed the results of all patients at a mean follow-up of 24.7+/-2.4 months. Iatrogenic perforation of the lateral cortex occurred twice and medial migration in eight patients. Superficial skin infection developed in one. Nail breakage after fracture healing was observed twice. Twelve patients sustained clavicular shortening of > or =5 mm in relation to the intact contralateral side. After 6 months the mean constant score was 94.3+/-2 points, and the mean DASH score was 5.4+/-2.2 points. CONCLUSION Intramedullary stabilisation of mid-clavicular fractures with titanium elastic nails is a minimally invasive technique with good functional results. Patients must be informed about the possibility of open reduction in about half of the cases as well as shoulder asymmetry, migration of the nail, and iatrogenic nerve and vessel injury.
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Affiliation(s)
- M C Müller
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Strasse 25, 53105 Bonn.
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Abstract
Clavicular fractures represent 2.6% to 5% of all fractures, and middle third fractures account for 69% to 82% of fractures of the clavicle. The junction of the outer and middle third is the thinnest part of the bone and is the only area not protected by or reinforced with muscle and ligamentous attachments. These anatomic features make it prone to fracture, particularly with a fall on the point of the shoulder, which results in an axial load to the clavicle. Optimal treatment of nondisplaced or minimally displaced midshaft fracture is with a sling or figure-of-8 dressing; the nonunion rate is very low. However, when midshaft clavicular fractures are completely displaced or comminuted, and when they occur in elderly patients or females, the risk of nonunion, cosmetic deformity, and poor outcome may be markedly higher. Thus, some surgeons propose surgical stabilization of a complex midshaft clavicular fracture with either plate-and-screw fixation or intramedullary devices. Further randomized, prospective trials are needed to provide better data on which to base treatment decisions.
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Affiliation(s)
- Kyle J Jeray
- Orthopaedic Surgery Education, Greenville Hospital Systems, Greenville, SC 29605, USA
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Andermahr J, Jubel A, Elsner A, Prokop A, Tsikaras P, Jupiter J, Koebke J. Malunion of the clavicle causes significant glenoid malposition: a quantitative anatomic investigation. Surg Radiol Anat 2006; 28:447-56. [PMID: 16943999 DOI: 10.1007/s00276-006-0122-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2005] [Accepted: 03/27/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE An experimental cadaver model was used to assess the effects of a malunited fracture of the middle third of the clavicle on the functional anatomy of the shoulder joint. METHOD Anatomic samples were prepared with simulated shortening and axial malposition of the clavicle. From these, alterations in glenoid fossa position were measured and depicted graphically. RESULTS Healing of clavicle fractures with bony shortening leads to a ventromedialcaudal shift in glenoid fossa position. The following malpositions of the clavicle lead to the respective glenoid fossa positional changes: caudal deviation leads to a mediocaudal shift, cranial deviation leads to a dorsolateral shift of the glenoid fossa, ventral deviation causes a ventrolateral shift, dorsal deviation leads to mediocaudal shift of the fossa, cranial rotation leads to ventrolateral shift in fossa position, and caudal rotation leads to a dorsomedial shift in glenoid fossa position. CONCLUSION Clinical implication of these data is that bony shortening in combination with caudal displacement leads to distinct functional deficits in abduction, particularly overhead motion. Using the above data, a vector model was created to calculate position of the glenoid fossa dependent on clavicle position/malposition. The model is a valuable tool to be used for planning open reduction and fixation of clavicular fractures or malunions.
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Affiliation(s)
- Jonas Andermahr
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital of Cologne, Joseph-Stelzmann-Strasse 9, Cologne, 50924, Germany.
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Andermahr J, Jubel A, Elsner A, Johann J, Prokop A, Rehm KE, Koebke J. Anatomy of the clavicle and the intramedullary nailing of midclavicular fractures. Clin Anat 2006; 20:48-56. [PMID: 16506232 DOI: 10.1002/ca.20269] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Intramedullary fixation is used increasingly to treat clavicular fractures. Anatomical variations in the clavicle of relevance to this procedure are analyzed. The length, diameters and curvature of the clavicle were measured in 196 specimens from the dissecting room. The calcium bone density was analyzed in 300 cross-sectional samples of 100 specimens. The thickness of cortical and medullary bone of 70 slices was analyzed from freshly plastinated clavicles with implants in place. The female clavicle was shorter, less curved, and had a lower concentration of calcium than the male clavicle. Measurement of cortical thickness showed a mean value of 1.05 +/- 0.23 mm at the most sternal measuring point, 2.05 +/- 0.29 mm at the midpoint of the clavicle, and 0.95 +/- 0.35 mm at the acromial end. The thinnest regions were the medial ventral cortex and the dorsal acromial cortex. These measurements explain clinical observations on nail perforation. The diameter of the medullary canal measured 6.7 +/- 2.6 mm at its narrowest part, so that reaming (i.e., predrilling the medullary canal) prior to 3.5 mm titanium nail insertion is not necessary. The main difficulties encountered when placing a nail are secondary to the S-curvature of the clavicle. In 80% of fractures, the break is located at the narrowest diameter of the medullary canal. Thus, the clavicle displays definite gender- and side-specific anatomical features in terms of length, diameter, curvature, and calcium concentration. These should be considered when performing intramedullary fixation.
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Affiliation(s)
- Jonas Andermahr
- Clinic of Trauma-, Hand- and Reconstructive Surgery, University of Cologne, Köln, Germany.
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Parsons M, Blitzer CM. Small-Incision, Intramedullary Compression Osteosynthesis of Acute and Non-United Midshaft Clavicle Fractures. TECHNIQUES IN SHOULDER AND ELBOW SURGERY 2005. [DOI: 10.1097/01.bte.0000187285.99726.0e] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Jubel A, Andermahr J, Prokop A, Lee JI, Schiffer G, Rehm KE. Die Behandlung der diaphysären Klavikulafraktur. Unfallchirurg 2005; 108:707-14. [PMID: 15977006 DOI: 10.1007/s00113-005-0970-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The aim of this prospective study was to compare the results achieved in two groups of patients treated for mid-clavicular fracture. METHODS The first group of 27 patients was treated nonoperatively with a rucksack bandage, whereas the second group underwent intramedullary fixation with a titanium pin, using a minimally invasive technique. Within the follow-up period of 6 months, results were evaluated seven times. RESULTS During the whole period significantly (p<0.05) better results were observed in the group of operated patients concerning shoulder function, Constant score, DASH score, personal satisfaction, pain, and cosmetic result. In the second group return to work occurred in less than half the time of the first group. CONCLUSION Intramedullary nailing of mid-clavicular fractures is a safe and minimally invasive operation technique. Early functional and cosmetic results are not worse than results after nonoperative treatment with a rucksack bandage.
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Affiliation(s)
- A Jubel
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universität Köln.
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Jubel A, Andermahr J, Weisshaar G, Schiffer G, Prokop A, Rehm KE. Die intramedulläre Nagelung (ESIN) von Klavikulapseudarthrosen. Unfallchirurg 2005; 108:544-50. [PMID: 15868133 DOI: 10.1007/s00113-005-0937-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This prospective clinical trial was performed to assess healing, clinical outcome and complications after intramedullary nailing of midshaft clavicular nonunions. Over 2.5 years, 14 patients were included. Exclusion criteria were pathological fractures, bony defects, previous operative therapy, atrophic and infection pseudarthrosis and the patient's age: <18 years or >70 years. Results were evaluated after 3, 6, 12 and 18 months. Beginning 3 months after the operation, pain (VAS), subjective satisfaction, Constant score and DASH score were significantly better than preoperatively during the follow-up period (p<0.001). There were no infections, no implant displacements or refractures.Intramedullary fixation of midshaft clavicular nonunions with an elastic titanium nail is a safe, minimally invasive surgical technique, producing excellent functional and cosmetic results without additional bone grafting.
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Affiliation(s)
- A Jubel
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie der Universität zu Köln.
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