Clavicular non-union treated with fixation using locking compression plate without bone graft

[Clavicle nonunion]

After conservative treatment nonunion (pseudarthrosis) of the clavicle can be observed approximately 10 times more frequently (15-24%) than after surgical treatment (1.4%). Risk factors include the fracture location, displacement, fracture type, sex, the severity of the accident and refractures. The diagnosis of pseudarthrosis of the clavicle can be made by a thorough medical history, clinical examination and imaging procedures. The main symptom is pain, often accompanied by malalignment, instability, neurological symptoms and restricted mobility of the affected shoulder. The diagnosis is confirmed by X‑ray images and, if necessary, a computed tomography (CT) scan. Pseudoarthrosis is classified according to the morphological appearance in X‑ray images and the cause. A differentiation is made between vital and nonvital pseudarthroses. Only symptomatic pseudarthrosis requires treatment. Nonoperative methods, such as magnetic field therapy or ultrasound are minimally effective. Surgical interventions are indicated for pain, movement restrictions or neurovascular problems. The goals of surgical treatment are to restore the vitality, bone length and stability through angular stable osteosynthesis. In cases of surgical pretreatment the anteroinferior plate position offers a good alternative to the superior plate position. In some cases double plating osteosynthesis can be indicated. Autogenous bone material, allogeneic substitute material and vascularized grafts are used for bony defects. Surgical treatment shows high rates of healing but also carries an increased risk of infection.

Clavicle Shaft Non-Unions-Do We Even Need Bone Grafts?

Background: The surgical treatment of bony non-unions is traditionally performed with additional bone grafts when atrophic and/or stronger implants when hypertrophic. In the case of the clavicle shaft, however, in our experience, a more controversial method where no additional bone graft is needed leads to equally good consolidation rates, independent of the non-union morphology. This method requires the meticulous anatomical reconstruction of the initial fracture and fixation according to the AO principle of relative stability. Methods: A retrospective review following the STROBE guidelines was performed on a consecutive cohort of all patients who received surgical treatment of a midshaft clavicle non-union at the Medical Center of the University of Freiburg between January 2003 and December 2023. Patients were identified using a retrospective systematical query in the Hospital Information System (HIS) using the International Statistical Classification of Diseases and Related Health Problems Version 10 (ICD-10) codes of the German Diagnosis Related Groups (G-DRG). Two groups were formed to compare the consolidation rates of patients who received additional bone grafting from the iliac crest with those of patients who did not. A 3.5 mm reconstruction LCP plate was used in all patients. Consolidation rates were evaluated using follow-up radiographs and outcomes after material removal with a mean follow-up of 31.5 ± 44.3 months (range 0-196). Results: Final data included 50 patients, predominantly male (29:21); age: 46.0 ± 13.0 years, BMI 26.1 ± 3.7. Autologous bone grafts from the iliac crest were used in 38.0% (n = 19), while no bone addition was used in 62.0% (n = 30). Six patients were lost to follow-up. Radiological consolidation was documented after a mean of 15.1 ± 8.0 months for the remaining 44 patients. Consolidation rates were 94.4% (n = 17) in patients for whom additional bone grafting was used and 96.2% (n = 25) in patients for whom no graft was used. There was no relevant difference in the percentage of atrophic or hypertrophic non-unions between both groups (p = 0.2425). Differences between groups in the rate of consolidation were not significant (p = 0.7890). The complication rate was low, with 4.5% (n = 2). Conclusions: Independent of the non-union morphology, non-unions of the clavicle midshaft can be treated successfully with 3.5 mm locking reconstruction plates without the use of additional bone grafting in most cases.

Plate augmentation and hybrid bone grafting are effective treatments for atrophic nonunion of the femur with the original intramedullary nail retained in situ

The purpose of this study is to evaluate the efficacy of plate augmentation and hybrid bone grafting for treating atrophic nonunion of the femur with original intramedullary nail retained in situ.In this study, 36 patients with atrophic nonunion of the femur who underwent surgery using the technique of plate augmentation and a hybrid bone grafting while retaining the original intramedullary nail in situ in Xi'an Honghui Hospital from January 2019 to December 2021 were enrolled. 28 patients who met the inclusion and exclusion criteria were ultimately included in the study. These 28 patients, consisting of 20 males and 8 females with a mean age of 38 years, were evaluated based on factors such as operation time, intraoperative blood loss, the average hospitalization days. Additionally, the results and function of these patients were evaluated by union time, Wu's scores of limb function and incidence of serious complications.All 28 patients achieved bone union at the 12 month follow-up, with an average follow-up time of 14.6 ± 4.2 months.The average operation time was 68.3 ± 11.2 min, and the average intraoperative blood loss was 140 ± 22.6 ml. Patients were hospitalized for an average of 5.8 ± 1.1 days. Full clinical and radiological bone union was achieved on average at 5.1 ± 1.9 months. The mean value of Wu's scores at the 12 month follow-up was significantly higher than before the operation. Limb function was excellent in 27 patients and good in one patient at the 12 month follow-up. However, five patients experienced the lower limb vein thrombosis, including one deep vein thrombosis and four lower limb intermuscular vein thromboses. One patient had a superficial infections of the surgical incision site, while three patients reported pain and numbness where their iliac bone graft was extracted at the 12 month follow-up. The technique of plate augmentation and hybrid bone grafting, combined with retaining the original intramedullary nail in situ has been shown to be a safe, effective, simply and standardizable practice for treating atrophic femoral nonunion with an intact original IMN fixation.

Clavicle Nonunion and Malunion: Surgical Interventions for Functional Improvement

Clavicle nonunion and malunion are relatively uncommon but, when symptomatic, can result in pain and dysfunction that requires surgical intervention. Various reconstructive and grafting techniques are available to achieve stable fixation and union. In the setting of persistent nonunion, vascularized bone grafting may be necessary. A thorough understanding of the patient's type of nonunion and potential for healing is crucial for achieving satisfactory results because is thoughtful preoperative planning and surgical fixation.

No decay in outcomes at a mean 8 years following surgical treatment for aseptic fracture nonunion

PURPOSE

The purpose of this study is to compare medium to long term patient reported outcomes to one-year data for patients treated surgically for an aseptic fracture nonunion.

METHODS

305 patients surgically treated for a fracture-nonunion were prospectively followed. Data collected included pain scores measured by the Visual Analog Scale (VAS), clinical outcomes assessed by the Short Musculoskeletal Functional Assessment (SMFA), and range of motion. 75% of patients in this study had lower extremity fracture nonunions and 25% had upper extremity fracture nonunions. Femur fracture nonunions were the most common. Data at latest follow-up was compared to one-year follow-up using the independent t-test.

RESULTS

Sixty-two patients were available for follow-up data at an average of eight years. There were no differences in patient reported outcomes between one and eight years according to the standardized total SMFA (p = 0.982), functional index SMFA (p = 0.186), bothersome index SMFA (p = 0.396), activity index SMFA (p = 0.788), emotional index SMFA (p = 0.923), or mobility index SMFA (p = 0.649). There was also no difference in reported pain (p = 0.534). Range of motion data was collected for patients who followed up in clinic for an average of eight years after their surgical treatment. 58% of these patients reported a slight increase in range of motion at an average of eight years.

CONCLUSION

Patient functional outcomes, range of motion, and reported pain all normalize after one year following surgical treatment for fracture nonunion and do not change significantly at an average of eight years. Surgeons can feel confident in counseling patients that their results will last and they do not need to follow up beyond one year, barring pain or other complications.

LEVEL OF EVIDENCE

Level IV.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

The technique of "autologous bone grafting through channels" combined with double-plate fixation is effective treatment of femoral nonunion

PURPOSE

The aims of this retrospective study were to evaluate the effective treatment of femoral nonunion using the technique of "autologous bone grafting through channels" combined with double-plate fixation.

METHODS

In this study, 186 patients with nonunion fracture of femur who underwent surgery using the technique of "autologous bone grafting through channels" combined with double-plate fixation in Hong Hui Hospital from May 2010 to July 2020 were enrolled. Totally, 122 males and 64 females with mean age of 44 years were evaluated. These patients were evaluated for the full clinical and radiological union time, duration of follow-up, levels of post-operative limb shortening, and range of motion of adjacent joints, and incidence of serious complications.

RESULTS

The mean follow-up time was 22 ± 6.2 months (range 12-44 months). Mean union time from surgery using our technique to full clinical and radiological union was 7.6 ± 1.2 months (range 4-9 months). All patients have achieved the union after one operation or two operations using the technique. The one-operation union rate is 98.4%. Post-operative severe complications were seen in seven patients which included deep vein thrombosis; the surgical site infection and the fracture nonunion. The range of motion in the adjacent joint of 17.7% (33/186) in all patients have an effect to the limb function. Six patients have the limb shortening more than 10 mm after surgery.

CONCLUSION

The technique of "autologous bone grafting through channels" combined with double-plate fixation is showed to be safe, effective, and easy to master and operate surgical option for treating the femoral nonunion.

Acromioclavicular Joint Injury and Repair

The acromioclavicular (AC) joint is commonly injured in athletes participating in contact and overhead throwing sports. Injuries range from simple sprains to complete ligamentous disruption, and they are classified by the established Rockwood grading system. High-grade injuries are associated with fractures around the AC joint and disruption of the superior shoulder suspensory complex, a ring of osseous and ligamentous structures at the superior aspect of the shoulder. Radiographs are the mainstay of imaging of the AC joint, with magnetic resonance imaging reserved for high-grade injuries to aid classification and plan surgical management. Low-grade AC joint injuries tend to be managed conservatively, but a wide range of surgical procedures have been described for higher grade injuries and fractures around the AC joint. This review illustrates the anatomy of the AC joint and surrounding structures, the imaging features of AC joint injury, and the most commonly performed methods of reconstruction and their complications.

Plate fixation of midshaft clavicle fractures for delayed union and non-union is a cost-effective intervention but functional deficits persist at long-term follow-up

BACKGROUND

The primary aim of this study was to compare the long-term functional outcome of midshaft clavicle fracture fixation for delayed (≥3 month) and non-union (≥6 month) compared to a matched cohort of patients that achieved union with non-operative management. The secondary aim was to assess cost-effectiveness of fixation.

METHODS

A consecutive series of patients over 10-years were retrospectively reviewed using the QuickDASH, Oxford Shoulder Score and EuroQol five-dimension summary index (EQ-5D). These patients were compared to a matched cohort that achieved union after non-operative management using propensity score matching.

RESULTS

Sixty patients (follow-up 79%, n = 60/76) at 4.1 years post-operative (1.1-10.0 years) had a QuickDASH of 16.5 (95% CI 11.6-21.5), Oxford Shoulder Score 41.5 (39.0-44.1) and EQ-5D 0.7621 (0.6822-0.8421). One in five patients were dissatisfied with their final outcome (n = 13/60). Functional outcome was inferior following fixation when compared to patients that united with non-operative management (QuickDASH 16.5 vs. 5.5, p < 0.001 and EQ-5D 0.7621 vs. 0.9073, p = 0.001). However, significant improvements were found when compared to pre-operative scores (QuickDASH p < 0.001 and EQ-5D p < 0.001). The cost per QALY for fixation was £5624.62 for the study cohort.

CONCLUSIONS

Clavicle fixation for delayed and non-union is a cost-effective intervention but outcomes are worse compared to patients that unite with non-operative management.

Safe and Effective Treatment of Compromised Clavicle Fracture of the Medial and Lateral Third Using Focused Shockwaves

A delay or failure to heal is the most common possible complication in clavicle fractures, especially in cases primarily treated conservatively. As the current standard therapy, surgical revision achieves good healing results, but is associated with potential surgery-related complications. Shockwave therapy as a non-invasive therapy shows similar reasonable consolidation rates in the non-union of different localizations, but avoids complications. Compromised clavicle fractures in the middle and lateral third treated with focused high-energy shockwave therapy were compared with those treated with surgical revision (ORIF). In addition, a three-dimensional computer simulation for evaluating the pressure distribution during shockwave application accompanied the clinical study. A comparable healing rate in bony consolidation was achieved in both groups. Significantly fewer complications, however, occurred in the shockwave group. The simulations showed safe application in this instance, particularly in avoiding lung tissue affection. When applied correctly, shockwaves represent a safe and promising therapy option for compromised clavicle fractures in the middle and lateral third.

Treatment of a Recalcitrant Non-union of the Clavicle

Background

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

Materials and methods

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

Results

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

Conclusion

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

How to cite this article

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Displaced mid-shaft clavicular fractures: state of the art for athletes and young active people

INTRODUCTION

Fractures ofthe clavicle are frequent injuries (between 4 and 10% of adult fractures) and mid-shaft diaphyseal fractures represent more than 80% of clavicle fractures. In a recent study from the USA in 2019, an incidence of 22.4 fractures per year per 100,000 people was reported. Multiple injury mechanisms are recognised, with sport accounting for 50 to 85% of these injuries. There is little or no consensus as to the optimal treatment but in recent years multiple studies have suggested operative management should be favoured in athletes and young active patients.

OBJECTIVES

These are (1) to present the anatomy and the anatomical-pathology of the fractures of the clavicle as well as the mechanisms of injury, (2), (3) to describe non-operative and operative treatment methods, (4) to review the literature around different treatment modalities and (5) to attempt to describe the best treatment for athletes.

METHODS

To collect and analyse the most recent articles of the literature regarding the management of displaced mid-shaft fractures of the clavicle for athletes and young active people.

RESULTS

Looking at studies of the general population, the results tend to favour surgical treatment with a smaller incidence of non-union and faster return to function. These results are mirrored in the athlete population where several studies have shown excellent anatomic restoration and functional recovery after plate fixation.

CONCLUSION

Based on this analysis, with the exception of patients who refuse operative management after an informed discussion, the treatment of choice in displaced clavicle fractures in athletes seems to be operative treatment with a plate and screws. However, prospective randomised studies comparing non-surgical treatment and plate osteosynthesis are missing and it is not possible to state that the latter is the best treatment.

Fracture nonunion in long bones: A literature review of risk factors and surgical management

Nonunion following a long bone fracture causes considerable morbidity when it occurs. Risk factors depend on specific fractures but there is a complex interplay of injury severity, comorbidities, patient medication and infection. The majority of nonunions occur after long bone fractures with the tibia, femur, forearm, humerus and clavicle predominating. Despite interest in the biological augmentation of fracture healing, the majority of nonunions can be effectively managed with conventional surgical techniques. In this review we present a review of risk factors for nonunion and the outcome following surgical management.

The efficiency of internal fixation with bone grafting at docking sites after bone transport for treatment of large segmental tibial bone defects

OBJECTIVE

To investigate the efficiency of internal fixation with bone grafting after bone transport for treatment in large-segment bone defects of the lower-limbs.

METHODS

This prospective study recruited 100 patients with lower limb tibial segmental bone defects, and based on a random number table they were divided into a control group (n=50, simple bone transport surgery) or an observation group (n=50, internal fixation with bone grafting at docking site after bone transport). The fracture healing time, bone healing index, external fixation time in both groups were compared. The knee function, joint range of motion, and the function of the ankle and hindfoot before and after surgery were also analyzed and compared between the two groups respectively, as well as the rate of complications in both groups was calculated.

RESULTS

Compared with the preoperative condition of patients, the Lysholm knee scale, ROM score, and AHS scores of patients in the two groups were significantly increased 10 months after surgery, moreover, those scores of the observation group were higher than that of the control group (P<0.05). The fracture healing time and external fixation time of patients were significantly declined in the observation group when compared to the control group, additionally, the bone healing index was also reduced significantly (P<0.05). When compared with patients in the control group, the ratios of bone healing and lower-limb functional recovery of patients in the observation group were significantly higher while the total complication incidence was decreased remarkably (P<0.05).

CONCLUSION

Internal fixation with bone grafting after bone transport can promote fracture healing, improve joint function, and reduce complications during treatment for a large segmental bone defects in the lower limbs.

Surgical outcome of upper extremity fractures in patients with Parkinson's disease

Patients with Idiopathic Parkinson’s Disease (PD) have an increased risk for fractures. Currently, many studies have reported inferior outcomes in PD patients after orthopedic procedures. However, there are very few studies assessing the outcome of upper extremity fractures (UEF) in PD patients. In this study, we reviewed 40 patients with PD that received surgical intervention for an UEF. We retrospectively reviewed patients with PD that received surgical fixation for an UEF at a tertiary trauma center. The primary objective was to determine the treatment failure rate after surgical fixation. The secondary outcomes include mode of failure, time to treatment failure, length of hospital stay, readmission rate, reoperation rate, and postoperative complications. A total of 40 patients with PD (42 fractures) underwent surgery. The most common fracture type was radius fracture (n = 19), followed by humerus fracture (n = 15), metacarpal/phalangeal fracture (n = 5), clavicle fracture (n = 2) and olecranon fracture (n = 1). The overall treatment failure rate was 40.5% (n = 17). The time to treatment failure was 1.24 ± 3.1 months and length of hospital stay was 6 ± 3.9 days, the readmission rate within 30 days was 14% (n = 6), and reoperation rate was 14% (n = 6). The complication rate was 16.6% (n = 7) and patients with humeral fractures appeared to have the longest hospital stays (6.6 days) and increased complication rates (13%, n = 2). Patients with PD have high treatment failure rates despite surgical fixation of an UEF. These patients often have a frail status with multiple comorbidities which may complicate their postoperative course.

Level of evidence level 4 case series.