Concomitant glenohumeral injuries in patients with distal clavicle fractures undergoing arthroscopic-assisted surgery: a systematic review

Pharmacological agents for bone fracture healing: talking points from recent clinical trials

INTRODUCTION

Pharmacological strategies might influence bone healing in terms of time to union or quality of mature bone. This expert opinion discussed the current level I evidence on the experimental pharmacological agents used to favor bone fracture healing.

AREAS COVERED

This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the 2020 PRISMA statement. In April 2023, the following databases were accessed: PubMed, Web of Science, Google Scholar, Embase. All the randomized clinical trials investigating pharmacological agents for bone fracture healing were accessed. No time constraint was set for the search. The search was restricted to RCTs. No additional filters were used in the database search. Data from 19 RCTs (4067 patients) were collected. 78% (3160 of 4067) were women. The mean length of the follow-up was 9.3 months (range, 1-26 months). The mean age of the patients was 64.4 years (range, 8-84 years).

EXPERT OPINION

Calcitonin could favor bone fracture healing. Bisphosphonates (alendronate, zoledronate, clodronate), monoclonal antibodies (denosumab, romosozumab), statins, vitamin D and calcium supplementation, strontium ranelate, and ibuprofen did not influence bony healing. Concerning the effect of parathormone, current level I evidence is controversial, and additional studies are required.

LEVEL OF EVIDENCE

Level I, systematic review of RCTs.

The Accuracy of Distal Clavicle Fracture Classifications-Do We Need an Amendment to Imaging Modalities or Fracture Typing?

Background: Despite its fair-to-moderate reliability, the “modified Neer classification” is widely accepted and used. The purpose of this study was to reevaluate its applicability. Methods: Of n = 59 patients with distal clavicle fractures, fractures were classified on standard radiographs. Afterwards, an MRI examination was performed, and fractures reclassified. The primary outcome parameter was quantifying the rate of misclassification. The secondary outcome parameters were the evaluation of the ligamentous injury constellations. Results: In all cases, the fracture course and ligamental integrity could be assigned to the fracture type. Correction of the classification was necessary in n = 5 (8.5%) cases. In n = 3 (5%) cases, a correction was necessary from Neer I to Craig IIc and thus from conservative to operative treatment. Mean coracoclavicular distance (CCD) in Neer I was 10.2 ± 2.1 mm versus 14.2 ± 3.9 mm in Craig IIc (p = 0.02). The mean fracture angle in Neer I was 25.1 ± 3.3° versus 36.8 ± 4.4° in Craig IIc (p = 0.02). Conclusion: Cross-sectional imaging resulted in higher precision. Nevertheless, recommendations remain for standard radiographs. The CCD and fracture angle should be considered. An angle of >30° can be assumed as a parameter of instability. A previously undescribed fracture type does not seem to exist. The modified Neer classification is an appropriate and complete fracture classification.

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

Background

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

Methods

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

Results

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

Conclusions

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

Conoid tubercle angle: attention should be paid to supraclavicular plate fixation

Background

The surgical protocol of ORIF for the treatment of mid-shaft clavicle fractures is common. However, poor plate fit or overhang usually occurs when the straight plate is selected for superior fixation. This is because the upper edge of the clavicle is not flat but has an angulation near the conoid tubercle. We termed that angulation, conoid tubercle angle (CTA). Supposed the straight plate is forcibly attached to the surface of the clavicle, it will potentially cause misalignment of the fracture end and with that comes a change of CTA. In this case, choosing the contoured plate, such as a commercial pre-contoured anatomic plate or manual-contoured plate, for superior fixation seems to meet the requirements for both plate fit and fracture alignment. Hence, we retrospectively compared the radiological parameters, including the plate overhang, and the alignment of the fractures reflected by the CTA, between the contoured plate (CP) and straight plate (SP) groups, to draw attention to the CTA and its effects to supraclavicular plate fixation.

Methods

From March 2018 to April 2021, 217 patients with clavicle fractures that met the inclusion criteria but not the exclusion criteria were included in our study. 112 patients were enrolled into the straight plate group (SP) and 105 patients into the contoured plate group (CP). Besides that, 154 healthy adults were recruited into the health group (HA).

Results

Patients were followed up for 6 to 40 months postoperative. A normal CTA (164.54 ± 4.78°) was obtained from the HA group. There were 50 cases with plate overhang in the SP group, which presented a statistical difference in comparison with the CP group. The value of CTA (169.65 ± 5.84°) in the SP group also indicated a statistical difference in comparison with the normal CTA. Subgroup analysis showed that the CTA (165.88 ± 5.42°) in the overhang subgroup (O) had no statistical difference in comparison with the normal CTA, but the CTA (172.68 ± 4.18°) in the non-overhang subgroup (N-O) had. 3 cases experienced non-traumatic re-fracture (within 3 months after the removal of the fixation) in the O subgroup; 10 cases experienced a poor reduction in the N-O subgroup. In the CP group, the CTA was 166.79 ± 5.68°, which indicated a statistical difference with the SP group. Subgroup analysis was performed, including the manual-contoured plate subgroup (M-C) and commercial pre-contoured anatomic plate subgroup (P-C). The value of CTA (M-C, 166.97 ± 6.33°; P-C, 166.44 ± 6.33°) manifested a statistical difference in comparison with the N-O subgroup. 2 and 8 cases, respectively, had screw loosening and poor reduction in the M-C subgroup. No postoperative complication occurred in the P-C subgroup.

Conclusion

CTA is a useful reference in the evaluation of the reduction obtained on radiographic examination, and a reference guiding the plate contouring. The commercial pre-contoured anatomic plate provides a normal CTA and well fits the biomechanical characteristics of the clavicle, which can be recommended for superior fixation.