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

A Retrospective Machine Learning Analysis to Predict 3-Month Nonunion of Unstable Distal Clavicle Fracture Patients Treated with Open Reduction and Internal Fixation

Background

This retrospective study aims to predict the risk of 3-month nonunion in patients with unstable distal clavicle fractures (UDCFs) treated with open reduction and internal fixation (ORIF) using machine learning (ML) methods. ML was chosen over traditional statistical approaches because of its superior ability to capture complex nonlinear interactions and to handle imbalanced datasets.

Methods

We collected UDCFs patients at Nanjing Luhe People's Hospital (China) between January 2015 and May 2023. The unfavorable outcome was defined as 3-month nonunion, as represented by disappeared fracture line and continuous callus. Patients meeting inclusion criteria were randomly divided into training (70%) and testing (30%) sets. Five ML models (logistic regression, random forest classifier, extreme gradient boosting, multi-layer perceptron, and category boosting) were developed. Those models were selected based on univariate analysis and refined using the Least Absolute Shrinkage and Selection Operator (LASSO). Model performance was evaluated using AUROC, AUPRC, accuracy, sensitivity, specificity, F1 score, and calibration curves.

Results

A total of 248 patients were finally included into this study, and 76 (30.6%) of them had unfavorable outcomes. While all five models showed similar trends, the CatBoost model achieved the highest performance (AUROC = 0.863, AUPRC = 0.801) with consistent identification of the risk factors mentioned above. The SHAP values identified the CCD as the significant predictor for assessing the risk of 3-month nonunion in patients with UDCFs within the Chinese demographic.

Conclusion

The refined model incorporated four readily accessible variables, wherein the CCD, HDL levels, and blood loss were associated with an elevated risk of nonunion. Conversely, the application of nerve blocks, including postoperative block, was correlated with a reduced risk. Our results suggest that ML, particularly the CatBoost model, can be integrated into clinical workflows to aid surgeons in optimizing intraoperative techniques and postoperative management to reduce nonunion rates.

Clinical efficacy of Endobutton combined with mini-plate in the treatment of Neer IIB (IIC) type distal clavicle fracture

Objective

This study aimed to investigate the clinical outcomes of employing Endobutton with a mini-plate for managing Neer IIB (IIC) type distal clavicle fractures.

Methods

A retrospective case-control approach was utilized, examining clinical data from 62 patients with Neer IIB (IIC) type distal clavicle fractures treated at our institution from January 2018 to December 2022. Patients were divided into 2 groups: 32 treated with an Endobutton and a mini-plate (study group) and 30 with a clavicular hook steel plate (control group). Surgical metrics such as duration, incision length, and hospital stay were documented. Follow-up assessments included fracture healing, postoperative complications, and the necessity for secondary internal fixation removal. Preoperative and postoperative coracoclavicular distances (CCD) were recorded at various intervals. Pain and shoulder joint functionality were evaluated using the Visual Analog Scale (VAS) and Constant-Murley score.

Results

All patients successfully underwent surgery and were followed up. The follow-up period for the study group was 12-23 months (18.7 ± 2.7), and for the control group, it was 12-22 months (15.8 ± 1.6). The surgery duration was significantly shorter in the control group [(65.12 ± 9.88) minutes] compared to the study group [(82.58 ± 7.36) minutes, P < 0.05]. In comparison, the incision length in the control group was longer than that in the study group [(69.58 ± 6.43) mm vs. 58.24 ± 4.83 mm, P < .05]. There were no significant di!erences in hospital stay and fracture healing time between the 2 groups (P > .05). In the control group, all patients required secondary removal of internal fixation, while in the study group, only 1 patient needed it. Complications such as subacromial bone erosion, distal clavicle osteolysis, subacromial impingement with shoulder pain, and skin irritation were observed in the control group, while only skin irritation due to thinness was noted in the study group, with statistically significant di!erences between the groups (P < .05). Postoperative CCD improved significantly in both groups. At the final follow-up, the increase in CCD was greater in the control group (1.819 ± 0.97 mm) compared to the study group (0.274 ± 0.18 mm, P < .05). The study group showed better VAS scores at 6months (1.22 ± 0.96) and the last follow-up [(1.22 ± 0.96), (0.68 ± 0.57) points] compared to the control group [(2.97 ± 0.86), (1.98 ± 0.84) points, P < .05]. The Constant-Murley functional scores were also better in the study group [(81.67 ± 5.54), (90.45 ± 3.42) points] than in the control group [(91.45 ± 3.44), (94.21 ± 1.43) points, P < .05].

Conclusion

The use of an Endobutton combined with a mini-plate for Neer IIB (IIC) type distal clavicle fractures offers significant advantages, including improved recovery of shoulder joint function, fewer postoperative complications, and reduced need for secondary internal fixation removal. This approach is a viable treatment option for Neer IIB (IIC) type distal clavicle fractures.

Level of Evidence

Level III, Therapeutic study.

Endobutton plates demonstrate superior efficacy in treating unstable distal clavicle fractures

OBJECTIVE

To compare the effectiveness of clavicular hook plates and Endobutton plates in treating unstable distal clavicle fractures (UDCFs).

METHODS

Data from 95 patients with UDCFs (Neer II and V types) were retrospectively analyzed. Among them, 55 cases were treated with clavicular hook plates (control group), and 40 cases with Endobutton plates (research group). Comparative analyses included intraoperative indicators (incision length, intraoperative blood loss, operation time), postoperative recovery metrics (fracture healing time, fracture displacement distance, hospitalization time), pain assessment (Visual Analogue Scale [VAS]), shoulder joint function (American Shoulder and Elbow Surgeons [ASES] questionnaire), postoperative complications (plate loosening, recurrent fractures, incision infection, and fracture end redisplacement), and overall clinical efficacy.

RESULTS

The research group demonstrated significantly shorter incision lengths, comparable intraoperative blood loss, longer operation times, and shorter fracture healing times compared to the control group (all P < 0.05). No significant differences were observed in fracture displacement distance or hospitalization time (both P > 0.05). However, VAS scores were significantly lower, while ASES scores (pain, function, and total) were notably higher in the research group (all P < 0.05). The incidence of postoperative complications was similar between the groups (P > 0.05), but the excellent and good treatment rate was significantly higher in the research group (P < 0.05).

CONCLUSIONS

Endobutton plates offer significantly better clinical outcomes compared to clavicular hook plates for treating UDCFs, demonstrating advantages in postoperative recovery, pain management, and functional improvement.

Outcomes following fixation of distal clavicle fractures utilizing arthroscopically assisted coracoclavicular ligament stabilization with a suspensory endobutton and cerclage tape

Background

Distal one-third clavicle fractures are frequently unstable and often require surgical fixation due to high rates of nonunion. Many common methods of fixation have high rates of union but are associated with hardware discomfort and need for secondary surgery. The purpose of this study was to evaluate the outcomes of a fixation technique involving arthroscopically assisted open reduction internal fixation of unstable distal clavicle fractures via a coracoclavicular (CC) suspensory endobutton and cerclage tape.

Methods

This was a retrospective case series evaluating patients who underwent fixation of unstable distal clavicle fractures via arthroscopically assisted CC stabilization by a single fellowship-trained shoulder and elbow surgeon between 2020 and 2022. Demographic and injury-related data were collected via chart review. Preoperative and postoperative radiographs were reviewed to evaluate for signs of radiographic union. Primary outcome measures included fracture union, complications, and need for additional procedures. Patients were also contacted via telephone to obtain American Shoulder and Elbow Surgeons scores.

Results

Six patients were eligible for inclusion in this study with a mean age of 52.8 ± 14.0 and a mean follow-up of 2.0 years (range 1.6-2.7 years). Mean American Shoulder and Elbow Surgeons scores were 86.2 ± 21.8 (range 52-100). There were no postoperative complications, signs of symptomatic hardware, or need for secondary surgery at the final follow-up among this cohort of patients. All patients had achieved and maintained full radiographic union at a mean radiographic follow-up of 5.5 months (range 2.0-12.9 months).

Conclusion

Arthroscopically assisted CC stabilization of distal clavicle fractures demonstrated high union rates while limiting complications or need for secondary hardware removal. Further analysis on a larger scale is recommended to determine long-term outcomes and direct comparison to other surgical techniques.

Hook plate fixation of Neer type II distal clavicle fractures results in satisfactory patient-reported outcomes but complications and revisions are high

BACKGROUND

Surgical treatment of distal clavicle fractures Neer type II is challenging. A gold standard has not yet been established, thus various surgical procedures have been described. The purpose of this study is to report the radiological and clinical outcomes using hook plate fixation in Neer type II distal clavicle fractures.

METHODS

We retrospectively reviewed data of 53 patients who underwent hook plate fixation between December 2009 and December 2019 with ≥ 2 years of follow-up. Patients with preexisting pathologies or concomitant injuries of the ipsilateral shoulder were excluded. Pre- and postoperative coracoclavicular distance (CCD), bony union and patient-reported outcomes were collected, including the Constant Score (CS) and Subjective Shoulder Value (SSV). Complications and revisions were recorded.

RESULTS

At a mean final follow-up of 6.2 years, mean SSV was 91.0% (range, 20-100) and mean CS was 80.9 points (range, 25-99). The mean preoperative CCD was 19.0 mm (range, 5.7-31.8), the mean postoperative CCD was 8.2 mm (range, 4.4-12.2) and the mean CCD following hardware removal was 9.7 mm (range, 4.7-18.8). The loss of reduction following hardware removal was statistically significant (P = 0.007). Eleven (20.8%) patients had complications, with 5 cases of deep or superficial infection (9.4%), four non-unions (7.5%), one periosteosynthetic fracture, one postoperative seroma, one implant failure and one symptomatic acromioclavicular joint arthritis (all 1.9%). A total of 10 patients (18.9%) underwent revision surgery at a mean of 113 (range, 7-631) days.

CONCLUSION

Medium-term patient-reported outcomes for hook plate fixation of Neer type II distal clavicle fractures are satisfactory; however, one in five patients suffers a complication with the majority of them requiring revision surgery.

Evidence on treatment of clavicle fractures

Depending on the severity of the injury and the involvement of the soft tissue envelope, clavicle fractures can be treated operatively or non-operatively. In the past, displaced fractures of the clavicle shaft in adults have been treated non-operatively. However, the rate of nonunion following non-operative treatment seems to be higher than previously reported. In addition, publications reporting better functional outcomes following operative treatment are increasing. In recent years this has led to a paradigm shift towards an increase of operative fracture treatment. The aim of this review article was to summarize the currently available evidence on the treatment of clavicle fractures. Classifications, indications, and treatment options for different fracture patterns of the medial, midshaft, and lateral clavicles are presented and discussed.

Low Ceiling Effects of the Forgotten Joint Score Compared With Legacy Measures After Joint-Preserving Procedures: A Systematic Review

PURPOSE

To determine, in patients undergoing joint preservation procedures, whether the Forgotten Joint Score (FJS) compares favorably with legacy measures.

METHODS

Medical databases (including PubMed/MEDLINE and Embase databases) were queried for publications with the terms "Forgotten Joint Score" and "hip," "knee," "arthroscopy," or "ACL." Fourteen studies met the inclusion criteria. Methodologic quality was assessed through the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist, and psychometric data were evaluated for ceiling or floor effects, convergent validity, internal consistency, reliability, responsiveness, measurement invariance, and measurement error by 2 fellowship-trained orthopaedic surgeons (B.D.K. and W.T.H.).

RESULTS

Data were collected from 14 studies using the FJS after joint-preserving procedures in 911 patients (959 joints). Four studies reported strong internal consistency with an average Cronbach α of 0.92. Two studies reported responsiveness with an effect size ranging from 0.6 to 1.16. One study reported reproducibility with an interclass correlation coefficient of 0.9 (95% confidence interval, 0.8-0.9). One study reported measurement error with an minimum detectable change (MDC)individual of 32% and MDCgroup of 4.5%. Studies reported moderate to very strong convergent validity across legacy measures for hip and knee preservation surgery. Ceiling effects were favorable compared with many legacy scores for hip and knee preservation. Three studies reported the minimal clinically important difference whereas 1 study reported the patient acceptable symptomatic state for the FJS.

CONCLUSIONS

The FJS is a methodologically sound outcome measure used to evaluate patient outcomes after hip and knee preservation surgery with overall low ceiling effects compared with legacy measures.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Hook Plate Versus Distal Locking Plate for the Fixation of Unstable Distal Clavicle Injuries, Outcomes and Complications: A Meta-Analysis

Numerous interventions are advised for the surgical management of distal clavicle fractures. Hook plate (HP) and distal locking plate (DLP) are among the commonly used techniques; nonetheless, no single procedure is deemed to be the benchmark treatment. Thus, the aim of the study is to conduct a comparative analysis, hopefully, to recommend the superior method between the two operations.

PubMed, Embase via Ovid and Web of science were electronically searched between January 2000 and to date for studies directly comparing HP to DLP. Comparative retrospective/prospective and randomized studies were incorporated. Constant-Murley score “CMS” at a minimum of 12 months, pain visual analogue scale “VAS”, coracoclavicular distance “CCD” and reported complications were analysed. Review manager software was used for the statistical analyses.

The total number of patients was 523; 274 (52.3%) with HP and 249 (47.6%) with DLP, 81 of which were associated with CC reconstruction. The mean follow up was 38.7 and 37.03 months for HP and DLP, respectively. CMS leaned towards the DLP group with no statistically significant difference (P=0.06). VAS was in favour of the DLP with again no statistically significant difference (P=0.12). In terms of CCD, the comparison favoured the HP with a lesser CCD postoperatively and a statistically significant difference (P<0.05). Complications were significantly higher in the HP group (P<0.0001).

Contrary to our hypothesis, though HP did show a better radiological outcome; nonetheless, DLP did demonstrate a better functional result with a lesser rate of complications and the ability to retain the implant avoiding a second surgery.

Comparative effectiveness of interventional therapeutic modalities for unresectable hepatocellular carcinoma: A systematic review and network meta‑analysis

It is unclear whether hepatic artery infusion chemotherapy (HAIC) or transcatheter arterial chemoembolization (TACE) is more efficient in the combination therapy of hepatocellular carcinoma (HCC). Head-to-head comparisons among HAIC-related therapies are lacking. For this network meta-analysis, PubMed, EMBASE and Cochrane Library databases were searched up to April 1, 2022. Randomized controlled trials (RCTs) were eligible if they evaluated the use or prolongation of TACE or HAIC in patients with advanced HCC and reported or collected survival data. A network meta-analysis was performed to synthesize data and make direct and indirect comparisons between treatments. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated to explore the efficacy of various treatment options on overall survival (OS), odds ratios (ORs) with 95% CI were used for overall response rate (ORR), whereas risk ratios (RRs) with 95% CI were used for serious adverse events (SAEs). The analysis of 7 trials including a total of 1,073 patients found that sorafenib with HAIC-oxaliplatin improved survival (HR=0.33, 95% CI: 0.25-0.44); the ORR was also improved in patients treated with sorafenib plus HAIC-oxaliplatin and sorafenib plus PF-HAIC (OR=22.18, 95% CI: 10.69-52.56; and OR=2.72, 95% CI: 1.43-5.36, respectively). The incidence of liver injury was elevated in patients treated with sorafenib plus TACE (OR=5.93, 95% CI: 2.70-15.41). However, no differences in the incidences of other SAEs were identified among the treatment groups. The present meta-analysis provides preliminary evidence for the comparative safety and efficacy of HAIC and TACE combined with sorafenib, and indicates the dominance of HAIC-oxaliplatin in HCC interventional therapy. However, high-quality RCTs are required to further confirm the efficacy of HAIC-oxaliplatin. The present study has been registered with PROSPERO (registration no. CRD42021288497).

Comparison of functional outcome and complications of locking plate versus coracoclavicular fixation in the treatment of unstable distal clavicle fractures: the multicenter, propensity-matched TRON study

PURPOSE

This multicenter, retrospective study aimed to compare clinical outcomes and complications between locking plate fixation and new coracoclavicular (CC) fixation for patients with unstable distal clavicle fracture.

METHODS

We included 142 patients in this TRON study. The mean follow-up was 15.5 (6-31) months. The patients were divided into two groups: the locking plate group (Group L) and CC fixation group (Group C). To adjust for baseline differences between the groups, a propensity score algorithm was used to match two groups in a 1:1 ratio. After matching, we compared operation time and the University of California Los Angeles (UCLA) shoulder score at 3 and 6 months postoperatively and at last follow-up as clinical outcomes and the rate of complications.

RESULTS

After matching, 20 cases from each group remained. Operation time was shorter in Group C (75 [22, 111] vs. 100 [38, 120] min; P = 0.023). At 3 months postoperatively, UCLA score in Group C was better, but no significant differences between the groups were found at 6 months and last follow-up after surgery. The rate of complications was not significantly different between the groups.

CONCLUSION

CC fixation might be equivalent to locking plate fixation in clinical outcome, and the operation time is shorter than that required for locking plate fixation.

Efficacy and safety of tension band wire versus plate for Mayo II olecranon fractures: a systematic review and meta-analysis

PURPOSE

For olecranon fractures, the choice of tension band wire (TBW) or plate fixation has long been controversial. Therefore, this study aimed to evaluate the efficacy and safety of TBW and plate in the treatment of patients with Mayo II olecranon fractures by Meta-analysis.

METHODS

PubMed, Embase, Cochrane, the Web of Science, China National Knowledge Infrastructure, Wanfang, and China Biomedical Database were searched for randomized controlled trials (RCTs) and cohort studies (CSs) where TBW was compared with plate for Mayo II olecranon fractures (OF). Subsequently, the data were extracted by two reviewers independently and were analysed via RevMan5.4.1. Besides, mean difference (MD), risk ratio (RR), and 95% confidence intervals (CIs) were calculated. Furthermore, Cochrane Risk of Bias Tool 2.0 and Newcastle-Ottawa Scale were adopted for assessing the risk of bias.

RESULTS

A total of 1RCT and 10 CSs were included, when 449 cases were treated with TBW and 378 with plate. The plate has favourable postoperative long-term (≥ 1 year) functional score in MEPS (MD: - 3.06; 95% CI - 5.50 to 0.62; P = 0.01; I2 = 41%) and Dash score (MD: 2.32; 95% CI 1.91, 2.73; P < 0.00001; I2 = 0%), also carrying fewer complications (RR: 2.13; 95% CI 1.48, 3.08; P < 0.0001; I2 = 58%). Besides, there exists no significant difference in postoperative long-term (≥ 1 year) elbow flexion (MD: - 1.82°; 95% CI - 8.54, 4.90; P = 0.60; I2 = 71%) and extension deficits (MD: 1.52°; 95% CI - 0.38, 3.42; P = 0.12; I2 = 92%). Moreover, TBW is featured with a shorter operation time (MD = - 5.87 min; 95% CI - 7.93, - 3.82; P < 0.00001; I2 = 0) and less intraoperative bleeding (MD: - 5.33 ml; 95% CI - 8.15, - 2.52; P = 0.0002; I2 = 0). In terms of fracture healing time, it is still controversial. Furthermore, the subgroup analysis has revealed that for Mayo IIA OF, the plate has a better outcome in the long-term (≥ 1 year) postoperative MEPS, the Dash score, and the incidence of postoperative complications than TBW, while there is no significant difference in the long-term (≥ 1 year) postoperative elbow motion between two groups.

CONCLUSIONS

Plate has better efficacy and safety for Mayo II OF. Considering that few studies are included in the meta-analysis, more high-quality RCTs are still required to confirm these findings. PROSPERO registration number: CRD42022313855.

Comparison of hook plate versus T-plate in the treatment of Neer type II distal clavicle fractures: a prospective matched comparative cohort study

BACKGROUND

This study aimed to compare the clinical and radiological outcomes of distal clavicle fracture fixation with a hook plate versus the standard non-locking T-plate for unstable Neer type II fractures.

METHODS

A prospective matched cohort study including two groups of hook plates and T-plates fixation was conducted in our two tertiary trauma centers. Patients with distal clavicle fractures Neer type II were assessed for union and the Constant-Murley score (CMS) at 1-, 3-, and 6-month follow-ups. Inadequate radiographic consolidation > 6 months after surgery was defined as non-union. Subscales of CMSpain, CMSactivities of daily living, CMSrange of motion (ROM), and CMSstrength were also compared between groups. According to recommendations, the implant was removed after union confirmation in the hook plate at a planned second surgery.

RESULTS

Sixty consecutive patients were enrolled: 30 in the T-plate group and 30 in the hook plate group. CMS showed similar functional outcomes for T-plates and hook plates at all follow-ups (Month 6: 92.0 vs. 91.7, P = 0.45). However, on the month 1 follow-up, the T-plate group scored higher than the hook plate group for ROM and pain (CMSpain = 13.0 vs. 12.3, P = 0.03; CMSROM = 35.2 vs. 33.2, P = 0.002). Despite this, Pain, ROM, and other CMS domains were comparable between groups (P > 0.05). The mean time to union was 2.5 + 1.4 months for the T-plate group and 2.3 + 1.6 months for the hook plate group (P = 0.44). There was one fixation failure in each group and one periprosthetic fracture in the hook plate group (two revisions for the hook plates and one for T-plates, P = 1.00). Non-union and other complications were not observed.

CONCLUSION

Both surgical approaches resulted in full recovery and good function. However, in the hook plate group ROM and pain scores were lower at 1 month. Standard non-locking T-plates are a viable alternative to hook plates with low cost and promising outcomes for treating displaced distal clavicle fractures.

Clinical and Radiological Outcomes of Closed-Loop, Double Button, Coracoclavicular Fixation for Extralateral (Neer Type IIC) Fractures of the Distal Clavicle

Background: The distal end of the clavicle accounts for 10-28% of all clavicle fractures of which 52.8% are considered displaced and require internal fixation due to their high percentage of non-union. Numerous surgical techniques have been described for the well-known Neer types IIA, IIB, and V. Still, the literature is scarce for the rare “extralateral” (type IIC) fracture where the fracture line is located lateral to the completely torn coracoclavicular (CC) ligaments; such small fractures are sometimes not amenable for standard locking plate fixation.

Methods: We present a series of seven patients treated surgically with closed-looped double button CC stabilization via an open approach. There were four males and three females with a mean age of 31 years (range: 19-46 years). The mechanism of injury was a motor vehicle accident in four cases and a fall from height in three cases. The average time from injury to surgery was 2.7 ± 1.3 days and the average follow-up period was 25.7 months (range: 16-48 months). A custom-made, closed-looped, double button device was made using the ProCinch Adjustable Cortical Fixation for anterior cruciate ligament (ACL) (Stryker, Kalamazoo, Michigan) and another standard or slotted button. The fracture was reduced anatomically and the device was tightened and secured with five to six knots. In two cases, additional interfragmentary sutures were used for extra stability. Postoperatively, the arm was immobilized in a simple sling for four weeks; passive assisted elevation up to 90 degrees was allowed from the second postoperative week, followed by active elevation after the sixth postoperative week. Radiological outcomes (bony union, loss of reduction, implant mispositioning, or subsidence of buttons) were assessed using serial plain radiographs. The Constant score (CS) and the Acromioclavicular Joint Instability Score (AJIS) were used for the final clinical evaluation, at least one year postoperatively.

Results: Bony union was achieved in all patients at a mean time of 2.7 months (range: 2.5-3.6 months). No cases of delayed union, loss of reduction, button migration, or subsidence were noted. The mean CS was 96.6 ± 3.4 and the mean AJIS score was 94.1 ± 4.7 in a mean follow-up period of 25.7 months (range: 16-48 months). One patient developed a hypertrophic scar and another had mild skin irritation by the suture knots; no other complications were noted except for one patient who developed an early superficial skin infection managed with antibiotics and debridement under local anesthesia. Four patients who participated in sports before injury were able to regain almost full activity seven to nine months after the operation. All were satisfied with the final result. Two patients showed ossification of the CC ligaments with no significant clinical implications.

Conclusions: Although we retrospectively reviewed a small series of patients, we were able to demonstrate a complete rate of fracture union and excellent clinical outcomes with no major complications. Type IIC distal clavicle fractures are rare and require special attention in terms of reduction and optimal fixation. Open CC fixation with closed-looped double buttons is a relatively easy and reproducible technique. We advocate the readjustment of Neer’s classification, including “extralateral” fractures as a IIC subtype.