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Hornung CM, Kramer R, Levine J, Hannink G, Hoogervorst P. Functional outcomes and complications of plate fixation for midshaft clavicle fractures by type and location: a systematic review and meta-analysis. JSES Int 2024; 8:407-422. [PMID: 38707570 PMCID: PMC11064701 DOI: 10.1016/j.jseint.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Background Various plate types are used in the surgical treatment of displaced midshaft clavicle fractures. These plates can be positioned in different locations on the clavicle, although no studies to date have elucidated optimal plate type and location of fixation. This systematic review compares the functional outcomes and complications in the management of displaced midshaft clavicle fractures using plate fixation by stratifying by both plate type and location. Methods A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted to identify all papers reporting functional outcomes, union rates, and/or complications using plates for the management of midshaft clavicle fractures. Multiple databases and trial registries were searched from inception until March 2022. A meta-analysis was conducted for functional outcomes and type of complication, stratified by plate type (locking, compression, or reconstruction) and location (superior or anteroinferior). Pooled estimates of functional outcome scores and incidence of complications were calculated using a random effects model. Risk of bias and quality were assessed using the risk of bias version 2 and ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tools. The confidence in estimates were rated and described according to the recommendations of the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) working group. Results Forty-five studies were included in the systematic review and 43 were included in the meta-analysis. Depending on plate type and location, pooled Constant-Murley Scores ranged from 89.23 to 93.48 at 12 months. Nonunion rates were 3% (95% confidence interval [CI] 1-6) for superior locking plates (GRADE Low). Rates of any complication (nonunion, hardware failure, hardware irritation, wound dehiscence, keloid, superficial infection, deep infection, delayed union, malunion, and/or persistent pain) by plate type and location ranged from 3% to 17% (GRADE Very Low to Moderate). Superior compression plates had the highest incidence of any complications (17% [95% CI 5-44], GRADE Very Low), while anterior inferior compression plates had the lowest incidence of any complication (3% [95% CI 0-15], GRADE Very Low). Hardware irritation was the most reported individual complication for superior locking plates and superior compression plates, 11% (95% CI 7-17, GRADE Low) and 11% (95% CI 3-33, GRADE Very Low), respectively. Conclusion Although most studies were of low quality, studies reporting functional outcomes generally showed good functional results and similar incidence of any complication regardless of plate type and location. There is no evidence of a plate and location combination to optimize patient functional outcomes or complications. We were unable to reliably evaluate union rates or individual complications for most plate types stratified by location.
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Affiliation(s)
- Christopher M. Hornung
- Department of Orthopaedic Surgery, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Riley Kramer
- Department of Orthopaedic Surgery, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Joshua Levine
- Department of Orthopaedic Surgery, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Gerjon Hannink
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Paul Hoogervorst
- Department of Orthopaedic Surgery, University of Minnesota School of Medicine, Minneapolis, MN, USA
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Kang Y, Zhang Q, Ma Y, Zhou M, Jia X, Lin F, Wu Y, Rui Y. Clinical effect of nice knot-assisted minimally invasive titanium elastic nail fixation to treat Robinson 2B midshaft clavicular fracture. BMC Musculoskelet Disord 2024; 25:59. [PMID: 38216916 PMCID: PMC10787378 DOI: 10.1186/s12891-024-07197-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 01/11/2024] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND The treatment of completely displaced midshaft clavicle fractures is still controversial, especially Robinson 2B fractures. Titanium elastic nail (TEN) fixation is a good option for simple fractures, but no reports exist on its use in complex fractures. This study aimed to present a surgical method using the Nice knot-assisted TEN fixation to treat Robinson 2B midshaft clavicular fractures. METHODS A retrospective analysis of 29 patients who underwent fixation with TEN and had a 1-year postoperative follow-up between 2016 and 2020 was performed. The fractures were classified as Robinson type 2B1 in 17 cases and type 2B2 in 12 cases. Length of the incision, postoperative shoulder function Disability of Arm Shoulder and Hand (DASH) score and Constant score, complications rate, and second surgical incision length were recorded. RESULTS The length of the incision was 2-6 cm (average 3.7 cm). All incisions healed by first intention, and no infection or nerve injury occurred. The Constant score was 92-100 (average 96) and the DASH score was 0-6.2 (mean, 2.64). TEN bending and hypertrophic nonunion occurred in one case (3.4%) and implant irritation occurred in four cases (13.8%) Fixation implants were removed at 12-26 months (mean, 14.6 months) after surgery, and the length of the second incision was 1-2.5 cm (average 1.3 cm). CONCLUSIONS Intramedullary fixation by TEN is approved as a suitable surgical technique in clavicular fracture treatment. Nice knot-assisted fixation provides multifragmentary fracture stabilization, contributing to good fracture healing. Surgeons should consider this technique in treating Robinson 2B midshaft clavicular fractures. TRIAL REGISTRATION Retrospectively registered. This study was approved by the Ethics Committee of Wuxi Ninth People's Hospital (LW20220021).
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Affiliation(s)
- Yongqiang Kang
- Medical College, Soochow University, Suzhou, Jiangsu, China
| | - Qingqing Zhang
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital, Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China
| | - Yunhong Ma
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital, Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China
| | - Ming Zhou
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital, Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China
| | - Xueyuan Jia
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital, Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China
| | - Fang Lin
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital, Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China
| | - Yongwei Wu
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital, Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China.
| | - Yongjun Rui
- Department of Traumatic Orthopedics, Wuxi Ninth People's Hospital, Soochow University, Liangxi Road, No.999, Binhu District, Wuxi, Jiangsu, China.
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Lin S, Huang J, Lamin BM, Zeng T, Tian Y, Liu L, Luo H. Effect of intramedullary fixation and plate fixation on postoperative wound complications in clavicle fractures: A meta-analysis. Int Wound J 2024; 21:e14361. [PMID: 37641210 PMCID: PMC10781614 DOI: 10.1111/iwj.14361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/31/2023] Open
Abstract
More and more meta-analyses have been conducted to compare the effects of intramedullary fixation (IF) and plate fixation (PF) on the outcome of midshaft clavicle fractures. It can affect the doctors' treatment decisions. A number of studies have been conducted in order to assist surgeons in selecting optimal operative procedures and to recommend operative treatment of clavicle fractures in accordance with the best available research. Our analysis of the IF and PF of clavicle fractures was done through a search for PubMed, Emabase, Web of Science, and Cochrane Library. Two different researchers analysed the research literature for quality of analysis and data extraction. The analysis of the data was done with RevMan 5.3. The 95% CI and OR models have been computed by means of either fixed-dose or randomize. In addition, RCT in 114 references have been reviewed and added for further analysis. It is concluded that the application of plate and intramedullary fixation in the middle clavicle operation has remarkable influence on the outcome of post-operation. There was a lower risk of postoperative wound infection in IF (OR, 5.92; 95% CI, 2.46, 14.27 p < 0.0001), smaller surgical incisions (MD, 6.57; 95% CI, 4.90, 8.25 p < 0.0001), and shorter operative time (MD, 17.09; 95% CI 10.42, 23.77 p < 0.0001), less blood loss (MD, 63.62; 95% CI, 55.84, 71.39 p < 0.0001) and shorter hospital stay (MD, 1.05; 95% CI, 0.84, 1.25 p < 0.0001). However, there is no statistical significance in the incidence of wound dehiscence. Thus, the effect of IF on the incidence of injury is better than that of the inner plate in the middle of the clavicle.
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Affiliation(s)
- Shangce Lin
- Medical SchoolYangtze UniversityJingzhouChina
- Department of OrthopedicsThe First People's Hospital of JingzhouJingzhouChina
| | - Jin Huang
- Medical SchoolYangtze UniversityJingzhouChina
| | | | - Teng Zeng
- Department of OrthopedicsThe First People's Hospital of JingzhouJingzhouChina
| | - Yaqin Tian
- Department of OrthopedicsThe First People's Hospital of JingzhouJingzhouChina
| | - Lian Liu
- Medical SchoolYangtze UniversityJingzhouChina
| | - Huasong Luo
- Department of OrthopedicsThe First People's Hospital of JingzhouJingzhouChina
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Berk T, Zderic I, Caspar J, Schwarzenberg P, Pastor T, Halvachizadeh S, Makelov B, Richards G, Pape HC, Gueorguiev B. A Novel Implant for Superior Pubic Ramus Fracture Fixation-Development and a Biomechanical Feasibility Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040740. [PMID: 37109698 PMCID: PMC10142566 DOI: 10.3390/medicina59040740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/10/2023] [Accepted: 04/05/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: Pubic ramus fractures are common in compound pelvic injuries known to have an increased rate of morbidity and mortality along with recurrent and chronic pain, impeding a patient's quality of life. The current standard treatment of these fractures is percutaneous screw fixation due to its reduced risk of blood loss and shorter surgery times. However, this is an intricate surgical technique associated with high failure rates of up to 15%, related to implant failure and loss of reduction. Therefore, the aim of this biomechanical feasibility study was to develop and test a novel intramedullary splinting implant for fixation of superior pubic ramus fractures (SPRF), and to evaluate its biomechanical viability in comparison with established fixation methods using conventional partially or fully threaded cannulated screws. Materials and Methods: A type II superior pubic ramus fracture according to the Nakatani classification was created in 18 composite hemi-pelvises via a vertical osteotomy with an additional osteotomy in the inferior pubic ramus to isolate the testing of three SPRF fixation techniques performed in 6 semi-pelvises each using either (1) a novel ramus intramedullary splint, (2) a partially threaded ramus screw, or (3) a fully threaded ramus screw. Results: No significant differences were detected among the fixation techniques in terms of initial construct stiffness and number of cycles to failure, p ≥ 0.213. Conclusion: The novel ramus intramedullary splint can be used as an alternative option for treatment of pubic ramus fractures and has the potential to decrease the rate of implant failures due to its minimally invasive implantation procedure.
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Affiliation(s)
- Till Berk
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Ivan Zderic
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - Jan Caspar
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | | | - Torsten Pastor
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland
| | - Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Harald-Tscherne Laboratory for Orthopedic and Trauma Research, University of Zurich, Sternwartstrasse 14, 8091 Zurich, Switzerland
| | - Biser Makelov
- University Multiprofile Hospital for Active Treatment 'Prof. Stoyan Kirkovitch', Trakia University, 6003 Stara Zagora, Bulgaria
| | - Geoff Richards
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
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Traumatic brain injuries are ignored or discriminated in prospective clinical trials on shoulder fractures: a systematic review. INTERNATIONAL ORTHOPAEDICS 2023; 47:17-50. [PMID: 36435944 DOI: 10.1007/s00264-022-05642-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 10/10/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Current literature suggests a significant epidemiological association between traumatic brain injury (TBI) and proximal upper limb fractures in addition to major clinical consequences. A systematic review was conducted to assess how TBI is taken into consideration in interventional studies on shoulder fractures. METHODS The following data sources were used: MEDLINE, EMBASE, EBM Reviews, CINAHL, and OpenGrey databases. Study selection included interventional randomized clinical trials and prospective cohort studies on shoulder fractures published in English or French between 2008 and 2020. Studies on pathologic fractures, chronic fracture complications, nonhuman subjects, and biomechanics were excluded. Articles were reviewed by two independent authors according to the PRISMA guidelines. Baseline characteristics, exclusion criteria, and input relevant to TBI were recorded. Methodological quality was assessed with the Cochrane risk of bias tool for randomized clinical trials and the Newcastle-Ottawa Scale for cohort studies. RESULTS One-hundred-thirteen studies met the inclusion criteria. None discussed the possible impact of TBI on their results. Only three (2.7%) studies considered TBI relevant and included these patients in their cohort. Furthermore, 43/113 (38.1%) excluded patients with injuries or mechanisms strongly related to traumatic brain injuries: head injuries (4); moderate and/or severe TBI (7); high energy traumas (3); Polytrauma subjects (33). CONCLUSION TBI are ignored or discriminated in prospective clinical trials on shoulder fractures. The exclusion of these cases impacts generalizability as their prevalence is significant. Considering the major impact of TBI on important outcomes, its presence should always be assessed to ensure high quality evidence. LEVEL OF EVIDENCE Systematic Review, Therapeutic Level II.
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Wall KC, Reddy GB, Corrigan KL, Toth AP, Garrigues GE. Operative Versus Nonoperative Management of Displaced Midshaft Clavicle Fractures: A Cost-effectiveness Analysis. Orthopedics 2022; 45:e243-e251. [PMID: 35700404 DOI: 10.3928/01477447-20220608-08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
To date, the optimal management of displaced midshaft clavicle fractures remains unknown. Operatively, plate or nail fixation may be used. Nonoperatively, the options are sling or harness. Given the equivocal effectiveness between approaches, the costs to the health care system and the patient become critical considerations. A decision tree model was constructed to study plate and sling management of displaced midshaft clavicle fractures. Primary analysis used 6 randomized controlled trials that directly compared open reduction and internal fixation with a plate to sling. Secondary analysis included 18 studies that studied either plate, sling, or both. Incremental cost-effectiveness ratios (ICERs) were calculated using quality-adjusted life-years (QALYs). Second-order Monte Carlo probabilistic sensitivity analysis (PSA) was subsequently conducted. In primary analysis, at a willingness-to-pay (WTP) threshold of $100,000, operative management was found to be less cost-effective relative to nonoperative management, with an ICER of $606,957/QALY (0.03 additional QALYs gained for an additional $16,120). In PSA, sling management was cost-effective across all WTP ranges. In secondary analysis, the ICER decreased to $75,230/QALY. Primary analysis shows that plate management is not a cost-effective option. In secondary analysis, the incremental effectiveness of plate management increased enough that the calculated ICER is below the WTP threshold of $100,000; however, the strength of evidence in secondary analysis is lower than in primary analysis. Thus, because neither option is dominant in this model, both plate and sling remain viable approaches, although the cost-conscious decision will be to treat these fractures with a sling until future data suggest otherwise. [Orthopedics. 2022;45(5):e243-e251.].
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7
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Shi F, Hu H, Tian M, Fang X, Li X. Comparison of 3 treatment methods for midshaft clavicle fractures: A systematic review and network meta-analysis of randomized clinical trials. Injury 2022; 53:1765-1776. [PMID: 35459544 DOI: 10.1016/j.injury.2022.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/01/2022] [Accepted: 04/05/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Our study aims to evaluate the fracture nonunion rate and the functional score of plate and screw fixation, intramedullary nailing and non-surgical treatment in midshaft clavicle fractures patients using a network meta-analysis of data from clinical randomized controlled trials. MATERIAL/METHODS The studies were abstracted from Medline, Embase, Web of Science, Google Scholar and the Cochrane Central Register of Controlled Trials. RCTs meeting the inclusion and exclusion criteria were selected. Statistical analyses were conducted using Stata software, version 14.0 (Stata Corporation, College Station, Texas, USA). RESULTS 24 randomized controlled trials involving 2161 participants were included. The studies were published between 2007 and 2019. A total of 3 treatment methods-plate and screw fixation, intramedullary nailing and non-surgical treatment- were included in the literature. The treatments were ranked based on the Surface Under the Cumulative Ranking Curve (SUCRA) probability. In terms of the constant score, the treatment methods were ranked as follows: intramedullary nailing, plate and screw fixation and non-surgical treatment. In terms of the DASH index, the treatment methods were ranked as follows: intramedullary nailing, plate and screw fixation and non-surgical treatment. In terms of the nonunion rate, the treatment methods were ranked as follows: intramedullary nailing, plate and screw fixation and non-surgical treatment. CONCLUSION Non-surgical treatment has a high rate of nonunion for clavicular fractures with obvious displacement and notable comminution. Surgical treatment reduces the nonunion rate leads to better functional scores at long-term follow-up, although there may be no significant clinical differences. The fracture nonunion rate of plate screw fixation group and intramedullary nail group was low and the functional prognosis was similar. More RCTs focused on clavicular fractures are needed to further substantiate this conclusion.
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Affiliation(s)
- Fangling Shi
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, Ningbo 315040, China
| | - Haoliang Hu
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, Ningbo 315040, China
| | - Mintao Tian
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, Ningbo 315040, China
| | - Xuanliang Fang
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, Ningbo 315040, China
| | - Xueyuan Li
- Department of Hand Surgery, Department of Plastic Reconstructive Surgery, Ningbo No. 6 Hospital, Ningbo 315040, China.
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Yan MZ, Yuen WS, Yeung SC, Wing-yin CW, Wong SCY, Si-qi WW, Tian E, Rashed S, Yung CSY, Fang CX. Operative management of midshaft clavicle fractures demonstrates better long-term outcomes: A systematic review and meta-analysis of randomised controlled trials. PLoS One 2022; 17:e0267861. [PMID: 35486618 PMCID: PMC9053819 DOI: 10.1371/journal.pone.0267861] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/16/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Midshaft clavicular fractures are common amongst young adults. Conservative or surgical treatment for definitive fracture management has been widely debate, both with their pros and cons. Previous meta-analyses compared the clinical outcomes between conservative and surgical treatment options of midshaft clavicular fractures but failed to elucidate any difference in functional improvement. We postulate that functional improvement after fracture union plateaus and the clinical outcome after treatment varies at different time points. This meta-analysis will focus on the synthesis comparison of outcomes at early, short-term results (3 months), intermediate-term (6 to 12 months) and long-term (>24 months) clinical outcomes. Methods A systematic search was done on databases (Pubmed, Embase, Medline, Cochrane) in June 2021. Search keywords were: midshaft clavicular fractures and clinical trials. Clinical trials fulfilling the inclusion criteria were selected for comparison and the clinical outcomes of midshaft clavicular fractures using surgical and non-surgical interventions in terms of improvement in the Disabilities of the Arm, Shoulder and Hand (DASH) score, Constant-Murley Score (CMS), time to union and risk ratio of treatment related complications were analysed in correlation with post-treatment timeframe. Results Of the 3094 patients of mean age 36.7 years in the 31 selected studies, surgical intervention was associated with improved DASH score (standard-mean difference SMD -0.22, 95% CI -0.36 to -0.07, p = 0.003; mean difference MD -1.72, 95% CI -2.93 to -0.51, p = 0.005), CMS (SMD 0.44, 95% CI 0.17–0.72, p = 0.001; MD 3.64, 95% CI 1.09 to 6.19, p = 0.005), time to union (non-adjusted SMD -2.83, 95% CI -4.59 to -1.07, p = 0.002; adjusted SMD -0.69, 95% CI -0.97 to -0.41, p<0.001) and risk ratio of bone-related complications including bone non-union, malunion and implant failure (0.21, 95% CI 0.1 to 0.42; p<0.001). Subgroup analysis based on time period after treatment showed that surgical intervention was far superior in terms of improved DASH score at the intermediate-term results (6–12 months later, SMD -0.16, 95% CI -0.30 to -0.02, p = 0.02; and long term results (>24 months SMD -4.24, 95% CI -7.03 to -1.45, p = 0.003) and CMS (>24 months, SMD 1.03, 95% CI 0.39 to 1.68, p = 0.002; MD 5.77, 95% CI 1.63 to 9.91, p = 0.006). Surgical outcome is independent of fixation with plates or intra-medullary nails. Conclusion Surgical intervention was associated with better clinical outcomes compared with non-surgical approach for midshaft clavicular fractures in terms of improvement in functional scores DASH, CMS, time to union and fracture related complications, although not to the minimal clinically significant difference. Benefits in the long-term functional improvements are more pronounced.
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Affiliation(s)
- Michael Zhipeng Yan
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Wing-sze Yuen
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Sung-ching Yeung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Christie Wong Wing-yin
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Sonia Choi-ying Wong
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Walter Wang Si-qi
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Elaine Tian
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Shireen Rashed
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Colin Shing Yat Yung
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
| | - Christian Xinshuo Fang
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, Hong Kong, China
- * E-mail:
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9
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Zhao JX, Zhao YP, Mao Z, Yin PB, Hao M, Lyu HC, Cui X, Zhang LC, Tang PF. Intramedullary nailing versus plating fixation for the treatment of midshaft clavicular fractures: A meta-analysis of randomized controlled trials. Injury 2022; 54 Suppl 2:S70-S77. [PMID: 35177266 DOI: 10.1016/j.injury.2022.02.026] [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: 08/15/2020] [Accepted: 02/07/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE This study was to test the hypothesis that intramedullary (IM) nailing fixation of midshaft clavicle fractures could result in better clinical outcomes and lower complications rates than plating fixation. METHODS PubMed, Embase, and the Cochrane Library database were used to search all English language published randomized controlled trials (RCTs) of midshaft clavicle fractures using plating versus IM nailing. The characteristics of the study participants were collected. Outcomes of postoperative shoulder functional measurements, operative data and complications rates were meta-analyzed. RESULTS Eight hundred and ninety-five patients in ten RCTs and three quasi-RCTs were involved in the meta-analysis. The results of meta-analysis of these studies showed that the functional outcome evaluated by the Constant Shoulder and Disabilities of the Arm, Shoulder and Hand (DASH) scores after accepting IM nailing was significantly better than that of plating fixation at one year post-operatively (P < 0.01), with the heterogeneity of 43% and 91%, respectively. Sensitivity analyses of the pooled results of Constant and DASH scores displayed that the functional advantage of IM nailing fixation comes from the subgroup of locked IM nailing. Further, regarding the operative statistics, operative time, blood loss and wound length were significantly less in the IM nailing group than the plating group (P < 0.001). The rates of infection, major complications and complications-related revision surgery were significantly higher in the plating group than the IM nailing group; however, there were no significantly statistical differences in other complications, e.g., nonunion, refracture after hardware removal, implant failure, symptomatic hardware, etc. (P > 0.05). CONCLUSION The observations in this review suggested that IM nailing, especially locked IM nailing, could provide better shoulder functional outcome at one-year follow-up. Moreover, IM nailing fixation could effectively reduce operative time, blood loss, rates of infection, major complications, and revision surgery than plating. Further high-quality clinical trials with large samples and consistent designs are still needed to verify the long-term functional advantage of locked and unlocked IM nailing for midshaft clavicle fractures. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Jing-Xin Zhao
- Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China; China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China.
| | - Yan-Peng Zhao
- Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China; China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China.
| | - Zhi Mao
- Department of Critical Care Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing, China.
| | - Peng-Bin Yin
- Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China; China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China.
| | - Ming Hao
- Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China; China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China.
| | - Hou-Chen Lyu
- Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China; China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China.
| | - Xiang Cui
- Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China; China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China.
| | - Li-Cheng Zhang
- Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China; China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China.
| | - Pei-Fu Tang
- Department of Orthopaedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, China; China National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China.
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Ju WN, Cheng S, Qiao WS, Qi BC. Functional outcomes and adverse effects following three interventions for displaced midshaft clavicular fractures: A Bayesian network meta-analysis of randomized controlled trials. Orthop Traumatol Surg Res 2021; 107:103066. [PMID: 34537389 DOI: 10.1016/j.otsr.2021.103066] [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: 07/15/2020] [Revised: 02/18/2021] [Accepted: 03/12/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The efficacy of the most commonly used interventions for clavicle fractures remains controversial. These interventions are: open reduction and plate fixation (ORPF), non-surgical intervention (NSI), and use of an intramedullary nail (IMN). In adult patients with clavicle fractures, choosing which intervention might be best is challenging. MATERIALS AND METHODS PubMed, Journals@Ovid Full Text, Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, and Embase were performed to search English-language studies from the inception to February 2020. Randomized controlled trials (RCTs) comparing any of these three interventions were included. Patient and baseline characteristics, nonunion, major complications, Constant-Murley score (CMS), and Disabilities of the Arm, Shoulder and Hand score (DASH) were extracted. Then, we evaluated the functional outcomes and adverse effects after use of these three interventions for the management of displaced midshaft clavicle fractures in a Bayesian network meta-analysis. RESULTS A Bayesian random-effects model was conducted, and nonunion and major complications were evaluated with: risk ratio (RR) and 95% confidential interval (CI); while CMS and DASH were evaluated with mean differences (MD) and the corresponding 95% confidential interval CI. The rank probability of each endpoint was assessed on the basis of the surface area under the cumulative ranking curve (SUCRA). DISCUSSION ORPF is most likely to be successful in achieving objective functional outcomes as captured by the CMS, and IMN demonstrates significant efficacy for subjective functional outcomes, as captured by DASH scores. Compared with the other interventions examined, IMN was associated with decreased risk for adverse effects. LEVELS OF EVIDENCE I; meta-analysis.
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Affiliation(s)
- Wei-Na Ju
- Department of Neurology and neuroscience center, the First Hospital of Jilin University, Changchun 130021, China
| | - Shihuan Cheng
- Department of Rehabilitation, the First Hospital of Jilin University, Changchun 130021, China
| | - Wei-Song Qiao
- Department of Orthopedic Traumatology, the First Hospital of Jilin University, No. 1 Xinmin Street, Changchun 130021, China
| | - Bao-Chang Qi
- Department of Orthopedic Traumatology, the First Hospital of Jilin University, No. 1 Xinmin Street, Changchun 130021, China.
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Mendes AF, Curado RF, Dias JM, Mota Neto JD, Carrazzone OL, Pagan AR, Labronici PJ, Labronici GJ, Goes MPDA, Mouraria GG, Zogbi DR, Brigatto RM, Uehara A, Parro OC, Hisano FM, Teixeira BDS, Silva RW, Lazarini RF, Godinho AC, Godinho PC, França FDO, Godinho GG, Freitas JMA, Mariosa CAM, Souza BGSE, De Oliveira VM, De Simoni LF, Pereira CC, Antunes Filho J, Matsunaga FT, Belloti JC, Tamaoki MJS. Protocol of BRICS: Brazilian multicentric pragmatic randomised trial of surgical interventions for displaced diaphyseal clavicle fracture study: MIPO versus ORIF for the treatment of displaced midshaft clavicle fractures. BMJ Open 2021; 11:e052966. [PMID: 34716165 PMCID: PMC8559127 DOI: 10.1136/bmjopen-2021-052966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Fractures of the diaphysis of the clavicle are common; however, treatment guidelines for this condition are lacking. Surgery is associated with a lower risk of non-union and better functional outcomes but a higher risk of complications. Open reduction and internal fixation with plates and screws are the most commonly performed techniques, but they are associated with paraesthesia in the areas of incisions, extensive surgical exposure and high rates of implant removal. Minimally invasive techniques for treating these fractures have a lower rate of complications. The aim of this study is to evaluate which surgical treatment option (minimally invasive osteosynthesis or open reduction and internal fixation) has better prognosis in terms of complications and reoperations. METHODS AND ANALYSIS The study proposed is a multicentric, pragmatic, randomised, open-label, superiority clinical trial between minimally invasive osteosynthesis and open reduction and internal fixation for surgical treatment of patients with displaced fractures of the clavicle shaft. In the proposed study, 190 individuals with displaced midshaft clavicle fractures, who require surgery as treatment, will be randomised. The assessment will occur at 2, 6, 12, 24 and 48 weeks, respectively. The primary outcome of the study will be the number of complications and reoperations. For sample size calculation, a moderate effective size between the techniques was considered in a two-tailed test, with 95% confidence and 90% power. Complications include cases of infection, hypertrophic scarring, non-union, refracture, implant failure, hypoesthesia, skin irritation and shoulder pain. Reoperations are defined as the number of surgeries for pseudoarthrosis, implant failure, infection and elective removal of the implant. ETHICS AND DISSEMINATION Study approved by the institutional ethics committee (number 34249120.9.0000.5505-V.3). The results will be disseminated by publications in peer-reviewed journals and presentations in medical meetings. TRIAL REGISTRATION NUMBER RBR-3czz68)/UTN U1111-1257-8953.
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Affiliation(s)
- Adriano Fernando Mendes
- Serviço de Ortopedia e Traumatologia, Universidade Federal de Juiz de Fora Hospital Universitário, Juiz de Fora, Brazil
- Departamento de Ortopedia e Traumatologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Rodrigo Fleury Curado
- Departamento de Ortopedia, Faculdade de Medicina de São José do Rio Preto, Sao Jose do Rio Preto, Brazil
| | - Jair Moreira Dias
- Serviço de Ortopedia e Traumatologia, Universidade Federal de Juiz de Fora Hospital Universitário, Juiz de Fora, Brazil
| | - José Da Mota Neto
- Serviço de Ortopedia e Traumatologia, Universidade Federal de Juiz de Fora Hospital Universitário, Juiz de Fora, Brazil
- Serviço de Ortopedia e Traumatologia, Hospital Maternidade Therezinha de Jesus, Juiz de Fora, Brazil
| | - Oreste Lemos Carrazzone
- Departamento de Ortopedia, Faculdade de Medicina de São José do Rio Preto, Sao Jose do Rio Preto, Brazil
| | - Alexandre Rosa Pagan
- Departamento de Ortopedia, Faculdade de Medicina de São José do Rio Preto, Sao Jose do Rio Preto, Brazil
| | - Pedro José Labronici
- Faculdade de Medicina, Universidade Federal Fluminense Hospital Universitario Antonio Pedro, Niteroi, Brazil
- Serviço de Ortopedia e Traumatologia, Hospital Santa Teresa, Petropolis, Brazil
| | | | | | | | | | | | - Anderson Uehara
- Serviço de Ortopedia e Traumatologia, Hospital Santa Marcelina, Sao Paulo, Brazil
| | - Otávio Costa Parro
- Serviço de Ortopedia e Traumatologia, Hospital Santa Marcelina, Sao Paulo, Brazil
| | | | - Bruno De Souza Teixeira
- Serviço de Ortopedia e Traumatologia, Hospital Universitario Ciencias Medicas, Belo Horizonte, Brazil
| | - Rafael Waldolato Silva
- Serviço de Ortopedia e Traumatologia, Hospital Universitario Ciencias Medicas, Belo Horizonte, Brazil
| | - Rafael Fuchs Lazarini
- Department of Orthopaedics and Traumatology, Hospital Felicio Rocho, Belo Horizonte, Brazil
| | - André Couto Godinho
- Grupo de Cirurgia do Ombro dos Hospitais Belo Horizonte e LifeCenter, Hospital Belo Horizonte, Belo Horizonte, Brazil
| | - Pedro Couto Godinho
- Grupo de Cirurgia do Ombro dos Hospitais Belo Horizonte e LifeCenter, Hospital Belo Horizonte, Belo Horizonte, Brazil
| | - Flavio De Oliveira França
- Grupo de Cirurgia do Ombro dos Hospitais Belo Horizonte e LifeCenter, Hospital Lifecenter, Belo Horizonte, Brazil
| | - Glaydson Gomes Godinho
- Grupo de Cirurgia do Ombro dos Hospitais Belo Horizonte e LifeCenter, Hospital Belo Horizonte, Belo Horizonte, Brazil
| | - José Marcio Alves Freitas
- Grupo de Cirurgia do Ombro dos Hospitais Belo Horizonte e LifeCenter, Hospital Belo Horizonte, Belo Horizonte, Brazil
| | | | | | - Valdeci Manoel De Oliveira
- Serviço de Ortopedia e Traumatologia, Hospital Maternidade Therezinha de Jesus, Juiz de Fora, Brazil
- Faculdade de Medicina, Universidade Federal de Juiz de Fora Hospital Universitário, Juiz de Fora, Brazil
| | - Leandro Furtado De Simoni
- Serviço de Ortopedia e Traumatologia, Hospital Maternidade Therezinha de Jesus, Juiz de Fora, Brazil
- Serviço de Ortopedia e Traumatologia, Hospital Monte Sinai, Juiz de Fora, Brazil
| | | | - Jurandir Antunes Filho
- Serviço de Ortopedia e Traumatologia, Universidade Federal de Juiz de Fora Hospital Universitário, Juiz de Fora, Brazil
- Serviço de Ortopedia e Traumatologia, Hospital Monte Sinai, Juiz de Fora, Brazil
| | - Fabio Teruo Matsunaga
- Departamento de Ortopedia e Traumatologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
- Grupo de Cirurgia de Ombro e Cotovelo, Universidade Federal de Sao Paulo Escola Paulista de Medicina, Sao Paulo, Brazil
| | - João Carlos Belloti
- Orthopedics and Traumatology - Division of Hand Surgery and Upper Limb, Universidade Federal de Sao Paulo Escola Paulista de Medicina, Sao Paulo, Brazil
| | - Marcel Jun Sugawara Tamaoki
- Departamento de Ortopedia e Traumatologia, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
- Grupo de Cirurgia de Ombro e Cotovelo, Universidade Federal de Sao Paulo Escola Paulista de Medicina, Sao Paulo, Brazil
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Song HS, Kim H. Current concepts in the treatment of midshaft clavicle fractures in adults. Clin Shoulder Elb 2021; 24:189-198. [PMID: 34488301 PMCID: PMC8423531 DOI: 10.5397/cise.2021.00388] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/25/2021] [Indexed: 11/25/2022] Open
Abstract
Midshaft clavicle fractures are the most common fracture of the clavicle accounting for 80% of all clavicle fractures. Traditionally, midshaft clavicle fractures are treated with conservative treatment even when prominent displacement is observed; however, recent studies revealed that nonunion or malunion rate may be higher with conservative treatment. Moreover, recent studies have shown better functional results and patient satisfaction with surgical treatment. This review article provides a review of clavicle anatomy, describes the current clavicle fracture classification system, and outlines various treatment options including current surgical options for clavicle fracture in adults.
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Affiliation(s)
- Hyun Seok Song
- Department of Orthopedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyungsuk Kim
- Department of Orthopedic Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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13
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Examining the novel use of continuous compression implants in clavicle reconstruction: A biomechanical study. Clin Biomech (Bristol, Avon) 2021; 88:105437. [PMID: 34311318 DOI: 10.1016/j.clinbiomech.2021.105437] [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: 11/23/2020] [Revised: 06/15/2021] [Accepted: 07/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Current implants for clavicle fractures are known to cause poor cosmesis and irritation, which may require implant removal. Low-profile shape-memory staples provide an attractive alternative, but their biomechanical utility in clavicle reconstruction is unknown. We hypothesized that shape-memory reconstructions would be more compliant compared to traditional constructs but would also outperform conventional plates during cyclic loading to failure. METHODS This study was performed with 36 synthetic clavicles and 12 matched pairs of cadaveric specimens. The synthetic study tested four reconstructions: a single superiorly placed staple (n = 6), a single anteroinferiorly-placed staple (n = 6), a 3.5 mm reconstruction plate (n = 12), and two orthogonally placed staples (n = 12). The cadaveric study tested three constructs: reconstruction plate (n = 8), two orthogonal staples (n = 8), and a 2.7 mm reconstruction plate combined with a superior staple (n = 8). Non-destructive 4-point bending, compression, and torsion assays were performed prior to destructive cantilever bending and cyclic torsion tests. FINDINGS The single staple and double staple groups demonstrated significantly decreased resistance to bending (p < 0.001) and torsion (p ≤ 0.027) when compared to reconstruction plate groups. The double staple group sustained significantly fewer cycles to failure than the reconstruction plate group in cyclic torsional tests (p = 0.012). The synthetic models produced higher stiffness and failure mechanisms that were completely different from cadaveric specimens. INTERPRETATION Shape memory alloy implants provided inadequate stiffness for clavicle fixation but may have utility in other orthopaedic applications when used as a supplementary compression device in conjunction with traditional plated constructs. Synthetic bones have limited capacity for modeling fragility fractures.
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14
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Martin JR, Saunders PE, Phillips M, Mitchell SM, Mckee MD, Schemitsch EH, Dehghan N. Comparative effectiveness of treatment options for displaced midshaft clavicle fractures : a systematic review and network meta-analysis. Bone Jt Open 2021; 2:646-654. [PMID: 34402306 PMCID: PMC8384438 DOI: 10.1302/2633-1462.28.bjo-2021-0112.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aims The aims of this network meta-analysis (NMA) were to examine nonunion rates and functional outcomes following various operative and nonoperative treatments for displaced mid-shaft clavicle fractures. Methods Initial search strategy incorporated MEDLINE, PubMed, Embase, and the Cochrane Library for relevant randomized controlled trials (RCTs). Four treatment arms were created: nonoperative (NO); intramedullary nailing (IMN); reconstruction plating (RP); and compression/pre-contoured plating (CP). A Bayesian NMA was conducted to compare all treatment options for outcomes of nonunion, malunion, and function using the Disabilities of the Arm Shoulder and Hand (DASH) and Constant-Murley Shoulder Outcome scores. Results In all, 19 RCTs consisting of 1,783 clavicle fractures were included in the NMA. All surgical options demonstrated a significantly lower odds ratio (OR) of nonunion in comparison to nonoperative management: CP versus NO (OR 0.08; 95% confidence interval (CI) 0.04 to 0.17); IMN versus NO (OR 0.07; 95% CI 0.02 to 0.19); RP versus NO (OR 0.07; 95% CI: 0.01 to 0.24). Compression plating was the only treatment to demonstrate significantly lower DASH scores relative to NO at six weeks (mean difference -10.97; 95% CI -20.69 to 1.47). Conclusion Surgical fixation demonstrated a lower risk of nonunion compared to nonoperative management. Compression plating resulted in significantly less disability early after surgery compared to nonoperative management. These results demonstrate possible early improved functional outcomes with compression plating compared to nonoperative treatment. Surgical fixation of mid-shaft clavicle fractures with compression plating may result in quicker return to activity by rendering patients less disabled early after surgery. Cite this article: Bone Jt Open 2021;2(8):646–654.
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Affiliation(s)
- John R Martin
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Patrick E Saunders
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | | | - Sean M Mitchell
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Michael D Mckee
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | | | - Niloofar Dehghan
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, Arizona, USA.,The CORE Institute, Phoenix, Arizona, USA
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15
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Park HY, Kim SJ, Sur YJ, Jung JW, Kong CG. Refracture after locking compression plate removal in displaced midshaft clavicle fractures after bony union: a retrospective study. Clin Shoulder Elb 2021; 24:72-79. [PMID: 34078014 PMCID: PMC8181845 DOI: 10.5397/cise.2021.00059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/27/2021] [Indexed: 11/25/2022] Open
Abstract
Background A midshaft clavicle fracture is a common fracture that typically responds well to open reduction and internal fixation (ORIF). However, refracture can occur after implant removal (IR). This study aimed to analyze the rate of refracture and related factors after removal of the locking compression plate (LCP) for displaced midshaft clavicle fractures. Methods We retrospectively reviewed the medical records of 201 patients who had undergone ORIF with LCP for midshaft clavicle fractures after IR after bony union from January 2011 to May 2018 at our institute. We evaluated basic demographic characteristics and radiographic parameters. All patients were treated with an LCP for primary fracture. The patients were divided into two groups: a refracture group that experienced a second fracture within 1 year after IR and a no-fracture group. Results There were four cases (1.99%) of refracture; three were treated conservatively, while one was treated surgically. All patients achieved bony union. The average interval between refracture and IR was 64 days (range, 6–210 days). There was a significant difference in classification of fractures (AO Foundation/Orthopaedic Trauma Association [AO/OTA] classification) between the two groups. However, other patient demographics and radiographic measurements between refracture and IR, such as bone diameter, showed no significant difference between the two groups. Conclusions This study showed that one in 50 patients suffered from refracture after removal of the LCP. Thus, if patients desire IR, the surgeon should explain that there is a relatively higher possibility of refracture for cases with simple or segmental fractures than for other types of fracture.
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Affiliation(s)
- Ho-Youn Park
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Seok-Jung Kim
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Yoo-Joon Sur
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Jae-Woong Jung
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Chae-Gwan Kong
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
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STORTI THIAGOMEDEIROS, CAMILO MAURÍCIOSIQUEIRA, SILVA RAFAELFRANCISCOALVES, FARIA RAFAELSALOMONSILVA, SIMIONATTO CAROLINALIMA, PANIAGO ALEXANDREFIRMINO. CLINICAL EVALUATION OF THE TREATMENT OF CLAVICLE FRACTURES: INTRAMEDULLARY NAIL × PLATE. ACTA ORTOPEDICA BRASILEIRA 2021; 29:34-38. [PMID: 33795967 PMCID: PMC7976870 DOI: 10.1590/1413-785220212901231439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: Studies confirm the benefit of surgical treatment for fixation of displaced midshaft clavicle fractures. Plate fixation and intramedullary nail are the two most used techniques. Our study seeks to compare these two surgical techniques. Methods: This is a retrospective study, conducted by the evaluation of patients treated for displaced midshaft clavicle fracture with intramedullary nail, and plate and screws. Socioeconomic variables were collected, a visual pain scale questionnaire was applied, the shoulder function was measured using CONSTANT and UCLA scores, and radiography was performed to verify the consolidation and evaluation of the final clavicle shortening. Results: Sixty-five patients were evaluated, 36 (55.4%) of which were subjected to clavicle fixation with plate and screws and 29 (44.6%) with intramedullary nail. The median shortening was 0.1mm for plate and 5.8mm for nail (p = 0.001). The UCLA score shows an average of 35 in the plate group and 35 in the intramedullary group. The median CONSTANT scores were 96.5 for plate and 95 for nail, without significance. In all groups, 13 (20%) complications were registered, 9 fixed with plate and 4 fixed with intramedullary nail. The most common complication was skin erosion with exposure of the synthetic material. Conclusion: The two techniques present satisfactory results for the treatment of displaced midshaft clavicle fractures. Level of Evidence III, Therapeutic Studies Investigating the Results of Treatment.
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Affiliation(s)
- THIAGO MEDEIROS STORTI
- Instituto do Ombro de Brasília, Brazil; Hospital Ortopédico e Medicina Especializada, Brazil
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Li L, Yang X, Xing F, Jiang J, Tang X. Plate fixation versus intramedullary nail or Knowles pin fixation for displaced midshaft clavicle fractures: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2020; 99:e22284. [PMID: 32991430 PMCID: PMC7523859 DOI: 10.1097/md.0000000000022284] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Plate fixation and intramedullary nail/Knowles pin fixation methods are commonly used to treat displaced midshaft clavicle fractures. However, the differences between these 2 methods are unclear. OBJECTIVE This meta-analysis aimed to compare plate fixation and intramedullary nail/Knowles pin fixation for displaced midshaft clavicle fractures. METHODS We searched PubMed, EBM reviews, and Ovid Medline online for studies related to comparison of plate fixation versus intramedullary nail/Knowles pin fixation for displaced midshaft clavicle fracture from inception to June 30, 2019. Relevant literature search, data extraction, and quality assessment will be performed by 2 researchers independently. The methodological quality of all included studies was appraised using the Cochrane system for randomized trials. The RevMan 5.2 software was used for heterogeneity assessment, generating funnel-plots, data synthesis, sensitivity analysis, and determining publication bias. The fixed-effects or random-effects model was used to calculate mean difference (MD)/relative risks (RRs) and 95% confidence intervals (CIs). RESULTS This meta-analysis included 839 patients from 12 randomized controlled trials. We found that compared to plate fixation, intramedullary nail/Knowles pin fixation yielded a higher shoulder constant score [MD = -2.43, 95% CI (-3.46 to -1.41), P < .00001] and lower disabilities of the arm, shoulder and hand (DASH) score [MD = 2.98, 95% CI (0.16-5.81), P = .04], and lower infection rates [RR = 2.05, 95% CI (1.36-3.09), P = .003], operation time [MD = 20.20, 95% CI (10.80-29.60), P < .0001], incision size [MD = 6.09, 95% CI (4.54-7.65), P < .00001], and hospital stay [MD = 1.10, 95% CI (0.56-1.64), P < .00001] but with a higher removal rate [RR = 0.52, 95% CI (0.41-0.65), P < .00001] compared to plate fixation. There were no significant differences in nonunion, reintervention, or revision and refracture between these two methods. The limitation is that many studies did not demonstrate the random generated details, and only English articles were enrolled in this meta-analysis. CONCLUSIONS Intramedullary nail/Knowles pin fixation might be an optimum choice for treating displaced midshaft clavicle fractures, with similar performance in terms of the nonunion, reintervention, or revision and refracture, and better shoulder constant and DASH scores, infection rates, and operative parameters.
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Affiliation(s)
- Lang Li
- Department of Pediatric Surgery
| | | | - Fei Xing
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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18
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Ju W, Mohamed SO, Qi B. Comparison of plate fixation vs. intramedullary fixation for the management of mid-shaft clavicle fractures: A systematic review and meta-analysis of randomised controlled trials. Exp Ther Med 2020; 20:2783-2793. [PMID: 32765773 PMCID: PMC7401851 DOI: 10.3892/etm.2020.9002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/22/2020] [Indexed: 11/06/2022] Open
Abstract
A number of meta-analyses have compared clinical outcomes following plate vs. intramedullary fixation for midshaft clavicle fractures (MSCF), but with conflicting results. There is a requirement for updated level-1 evidence to guide clinicians managing MSCF. The aim of the present systematic review and meta-analysis was to compare clinical outcomes following plate vs. intramedullary fixation of MSCF. The PubMed, Scopus, BioMed Central, Cochrane Central Register of Controlled Trials and Google Scholar databases were searched for records added until 1st July 2019. A total of 10 randomised controlled trials (RCTs) were included. Shoulder function was assessed using the Constant-Murley Shoulder Outcome questionnaire and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH). There was no statistically significant difference in Constant-Murley scores between plate and intramedullary fixation [Mean difference (MD)=0.75; 95% CI: -2.49 to 3.99; P=0.65; I2=85%]. Similarly, there was no statistically significant difference in DASH scores between the two groups (MD=1.55; 95% CI: -1.12 to 4.23; P=0.26; I2=89%). There was no statistically significant difference in complications requiring non-routine surgery between plate and intramedullary fixation [risk ratio (RR)=1.80, 95%CI: 0.80-4.05, P=0.15; I2=0%]. There was an increased risk of complications that did not require non-routine surgery with plate fixation as compared to intramedullary fixation (RR=2.38, 95%CI: 1.22-4.62, P=0.01; I2=70%). Plate fixation was also associated with an increased risk of infection and complications of cosmetic dissatisfaction. The present results indicated no difference in long-term functional outcomes between plate and intramedullary fixation of MSCF. Plate fixation was associated with an increased risk of complications not requiring non-routine surgery. Further high-quality RCTs shall strengthen the evidence on this subject.
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Affiliation(s)
- Weina Ju
- Department of Neurology and Neuroscience Center, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Sayid Omar Mohamed
- Department of Orthopedics, Jazeera University Hospital, Mogadishu BN SO 935, Somalia
| | - Baochang Qi
- Department of Orthopedic Traumatology, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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Johnson CS, Acebo JB, Aya K, Somerson JS. Transient Brachial Plexopathy After Fixation of a Clavicle Fracture Nonunion: A Case Report. JBJS Case Connect 2020; 10:e0434. [PMID: 32649110 DOI: 10.2106/jbjs.cc.19.00434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE A 54-year-old man presented with a comminuted left midclavicle fracture that progressed to a symptomatic nonunion after nonsurgical management. Nonunion open reduction and internal fixation (ORIF) was performed, but a left brachial plexopathy developed 48 hours postoperatively. Imaging failed to demonstrate an emergent cause. The patient was monitored and completely recovered, with occasional neuralgia and mildly limited forward elevation of the shoulder. CONCLUSION Development of a brachial plexopathy 48 hours after routine clavicle nonunion ORIF using plate fixation is an unusual complication. Future studies are needed to determine if this "wait-and-see" approach can be generalized to similar cases.
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Affiliation(s)
- Connor S Johnson
- 1School of Medicine, The University of Texas Medical Branch, Galveston, Texas 2Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas
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Dual Mini-Fragment Plating Is Comparable With Precontoured Small Fragment Plating for Operative Diaphyseal Clavicle Fractures: A Retrospective Cohort Study. J Orthop Trauma 2020; 34:e229-e232. [PMID: 31868765 DOI: 10.1097/bot.0000000000001727] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare precontoured (Pc) small fragment plating to dual mini-fragment plating (DmF) for open reduction and internal fixation of diaphyseal clavicle fractures. DESIGN Retrospective cohort. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS A total of 133 patients with displaced fractures of the diaphyseal clavicle (OTA/AO 15-B1, -2, and -3) treated with open reduction and internal fixation with a minimum of 1 year follow-up or until radiographic and clinical union. INTERVENTION Two patient cohorts were identified: (1) patients treated with orthogonal DmF plate constructs and (2) patients treated with Pc clavicle-specific plates. OUTCOME MEASUREMENTS Union rate and implant removal were assessed using standard descriptive statistics. Odds ratios, 95% confidence intervals, and P values (P) were calculated. RESULTS There were 60 DmF and 74 Pc patients. There were no significant differences between groups with respect to age, sex, surgeon, body mass index, or mode of fixation. There was no significant difference in union (98.3% DmF; 100% Pc, P = 0.45) or maintenance of reduction (98.3% DmF; 100% Pc, P = 0.45). A total of 8% of DmF patients had symptomatic implant removal compared with 20% of Pc patients (odds ratio 0.36, confidence interval 0.12-1.05, P = 0.061). CONCLUSIONS This retrospective comparative study found no difference in union or maintenance of reduction for diaphyseal clavicle fractures fixed with DmF compared with Pc plating. Patients treated with DmF plates may have lower rates of symptomatic implant removal. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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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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Vannabouathong C, Chiu J, Patel R, Sreeraman S, Mohamed E, Bhandari M, Koval K, McKee MD. An evaluation of treatment options for medial, midshaft, and distal clavicle fractures: a systematic review and meta-analysis. JSES Int 2020; 4:256-271. [PMID: 32490412 PMCID: PMC7256900 DOI: 10.1016/j.jseint.2020.01.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background The majority of clavicle fractures are midshaft injuries, although fractures of the distal or medial fragment also occur. The aim of this study was to review the current evidence on these injuries to help inform future treatment plans. Methods We searched for studies comparing interventions for medial, midshaft, or distal clavicle fractures; however, we did not identify any comparative studies on medial fractures and performed a secondary search on this topic. We conducted Bayesian network meta-analyses, although this was not feasible with studies on medial fractures and we described their results qualitatively. Results For midshaft fractures, we found statistically significant improvements in function and time to radiographic union with plating, an elastic stable intramedullary nail (ESIN), and the Sonoma CRx intramedullary nail over nonoperative treatments. Both plating and an ESIN also showed significantly lower risks of nonunion and malunion relative to nonoperative methods. For distal fractures, a locking plate (LP) with or without coracoclavicular (CC) suturing yielded significantly better outcomes over K-wires with or without tension bands, CC suturing alone, an LP with a CC screw, a hook plate, and a sling. For medial fractures, plating may result in more favorable functional and union-related outcomes, although implant irritation may occur. In addition, K-wires, tension bands, and a screw with sutures demonstrated success when plating was technically not feasible in a few cases, whereas treatment with a sling may result in reduced function and a higher risk of complications relative to surgery. Conclusion This study can provide guidance on the management of medial, midshaft, and distal clavicle fractures. The current evidence suggests that plating, an ESIN, and a CRx intramedullary nail are all good options for midshaft fractures; an LP with or without CC suturing should be preferred for distal fractures; and plating is also acceptable for medial fractures, provided that the patient is deemed suitable for surgery and has the adequate bone stock and sufficiently sized medial fragment necessary to implant the device. Patient preferences for certain outcomes should be considered, which may result in different treatment recommendations.
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Affiliation(s)
- Christopher Vannabouathong
- OrthoEvidence, Burlington, ON, Canada
- Corresponding author: Christopher Vannabouathong, MSc, OrthoEvidence, 3228 S Service Rd, Ste 206, Burlington, ON, Canada, L7N 3H8.
| | - Justin Chiu
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Rahil Patel
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Shreyas Sreeraman
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Elias Mohamed
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Kenneth Koval
- Department of Orthopaedic Surgery, Memorial Hospital, Gulfport, MS, USA
| | - Michael D. McKee
- Department of Orthopaedic Surgery, University of Arizona College of Medicine–Phoenix, Phoenix, AZ, USA
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Functional outcomes, union rate, and complications of the Anser Clavicle Pin at 1 year: a novel intramedullary device in managing midshaft clavicle fractures. JSES Int 2020; 4:272-279. [PMID: 32490413 PMCID: PMC7256888 DOI: 10.1016/j.jseint.2020.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Surgical management of displaced midshaft clavicle fractures in adults leads to better union rates, improved early functional outcomes, and increased patient satisfaction compared with nonoperative treatment. However, both intramedullary fixation and plate osteosynthesis are subject to a specific array of disadvantages and complications. The Anser Clavicle Pin is a novel intramedullary device designed to address these disadvantages and complications. The aim of this study was to evaluate the union rate, functional outcomes, and complications of the Anser Clavicle Pin at 1-year follow-up. Methods A prospective explorative case series including 20 patients with displaced midshaft clavicle fractures was performed in 2 hospitals. The primary outcomes were union rate, functional outcomes (Constant-Murley score and Disabilities of the Arm, Shoulder and Hand score), and complications. The secondary outcomes were closed reduction rate, operative time, image-intensifier time, hospital stay, incision length, time to radiologic union, postoperative pain reduction, reoperation rate, health-related quality-of-life score, and patient satisfaction. Results There was a 100% union rate. The Constant-Murley score at 1 year was 96.7 (standard deviation [SD], 5). The Disabilities of the Arm, Shoulder and Hand score was 5.1 (SD, 10). There were no infections, neuropathy of the supraclavicular nerve, or hardware irritation requiring removal of hardware. Three device-related complications (15%) occurred, including plastic deformation, protrusion, and hardware failure. The satisfaction score was 8.9 (SD, 1) on the visual analog scale at the 1-year follow-up. Conclusion Managing displaced midshaft clavicle fractures with the Anser Clavicle Pin results in a 100% union rate and excellent functional outcomes and patient satisfaction. It has a low non-device-related complication rate, and the device-related complications that occurred in this series may be prevented in the future.
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Ullah K, Khan S, Wang YQ, Zhao ZH, Cheng P, Sapkota B, Ren L, Khan S, Rehman MU, Xue Y. Bilaterally Threaded, Minimal Invasive, Elastic Locking Intramedullary Nailing (ELIN) for the Treatment of Clavicle Fractures. Orthop Surg 2020; 12:321-332. [PMID: 32077261 PMCID: PMC7031594 DOI: 10.1111/os.12612] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 12/16/2019] [Accepted: 12/20/2019] [Indexed: 11/30/2022] Open
Abstract
Objective To evaluate and present the effectiveness of this innovatively designed, elastic locking intramedullary nail (ELIN) in fixation of clavicle fractures. Methods The study included 38 patients from July 2014 to July 2017. All of them received intramedullary fixation treated with ELIN, 22 were males and 16 females. The mean age of the patients was 54 years. There were twenty right‐side and 18 left‐side clavicular fractures. Radiographs were taken to assess the fracture type: 21 were type A, 16 type B, and one type C. General anesthesia or cervical block was given to all patients. A small incision of 3–5 cm was given only to those who needed mini‐open reduction. The administration of ELIN and reduction of the fracture was made sure with a C arm machine. After a follow‐up of 8 to 33 months, the clinical outcomes were assessed and evaluated. The constant scores and disabilities of the arm, shoulder and hand questionnaire (DASH) were used to determine the outcomes and functional status of the patients. The study was done accordingly to the guidelines provided by the ethics committee. Results Mean operation time was 25.63 min. Mean follow‐up time was 16.5 months. The rate of closed reduction and open reduction was 84% and 16% respectively. There was no shortening of the clavicle. There was no breakage of the nail, though bending of the nail occurred in one patient. Superficial skin infection occurred in three patients at insertion points or the nail tip which was embedded subcutaneously. Skin erosion with nail exposure occurred in a patient with no significant infection. All the other patients had excellent shoulder function. A mini scar was observed in seven patients all the other patients had no scar. Asymmetry was observed in three patients. The mean Constant score was 98.47 and the mean DASH score was 1.55 at the last follow‐up. The implant was removed in all the patients. Conclusion Clavicular fractures treated with ELIN is minimally invasive, which presents a safe and novel surgical technique with less complications and a high success rate, excellent aesthetic and quick recovery after surgery. ELIN restores the micro‐dynamic stress at the fracture ends and promotes fracture healing, keeps intact the fracture hematoma and maintains the blood supply, accelerates healing and thus leads to faster osseous healing and better restoration of clavicle length.
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Affiliation(s)
- Kifayat Ullah
- Department of Orthopedic Surgery, Tianjin Fourth Central Hospital, Tianjin Medical University, Tianjin, China
| | - Saima Khan
- Department of Infertility and Reproductive Endocrinology, Tianjin Medical University Central Hospital of Obstetrics and Gynecology, Tianjin, China
| | - Yong-Qing Wang
- Department of Orthopedic Surgery, Tianjin Fourth Central Hospital, Tianjin Medical University, Tianjin, China
| | - Zhi-Hui Zhao
- Department of Orthopedic Surgery, Tianjin Fourth Central Hospital, Tianjin Medical University, Tianjin, China
| | - Peng Cheng
- Department of Orthopedic Surgery, Tianjin Fourth Central Hospital, Tianjin Medical University, Tianjin, China
| | | | - Liang Ren
- Department of Orthopedic Surgery, Tianjin Fourth Central Hospital, Tianjin Medical University, Tianjin, China
| | - Samiullah Khan
- Department of Gastroenterology and Hepatology, Tianjin Medical University General Hospital, Tianjin, China
| | - Mujeeb Ur Rehman
- Department of Cardiovascular and Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yuan Xue
- Department of Orthopedic Surgery, Tianjin Medical University General Hospital, Tianjin, China
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What Is the Best Evidence for Management of Displaced Midshaft Clavicle Fractures? A Systematic Review and Network Meta-analysis of 22 Randomized Controlled Trials. Clin Orthop Relat Res 2020; 478:392-402. [PMID: 31574019 PMCID: PMC7438117 DOI: 10.1097/corr.0000000000000986] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Displaced mid-third clavicle fractures are common, and their management remains unclear. Although several meta-analyses have compared specific operative techniques with nonoperative management, it is not possible to compare different operative constructs with one another using a standard meta-analysis. Conversely, a network meta-analysis allows comparisons among more than two treatment arms, using both direct and indirect comparisons between interventions across many trials. To our knowledge, no network meta-analysis has been performed to compare the multiple treatment options for displaced clavicle fractures. QUESTIONS/PURPOSES We performed a network meta-analysis of randomized, controlled trials (RCTs) to determine from among the approaches used to treat displaced midshaft clavicle fractures: (1) the intervention with the highest chance of union at 1 year, (2) the intervention with the lowest risk of revision surgery, and (3) the intervention with the highest functional outcome scores. Secondarily, we also (4) compared the surgical subtypes in the available RCTs on the same above endpoints. METHODS MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were reviewed for relevant randomized controlled trials published up to July 25, 2018. Two hundred and eighty four papers were reviewed, with 22 meeting inclusion criteria of RCTs with appropriate randomization techniques, adult population, minimum of 1 year follow-up and including at least one operative treatment arm. In total, 1002 patients were treated with a plate construct, 378 with an intramedullary device, and 585 patients were managed nonoperatively. Treatment subtypes included locked intramedullary devices (56), unlocked intramedullary devices (322), anterior plating (89), anterosuperior plating (150), superior plating (449) or plating not otherwise specified (314). We performed a network meta-analysis to compare and rank the treatments for displaced clavicle fractures. We considered the following outcomes: union achievement, revision surgery risk and functional outcomes (DASH and Constant Scores). The minimal clinically important difference (MCID) was considered for both Constant and DASH scores to be at 8 points, representing the average of MCID scores reported for both DASH and Constant in the evidence, respectively. RESULTS Union achievement was lower in patients treated nonoperatively (88.9%), and higher in patients treated operatively (96.7%, relative risk [RR] 1.128 [95% CI 1.1 to 1.17]; p < 0.001), Number needed to treat (NNT) = 10). Union achievement increased with any plate construct (97.8%, RR 1.13 [95% CI 1.1 to 1.7]; p < 0.0001, NNT = 9) and with anterior or anterosuperior plates (99.3%, RR 1.14 [95% CI 1.1 to 1.8]; p < 0.0001, NNT = 8). Risk of reoperation, when considering planned removal of hardware, was similar across all treatment arms. Lastly, operative treatment outperformed nonoperative treatment with minor improvements in DASH and Constant scores, though not approaching the MCID. At the subtype level, anterosuperior plating ranked highest in DASH and Constant functional scores with mean differences reaching 10-point improvement for Constant scores (95% CI 4.4 to 2.5) and 7.6 point improvement for DASH (95% CI 5.2 to 20). CONCLUSIONS We found that surgical treatment led to a greater likelihood of union at 1 year of follow-up among adult patients with displaced mid-third clavicle fractures. In aggregate, surgical treatment did not increase functional scores by amounts that patients were likely to consider clinically important. Use of specific subtypes of plating (anterior, anterosuperior) resulted in improvements in the Constant score that were slightly above the MCID but did not reach the MCID for the DASH score, suggesting that any outcomes-score benefits favoring surgery were likely to be imperceptible or small. In light of these findings, we believe patients can be informed that surgery for this injury can increase the likelihood of union incrementally (about 10 patients would need to undergo surgery to avoid one nonunion), but they should not expect better function than they would achieve without surgery; most patients can avoid surgery altogether with little absolute risk of nonunion. Patients who opt for surgery must be told that the decision should be weighed against complications and the possibility of undergoing a second procedure for hardware removal. Patients opting not to have surgery for acute midshaft clavicle fractures can be told that nonunion occurs in slightly more than 10% of patients, and that these can be more difficult to manage than acute fractures. LEVEL OF EVIDENCE Level I, therapeutic study.
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Huang X, Xiao H, Xue F. Clavicle nonunion and plate breakage after locking compression plate fixation of displaced midshaft clavicular fractures. Exp Ther Med 2019; 19:308-312. [PMID: 31853304 PMCID: PMC6909797 DOI: 10.3892/etm.2019.8216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 11/11/2019] [Indexed: 11/06/2022] Open
Abstract
Open reduction and plate fixation have been widely used for the treatment of displaced midshaft clavicular fractures (DMCF). The nonunion rate after plate fixation of DMCF has been reported to be between 0.1 and 15% and the construct failure rate is approximately 5%. Few studies have discussed the risk factors of construct failure. The aim of the present study was to identify possible risk factors of construct failure in plate fixation of DMCF and discuss the subsequent treatment strategies. Six patients who experienced plate breakage and clavicle nonunion between 2015 and 2017 were evaluated. All these patients were treated with open reduction and plate fixation of DMCF using a 3.5-mm locking compression plate. The plate breakage occurred 3-6 months after the initial injury. After the diagnosis of plate breakage, four patients underwent surgical management and two patients underwent nonoperative treatment. Potential risk factors for construct failure and efficacy of the subsequent treatment strategies were analyzed. We found that a risk factor for plate breakage was the increased stress in free hole area around the fracture zone. A second surgery for plate renewal and bone grafting may be necessary in a large percentage of these individuals. Based on the results of this study, our recommendation is that monocortical screws or simple obturators for the holes around the fracture zone should be used to protect the comminuted fragment for further damage and enhance plate strength. If a clavicle nonunion and plate breakage does occur, surgical repair and bone grafting provide high union rates and should be a necessary remedy.
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Affiliation(s)
- Xiaoyan Huang
- Department of Orthopedics, Shanghai Fengxian District Central Hospital, Shanghai 201400, P.R. China
| | - Haijun Xiao
- Department of Orthopedics, Shanghai Fengxian District Central Hospital, Shanghai 201400, P.R. China
| | - Feng Xue
- Department of Orthopedics, Shanghai Fengxian District Central Hospital, Shanghai 201400, P.R. China
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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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Vancleef S, Herteleer M, Carette Y, Herijgers P, Duflou JR, Nijs S, Vander Sloten J. Why off-the-shelf clavicle plates rarely fit: anatomic analysis of the clavicle through statistical shape modeling. J Shoulder Elbow Surg 2019; 28:631-638. [PMID: 30609957 DOI: 10.1016/j.jse.2018.09.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 09/11/2018] [Accepted: 09/16/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND The clavicle presents a large variability in its characterizing sigmoid shape. Prominent and nonproperly fitting fixation plates (FP) cause soft tissue irritation and lead to hardware removal. It is therefore key in FP design to account for shape variations. Statistical shape models (SSMs) have been built to analyze a cluster of complex shapes. The goal of this study was to describe the anatomic variation of the clavicle using SSMs. METHODS Two different SSMs of the clavicle were created, and their modes of variation were described. One model contained 120 left male and female clavicles. The other model consisted of 76 left and corresponding right clavicles, 41 originating from men and 35 from women. RESULTS The model of 120 left clavicles showed that 10 modes of variation are necessary to explain 95% of the variation. The most important modes of variation are the clavicle length, inferior-superior bow, and medial and lateral curvature. Statistically significant differences between male and female clavicles were seen in length, sigmoid shape, and medial curvature. Comparison in men between left and right revealed significant differences in length and medial curvature. For women, a statistically significant difference between left and right was only seen in the length. CONCLUSIONS Although the operative treatment of displaced midshaft clavicular fractures has clear benefits, the variable anatomy of the clavicle often makes it challenging for the surgeon to make the plate fit adequately. Based on the identified variability in the clavicle's anatomy, it seems unlikely that a clavicle plating system can fit the entire population.
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Affiliation(s)
| | - Michiel Herteleer
- Organ Systems, KU Leuven, Leuven, Belgium; Department of Traumatology, Universitaire Ziekenhuizen (UZ) Leuven, Leuven, Belgium
| | - Yannick Carette
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | | | - Joost R Duflou
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - Stefaan Nijs
- Department of Traumatology, Universitaire Ziekenhuizen (UZ) Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Ruzbarsky JJ, Khormaee S, Rauck RC, Warren RF. Fragility of randomized clinical trials of treatment of clavicular fractures. J Shoulder Elbow Surg 2019; 28:415-422. [PMID: 30771826 DOI: 10.1016/j.jse.2018.11.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 10/28/2018] [Accepted: 11/09/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Statistical significance, as reported by the P value, has traditionally been the most commonly reported way to determine whether a difference exists between clinical interventions. Unfortunately, P values alone confer little about the robustness of a study's conclusions. An emerging metric, the fragility index (FI), helps to address this challenge by quantifying the number of events per outcome group that would need to be reversed to the alternative outcome in order to raise the P value above the 0.05 threshold. METHODS Using systematic search strategy, we identified randomized controlled trials (RCTs) pertaining to clavicular fractures published in the last decade (2007-2017). Studies included for analysis involved 2 parallel arms, were published in English, allocated patients to treatment and control arms in a 1:1 ratio, and reported statistical significance (P < .05) for dichotomous variables. The FI was determined based on the Fisher exact test, using previously published methods. RESULTS Fifteen RCTs were included. The median FI was 2 (range, 0-17). Eleven studies (73.3%) had an FI of 2 or less. Seven of the trials (46.7%) reported that the number of patients lost to follow-up exceeded the FI. CONCLUSIONS The median FI reported in the recent literature on clavicular fractures is only 2. The FI is a useful metric to analyze the robustness of study conclusions that should complement other methods of critical data evaluation, including the P value or effect sizes. Future efforts are needed to increase institutional collaboration and patient recruitment to strengthen the robustness of RCT conclusions, especially in the realm of clavicular fracture management.
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Affiliation(s)
- Joseph J Ruzbarsky
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA.
| | - Sariah Khormaee
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Ryan C Rauck
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
| | - Russell F Warren
- Department of Orthopaedics, Hospital for Special Surgery, New York, NY, USA
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Vishwanathan K, Jain S, Patel A. Validity and responsiveness of the Nottingham clavicle score in clavicle shaft fractures treated with titanium elastic nailing. J Clin Orthop Trauma 2019; 10:497-502. [PMID: 31061576 PMCID: PMC6491903 DOI: 10.1016/j.jcot.2018.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 05/24/2018] [Accepted: 06/18/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The Nottingham Clavicle Score (NCS) has been recently described for functional outcome assessment after injuries to clavicle and the Acromioclavicular joint. However; validity and responsiveness are context specific psychometric terms and the NCS has not been previously described in surgically treated clavicle shaft fractures. Aim of the present study was to investigate validity and responsiveness of the NCS in clavicle fractures treated with titanium flexible nailing. METHODS This prospective study was undertaken on consecutively operated clavicle shaft fractures treated with titanium elastic nail from November 2013 to August 2016. Functional assessment using NCS was done at two and six months postoperatively. Construct validity was also evaluated by formulating the null hypothesis that there would be no difference in NCS at six months after open and closed reduction and in 15B1 and 15B2 fracture sub-types. The above two hypotheses were formulated based on previous studies that used Constant score and DASH score. Pre-specified hypothesis and results in accordance with the hypotheses suggest satisfactory construct validity. Responsiveness was evaluated using standardized response mean (SRM) and Effect size (ES). ES and SRM values ≥0.80 suggest satisfactory responsiveness. The proportion of patients having the least possible score of 0 points (floor effect) and the highest possible score of 100 points (ceiling effect) was evaluated at two and six months postoperatively. Floor and ceiling effect of <15% suggests satisfactory internal validity. RESULTS Thirty six consecutively operated patients were included in the study. The NCS at two months and six months was 69.6 ± 9.6 and 87.2 ± 7.1 respectively. The NCS at six months after fixation was 88.7 ± 4.8 in closed reduction cohort and 84.7 ± 9.4 in the open reduction cohort and this difference was not significant (p = 0.1). The NCS at six months after fixation was 85.3 ± 8.3 in 15B1 clavicular fractures and 89.7 ± 4.0 in 15B2 clavicular shaft fractures and this difference was also not significant (p = 0.07). All results pertaining to construct validity were in accordance with our hypothesis thereby suggesting that NCS demonstrates satisfactory construct validity. The ES and SRM were 1.8 and 2.6 respectively. NCS showed no ceiling (0%) or floor effect (0%) at two and six months postoperatively thereby suggesting adequate internal validity of the NCS. CONCLUSION NCS has satisfactory construct validity, internal validity and responsiveness in surgically treated clavicle shaft fractures with titanium elastic nailing.
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Affiliation(s)
- Karthik Vishwanathan
- Department of Orthopaedics, Pramukhswami Medical College, Karamsad 388325, India
- Corresponding author at: Department of Orthopaedics, Pramukhswami Medical College and Shri Krishna Hospital, Gokal Nagar, Karamsad 388325, India.
| | - Shantanu Jain
- Department of Orthopaedics, Pramukhswami Medical College, Karamsad 388325, India
- Department of Orthopaedics, Convenient Hospitals Limited, AB Road, LIG Square, Indore 452008, Madhya Pradesh, India
| | - Amit Patel
- Department of Orthopaedics, Pramukhswami Medical College, Karamsad 388325, India
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Abstract
Fractures of the clavicle are common injuries that occur across all age groups but are most frequently seen in the young, active patient population. Among the different types of clavicle fractures, those occurring in the middle third of the clavicular shaft are the most common. Historically, most of these fractures were treated by closed means even when notable displacement was present. Recently, there has been a renewed interest in assessing the best treatment option for these patients. Although nonsurgical treatment is a reliable method for treating many of these fractures, more recent data suggest that fractures with notable displacement (>2 cm of shortening or >100% displacement) and/or comminution have better short-term outcomes and lower rates of nonunion with surgical management. Current surgical options include superior plating, anterior-inferior plating, dual plating, and intramedullary nail fixation.
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Fuglesang HFS, Flugsrud GB, Randsborg PH, Hammer OL, Utvåg SE. Five-Year Follow-up Results of a Randomized Controlled Study Comparing Intramedullary Nailing with Plate Fixation of Completely Displaced Midshaft Fractures of the Clavicle in Adults. JB JS Open Access 2018; 3:e0009. [PMID: 30882049 PMCID: PMC6400504 DOI: 10.2106/jbjs.oa.18.00009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Surgical management of completely displaced midshaft fractures of the clavicle is becoming more frequent, although long-term follow-up with Level-I evidence is scarce. Plate fixation (PF) of comminuted fractures provides faster functional recovery than elastic stable intramedullary nailing (ESIN). The 12-month follow-up of this randomized controlled trial, published previously, found no clinical differences at that time on the group level, but subtle differences on the subgroup level indicated that the results after closed ESIN were better than those after open ESIN. The primary aim of the study reported here was to compare the long-term clinical outcomes and sequelae after open reduction with those after closed reduction and to help surgeons develop a treatment strategy of either PF or ESIN for selected patients. Methods: At a median follow-up of 66 months (range, 49 to 89 months), the 123 patients in the original study were invited to an online secure survey. We used the survey results to compare the PF and ESIN treatment arms and to perform predetermined subgroup analyses of closed compared with open ESIN in relation to Disabilities of the Arm, Shoulder and Hand (DASH) score, pain assessment, and implant removal. Results: The questionnaire was completed by 114 (93%) of the 123 patients. There were no differences between the 2 treatment arms with regard to the DASH score (ESIN, 3.1 ± 7.0 and PF, 3.7 ± 7.5; p = 0.9). The 27 patients who had been treated with closed ESIN had a significantly superior DASH score compared with the 27 patients who had been treated with open ESIN (closed, 0.7 ± 1.4 and open, 5.2 ± 8.9; p = 0.015) and compared with the patients who had been treated with PF (closed ESIN, 0.7 ± 1.4 and PF, 3.9 ± 7.5; p = 0.002). Patients who had been treated with closed ESIN also reported fewer sequelae than patients who had been treated with open ESIN or PF. Conclusions: The results of this study, combined with those of our prior 1-year follow-up of the same patients, indicate that it seems to be advantageous to perform closed ESIN. The long-term results after PF were similar to those after open ESIN, but PF resulted in faster functional recovery and fewer patients needing to have the implant removed. Therefore, if open reduction is necessary for a comminuted fracture, it seems that the advantages of the minimally invasive ESIN procedure are lost, and the surgeon should consider conversion to PF. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hendrik F S Fuglesang
- Orthopaedic Department, Akershus University Hospital, Lørenskog, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | | | - Ola-Lars Hammer
- Orthopaedic Department, Akershus University Hospital, Lørenskog, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway.,Norwegian Army Medical School, Oslo, Norway
| | - Stein Erik Utvåg
- Orthopaedic Department, Akershus University Hospital, Lørenskog, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
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Abstract
Clavicle fractures are common fractures and the optimal treatment strategy remains debatable. The present paper reviews the available literature and current concepts in the management of displaced and/or shortened midshaft clavicle fractures. Operative treatment leads to improved short-term functional outcomes, increased patient satisfaction, an earlier return to sports and lower rates of non-union compared with conservative treatment. In terms of cost-effectiveness, operative treatment also seems to be advantageous. However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar. The optimal treatment strategy should be one tailor-made to the patient and his/her specific needs and expectations by utilizing a shared decision-making model.
Cite this article: EFORT Open Rev 2018;3:374-380. DOI: 10.1302/2058-5241.3.170033
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Affiliation(s)
- Paul Hoogervorst
- OLVG Amsterdam, Department of Orthopaedics and Traumatology, Amsterdam
| | - Peter van Schie
- OLVG Amsterdam, Department of Orthopaedics and Traumatology, Amsterdam
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Toogood P, Huang A, Siebuhr K, Miclau T. Minimally invasive plate osteosynthesis versus conventional open insertion techniques for osteosynthesis. Injury 2018; 49 Suppl 1:S19-S23. [PMID: 29929686 DOI: 10.1016/s0020-1383(18)30297-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Osteosynthesis has evolved theoretically and practically throughout its evolution. Similar to trends in other surgical fields, surgical techniques in fracture fixation, such as minimally invasive plate osteosynthesis (MIPO), have moved from large dissections to more tissue sparing methods. These plating techniques have been developed for a variety of bones, but more universal clinical adoption will rely upon improved clinical outcomes. The current review will describe minimally invasive techniques, evaluate their rationale, and summarize evidence for their efficacy.
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Affiliation(s)
- Paul Toogood
- University of California, San Francisco (UCSF), Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital and Trauma Center, San Francisco, California, USA.
| | - Adrian Huang
- University of California, San Francisco (UCSF), Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Karl Siebuhr
- University of California, San Francisco (UCSF), Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Theodore Miclau
- University of California, San Francisco (UCSF), Department of Orthopaedic Surgery, Orthopaedic Trauma Institute, Mark Zuckerberg and Priscilla Chan San Francisco General Hospital and Trauma Center, San Francisco, California, USA
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Hulsmans MH, van Heijl M, Houwert RM, Burger BJ, Verleisdonk EJM, Veeger DJ, van der Meijden OA. Surgical fixation of midshaft clavicle fractures: A systematic review of biomechanical studies. Injury 2018. [PMID: 29523350 DOI: 10.1016/j.injury.2018.02.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Surgical treatment of displaced midshaft clavicle fractures requires a decision between plate fixation and intramedullary (IM) fixation. Numerous studies report on the biomechanical properties of various repair constructs. The goal of this systematic review was to provide an overview of studies describing the biomechanical properties of the most commonly used surgical fixations of midshaft clavicle fractures. Additionally, we aimed to translate these biomechanical results into clinically relevant conclusions. METHODS A computer-aided search of the EMBASE and PudMed/MEDLINE databases was conducted. Studies included for review compared biomechanical properties of plate fixation with IM fixation and superiorly positioned plates with anteroinferiorly positioned plates for midshaft clavicle fractures. RESULTS Fifteen studies were eligible for inclusion. Plate fixation seemed to form a more robust construct than IM fixation in terms of stiffness and failure loading. The remaining clavicle was stronger after removal of the IM device than after removal of the plate. Superior plating of transverse fractures generally seemed to provide greater stiffness and strength during bending loads than anteroinferior plating did. The absence of cortical alignment in wedge and comminuted fractures directly influenced the fixation stability for both IM fixation and plate fixation, regardless of location. CONCLUSION Each type of fracture fixation has biomechanical advantages and disadvantages. However, exact thresholds of stiffness for inducing healing and failure strength to withstand refractures are unknown. The clinical relevance of the biomechanical studies may be arguable. Since none of the studies investigate the effect of tissue adaptation over time they should be interpreted with caution.
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Affiliation(s)
- Martijn H Hulsmans
- Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Bosboomstraat 1, 3582 KE, Utrecht, The Netherlands
| | - Mark van Heijl
- Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Bosboomstraat 1, 3582 KE, Utrecht, The Netherlands
| | - Roderick M Houwert
- Utrecht Traumacenter, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Bart J Burger
- Department of Orthopaedic Surgery/Centre for Orthopaedic Research Alkmaar (CORAL), Medical Centre Alkmaar, Wilhelminalaan 12, 1815 JD, Alkmaar, The Netherlands
| | - Egbert Jan M Verleisdonk
- Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Bosboomstraat 1, 3582 KE, Utrecht, The Netherlands.
| | - Dirk Jan Veeger
- MOVE Research Institute, Department of Human Movement Sciences, Vrije Universiteit, Amsterdam, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - Olivier A van der Meijden
- Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Bosboomstraat 1, 3582 KE, Utrecht, The Netherlands; Department of Orthopaedic Surgery/Centre for Orthopaedic Research Alkmaar (CORAL), Medical Centre Alkmaar, Wilhelminalaan 12, 1815 JD, Alkmaar, The Netherlands
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36
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Hulsmans MHJ, van Heijl M, Frima H, van der Meijden OAJ, van den Berg HR, van der Veen AH, Gunning AC, Houwert RM, Verleisdonk EJMM. Predicting suitability of intramedullary fixation for displaced midshaft clavicle fractures. Eur J Trauma Emerg Surg 2017; 44:581-587. [PMID: 28993839 DOI: 10.1007/s00068-017-0848-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 09/25/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE Implant-related irritation is a technique-specific complication seen in a substantial number of patients treated with intramedullary nailing for clavicle fractures. The purpose of this study was to identify predictors for developing implant-related irritation in patients with displaced midshaft clavicle fractures treated with elastic stable intramedullary nailing. METHODS A retrospective analysis of the surgical database in two level 2 trauma centers was performed. Patients who underwent intramedullary nailing for displaced midshaft clavicle fractures between 2005 and 2012 in the first hospital were included. Age, gender, fracture comminution and fracture location were assessed as possible predictors for developing irritation using multivariate logistic regression analysis. These predictors were externally validated using data of patients treated in another hospital. RESULTS Eighty-one patients were included in initial analysis. In the multivariate analysis, comminuted fractures in comparison to non-comminuted fractures (72 vs. 38%, p = 0.027) and fracture location (p < 0.001) were significantly associated with the development of implant-related irritation. In particular, lateral diaphyseal fractures caused irritation compared to fractures on the medial side of the cut-off point (88 vs. 26%). External validation of these predictors in 48 additional patients treated in another hospital showed a similar predictive value of the model and a good fit. CONCLUSION Comminuted and lateral diaphyseal fractures were found to be statistically significant and independent predictors for developing implant-related irritation. We, therefore, believe that intramedullary nailing might not be suitable for these types of fractures. Future studies are needed to determine whether alternative surgical techniques or implants would be more suitable for these specific types of fractures.
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Affiliation(s)
| | - M van Heijl
- Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - H Frima
- Kantonsspital Graubünden, Chur, Switzerland
| | | | | | | | - A C Gunning
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - R M Houwert
- Utrecht Traumacenter, Utrecht, The Netherlands
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Anterior-Inferior Plating Results in Fewer Secondary Interventions Compared to Superior Plating for Acute Displaced Midshaft Clavicle Fractures. J Orthop Trauma 2017; 31:468-471. [PMID: 28548997 DOI: 10.1097/bot.0000000000000856] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine whether a difference in plate position for fixation of acute, displaced, midshaft clavicle fractures would affect the rate of secondary intervention. DESIGN Retrospective Comparative Study. SETTING Two academic Level 1 Regional Trauma Centers. PATIENTS Five hundred ten patients treated surgically for an acutely displaced midshaft clavicle fracture between 2000 and 2013 were identified and reviewed retrospectively at a minimum of 24 months follow-up (F/U). Fractures were divided into 2 cohorts, according to plate position: Anterior-Inferior (AI) or Superior (S). Exclusion criteria included age <16 years, incomplete data records, and loss to F/U. Group analysis included demographics (age, sex, body mass index), fracture characteristics (mechanism of injury, open or closed), hand dominance, ipsilateral injuries, time between injury to surgery, time to radiographic union, length of F/U, and frequency of secondary procedures. INTERVENTION Patients were treated either with AI or S clavicle plating at the treating surgeon's discretion. MAIN OUTCOME MEASURES Rate and reason for secondary intervention. STATISTICAL ANALYSIS Fisher exact test, t test. and odds ratio were used for statistical analysis. RESULTS Final analysis included 252 fractures/251 patients. One hundred eighteen (47%) were in group AI; 134 (53%) were in group S. No differences in demographics, fracture characteristics, time to surgery, time to union, or length of F/U existed between groups. Seven patients/7 fractures (5.9%) in Group AI underwent a secondary surgery whereas 30 patients/30 fractures (22.3%) in group S required a secondary surgery. An additional intervention secondary to superior plate placement was highly statistically significant (P < 0.001). Furthermore, because 80% of these subsequent interventions were a result of plate irritation with patient discomfort, the odds ratio for a second procedure was 5 times greater in those fractures treated with a superior plate. CONCLUSIONS This comparative analysis indicates that AI plating of midshaft clavicle fractures seems to lessen clinical irritation and results in significantly fewer secondary interventions. Considering patient satisfaction and a reduced financial burden to the health care system, we recommend routine AI plate application when open reduction internal fixation of the clavicle is indicated. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Midshaft Fractures of the Clavicle: A Meta-analysis Comparing Surgical Fixation Using Anteroinferior Plating Versus Superior Plating. J Orthop Trauma 2017; 31:461-467. [PMID: 28708779 DOI: 10.1097/bot.0000000000000936] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the outcomes of clavicle fracture fixation using anteroinferior versus superior plate placement. METHODS We performed a meta-analysis of studies that have reported on outcomes after superior or anteroinferior plate fixation for acute midshaft clavicle fractures (Orthopaedic Trauma Association 15-B). A computerized literature search in the Pubmed, Scopus, and Cochrane Library databases was used to identify relevant articles. Only full text articles without language restrictions were evaluated. The inclusion criteria consisted of: (1) fracture of the midshaft clavicle; (2) surgery for acute fractures (within 1 month of the fracture); (3) adult patients (16 years of age and older); and (4) open reduction and internal fixation with plate application in either the anteroinferior or superior position. Studies were excluded if they did not specify plate location, evaluated multitrauma patients, investigated minimally invasive procedures, or studied operations for revision, nonunion, malunion, or infection. The primary measured outcomes were symptomatic hardware (implant prominence or irritation) and surgery for implant removal. The secondary outcomes were time to union, fracture union, nonunion, malunion, Disabilies of the Arm, Shoulder and Hand score, Constant score, and implant failure. Frequencies and proportions of cases were recorded for binary outcomes, whereas mean and standard deviations were recorded for continuous outcomes. Other summary statistics provided were used to impute mean and standard deviations under the assumption of normality when these were not reported. Continuous outcomes were compared between groups using linear mixed effects models, whereas binary outcomes were compared using mixed effects logistic regression models, including fixed group effects and random study effects. P-values less than 0.05 were considered statistically significant. All analyses were performed using SAS v. 9.4 (SAS Institute Inc, Cary, NC). RESULTS A total of 1428 articles were identified among the 3 databases, of which 897 remained after removing duplicates. From that pool, 57 relevant studies were evaluated. Articles were excluded because of an inability to specify plate location (6), a subject pool not exclusively consisting of acute fractures (4) or midshaft fractures (2), a minimally invasive surgical approach (6), use of nonstandard plates (1), poor reporting of functional outcomes (2), and a duplicate group of patients (2). This left 34 articles to be used in the meta-analysis. Of these, 8 studies reported on patients with anteroinferior plating (N = 390) and 27 studies reported on patients with superior plating (N = 1104). No significant differences were found with respect to the functional shoulder scores (Disabilies of the Arm, Shoulder and Hand and Constant) between the 2 groups. There was no significant difference between each group for the probability of having a union (P = 0.41), malunion (P = 0.28), nonunion (0.29), or implant failure (P = 0.39). Patients in the superior plating group had a significantly higher probability of suffering from symptomatic hardware (0.17) as compared to patients in the anteroinferior plating group (0.08), (P = 0.005). In addition, the superior plating group had a significantly higher rate of surgery for implant removal (0.11 vs. 0.05), (P = 0.008). CONCLUSIONS The findings of this investigation demonstrate that plating along the superior and anteroinferior aspects of the clavicle lead to similar operative outcomes with respect to union, nonunion, malunion, and implant failure, as well as similar functional outcomes scores. Plates applied to the superior aspect of the clavicle are associated with higher rates of symptomatic hardware and more frequent implant removal. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Fuglesang HFS, Flugsrud GB, Randsborg PH, Oord P, Benth JŠ, Utvåg SE. Plate fixation versus intramedullary nailing of completely displaced midshaft fractures of the clavicle. Bone Joint J 2017; 99-B:1095-1101. [DOI: 10.1302/0301-620x.99b8.bjj-2016-1318.r1] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 04/19/2017] [Indexed: 11/05/2022]
Abstract
Aims This is a prospective randomised controlled trial comparing the functional outcomes of plate fixation and elastic stable intramedullary nailing (ESIN) of completely displaced mid-shaft fractures of the clavicle in the active adult population. Patients and Methods We prospectively recruited 123 patients and randomised them to either plate fixation or ESIN. Patients completed the Quick Disabilities of the Arm, Shoulder and Hand (DASH) score at one to six weeks post-operatively. They were followed up at six weeks, three and six months and one year with radiographs, and their clinical outcome was assessed using both the DASH and the Constant Score. Results Plate fixation provided a faster functional recovery during the first six months compared with ESIN, but there was no difference after one year. The duration of surgery was shorter for ESIN (mean 53.4 minutes, 22 to 120) than for plate fixation (mean 69.7 minutes, 35 to 106, p < 0.001). The recovery after ESIN was slower with increasing fracture comminution and with open reduction (p < 0.05). Conclusion Both methods return the patients to their pre-injury functional levels, but plate fixation has a faster recovery period in comminuted fractures than ESIN. ESIN has a shorter operative time and lower infection and implant rates of failure when using 2.5 mm nails or wider, suggesting that this is the preferred method in mid-shaft fractures with no comminution, whereas plate fixation is the superior method in comminuted fractures. Cite this article: Bone Joint J 2017;99-B:1095–1101
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Affiliation(s)
| | | | | | - P. Oord
- Stavanger University Hospital, Helse
Stavanger HF, Stavanger, Norway
| | - J. Š. Benth
- Campus Ahus, 6
HØKH, Research Centre, Akershus
University Hospital, Norway and University
of Oslo Faculty of Medicine, Institute of Clinical
Medicine, Campus AHUS, Oslo, Norway
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40
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Xu B, Lin Y, Wang Z, Cao J, Yang Y, Xia H, Zhang Y. Is intramedullary fixation of displaced midshaft clavicle fracture superior to plate fixation? Evidence from a systematic review of discordant meta-analyses. Int J Surg 2017; 43:155-162. [DOI: 10.1016/j.ijsu.2017.05.069] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 04/26/2017] [Accepted: 05/29/2017] [Indexed: 01/02/2023]
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41
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Dehghan N, Schemitsch EH. Intramedullary nail fixation of non-traditional fractures: Clavicle, forearm, fibula. Injury 2017; 48 Suppl 1:S41-S46. [PMID: 28449855 DOI: 10.1016/j.injury.2017.04.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Locked intramedullary fixation is a well-established technique for managing long-bone fractures. While intramedullary nail fixation of diaphyseal fractures in the femur, tibia, and humerus is well established, the same is not true for other fractures. Surgical fixations of clavicle, forearm and ankle are traditionally treated with plate and screw fixation. In some cases, fixation with an intramedullary device is possible, and may be advantageous. However, there is however a concern regarding a lack of rotational stability and fracture shortening. While new generation of locked intramedullary devices for fractures of clavicle, forearm and fibula are recently available, the outcomes are not as reliable as fixation with plates and screws. Further research in this area is warranted with high quality comparative studies, to investigate the outcomes and indication of these fractures treated with intramedullary nail devices compared to intramedullary nail fixation.
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Affiliation(s)
- Niloofar Dehghan
- Li Ka Shing Institute,St. Michael's Hospital, Toronto, Canada; Orthopaedic surgeon - The CORE Institute, Banner University Medical Center, Phoenix, Arizona, USA
| | - Emil H Schemitsch
- Division of Orthopaedics, Department of Surgery, Western University, London, Canada.
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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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Meeuwis MA, Pull Ter Gunne AF, Verhofstad MHJ, van der Heijden FHWM. Construct failure after open reduction and plate fixation of displaced midshaft clavicular fractures. Injury 2017; 48:715-719. [PMID: 28129880 DOI: 10.1016/j.injury.2017.01.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 01/16/2017] [Accepted: 01/21/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Worldwide, implants mostly used for fixation of displaced midshaft clavicular fractures (DMCF) are the easily to bend reconstruction plate and the stiffer small fragment locking compression plate. Construct failure rates after plate fixation of DMCF are reported around 5 percent. Possible risk factors for construct failure are implant type and fracture type. However, little is known about the influence of fracture fixation method on construct failure. The aim of this study was to assess construct failure in plate fixation of DMCF and to identify possible risk factors. METHODS All consecutive patients treated in a level 1 trauma centre with open reduction and fixation of DMCF using a 3.5-mm reconstruction plate or 3.5-mm small fragment locking compression plate between 2007 and 2015 were evaluated. Potential risk factors for construct failure were analysed using univariate analysis. RESULTS Two hundred and fifty-nine patients were analysed. Fifty DMCF (19%) were fixated with a reconstruction plate and 209 (81%) with a small fragment locking compression plate. Construct failure was seen in 18 patients (6.9%), including 5 broken plates and 13 with screw loosening. Eight percent of all reconstruction plates broke in contrast to 0.5 percent of all small fragment locking compression plates (p=0.001). All broken implants were used as a bridging plate. Loosening of screws was seen in older patients and when the plate was fixated with less than three bicortical screws on one side of the fracture (p=0.002). CONCLUSIONS Overall construct failure after open reduction and plate fixation of DMCF occurred in 6.9 percent. Risk factors for plate breakage were the use of a reconstruction plate and a bridging method for fracture fixation. Risk factors for screw loosening were an increasing patient age and plate fixation with less than three bicortical screws on one side of the fracture. RECOMMENDATIONS Based on the results of this study our recommendation is to use a small fragment locking compression plate for open reduction and internal fixation of DMCF. The surgeon should always strive to fixate the plate on both sides of the fracture with at least three bicortical screws.
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Affiliation(s)
- M A Meeuwis
- Dept. of Surgery, St. Elisabeth Hospital, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands.
| | - A F Pull Ter Gunne
- Dept. of Surgery, St. Elisabeth Hospital, P.O. Box 90151, 5000 LC, Tilburg, The Netherlands
| | - M H J Verhofstad
- Dept. of Surgery-Traumatology, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
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Ropars M, Thomazeau H, Huten D. Clavicle fractures. Orthop Traumatol Surg Res 2017; 103:S53-S59. [PMID: 28043849 DOI: 10.1016/j.otsr.2016.11.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 06/15/2016] [Accepted: 11/04/2016] [Indexed: 02/02/2023]
Abstract
Management of clavicle fracture has progressed over the last decade, notably with wider use of surgery in midshaft fracture, and new techniques for lateral fracture. Midshaft clavicle fracture treatment needs to be personalized and adapted to the patient's activity level. Whichever the segment involved, treatment for non-displaced fracture is functional; elbow-to-body sling immobilization seems the best tolerated. Apart from regular surgical indications (shoulder impaction, floating shoulder, open fracture or fracture with neurovascular complications), surgery is recommended in case of bone shortening exceeding 1.5cm in young active patients. The technique needs to take account of clavicle anatomy: notably periosteal vascularization in midshaft fracture and acromioclavicular ligament integrity and location in case of lateral fracture. Plate osteosynthesis should take account of bone diameter and 3D curvature; intramedullary fixation should take account of intramedullary canal morphology. Although iatrogenic vascular complications are rare, vessel relations and variants need to be known, especially in the medial end of the clavicle and midshaft. Lateral segment fractures are a particular entity. Large-scale randomized studies are needed to assess indications and results for the various possible internal fixation techniques: isolated or associated to ligament reconstruction, rigid or flexible, and open or arthroscopic.
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Affiliation(s)
- M Ropars
- Service de chirurgie orthopédique, CHU de Rennes, Pontchaillou University Hospital, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex, France.
| | - H Thomazeau
- Service de chirurgie orthopédique, CHU de Rennes, Pontchaillou University Hospital, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex, France
| | - D Huten
- Service de chirurgie orthopédique, CHU de Rennes, Pontchaillou University Hospital, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex, France
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High Irritation and Removal Rates After Plate or Nail Fixation in Patients With Displaced Midshaft Clavicle Fractures. Clin Orthop Relat Res 2017; 475:532-539. [PMID: 27830484 PMCID: PMC5213945 DOI: 10.1007/s11999-016-5113-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 09/28/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Studies comparing plate with intramedullary nail fixation of displaced midshaft clavicle fractures show faster recovery in the plate group and implant-related complications in both groups after short-term followup (6 or 12 months). Knowledge of disability, complications, and removal rates beyond the first postoperative year will help surgeons in making a decision regarding optimal implant choice. However, comparative studies with followup beyond the first year or two are scarce. QUESTIONS/PURPOSES We asked: (1) Does plate fixation or intramedullary nail fixation for displaced midshaft clavicle fractures result in less disability? (2) Which type of fixation, plate or intramedullary, is more frequently associated with implant-related irritation and implant removal? (3) Is plate or intramedullary fixation associated with postoperative complications beyond the first postoperative year? METHODS Between January 2011 and August 2012, patients with displaced midshaft clavicle fractures were enrolled and randomized to plate or intramedullary nail fixation. A total of 58 patients with plate and 62 patients with intramedullary nails initially were enrolled. Minimum followup was 30 months (mean, 39 months; range, 30-51 months). Two patients (3%) with plate fixation and two patients (3%) with intramedullary nails were lost to followup. The QuickDASH was obtained at final followup and compared between patients who had plate fixation and those who had intramedullary nail fixation. Postoperative complications measured include infection, implant-related irritation, implant failure, nonunion, and refracture after implant removal. Indications for implant removal included implant-related irritation, implant failure, nonunion, patient's wish, or surgeon's preference. RESULTS Between patients with plate versus intramedullary nail fixation, there were no differences in QuickDASH scores (plate, 1.8 ± 3.6; intramedullary nail, 1.8 ± 7.2; mean difference, -0.7; 95% CI, -2.2 to 2.04; p = 0.95). The proportion of patients having implant-related irritation was not different (39 of 56 [70%] versus 41 of 62 [66%]; relative risk, 1.05; 95% CI, 0.82-1.35; p = 0.683). Intramedullary fixation was associated with a higher likelihood of implant removal (51 of 62 [82%] versus 28 of 56 [50%]; relative risk, 1.65; 95% CI, 1.24-2.19; p < 0.001). Among the removed implants more plates than intramedullary nails were removed after the 1-year followup (12 of 28 [43%] versus six of 51 [12%]; p = 0.002). There were no infections, implant breakage, nonunions, or refractures between the 1-year and final followup in either group. CONCLUSIONS After a mean followup of 39 months, disability scores were excellent. Major complications did not occur after the 1-year followup. A frequent and bothersome problem after both surgical treatments is implant-related irritation, resulting in high rates of implant removal, after 1 year. Future research could focus on analyzing risk factors for implant irritation or removal. LEVEL OF EVIDENCE Level II, therapeutic study.
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Hussain N, Sermer C, Prusick PJ, Banfield L, Atrey A, Bhandari M. Intramedullary Nailing Versus Plate Fixation for the Treatment Displaced Midshaft Clavicular Fractures: A Systematic Review and Meta-Analysis. Sci Rep 2016; 6:34912. [PMID: 27762393 PMCID: PMC5071841 DOI: 10.1038/srep34912] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 09/21/2016] [Indexed: 11/09/2022] Open
Abstract
The two commonly performed surgical techniques used to repair displaced midshaft clavicle fractures are plate fixation or intramedullary nailing; however, despite recent evidence, the optimal method to treat such fractures remains a continued topic of debate. A meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate long term function, complications, and operative duration in adult patients receiving intramedullary nailing in comparison to plating. Seven RCTs and three quasi-randomized trials were included. No significant difference was found in long-term function between the two groups (MD: −0.66, 95% CI: −2.03 to 0.71, I2 = 62%, p = 0.34). Patients who received plating had a 2.19 times increased risk of treatment failure, but this failed to reach significance (95% CI: 0.93 to 5.15, I2 = 0%, p = 0.07). The risk of non-operative complications was 2.11 times higher in patients who received plating and this reached statistical significance (95% CI: 1.38 to 3.23, I2 = 53%, p = 0.0006). Finally, plating significantly prolonged operative duration by 20.16 minutes (95% CI: 16.87 to 23.44, I2 = 56%, p < 0.00001). Our results suggest that intramedullary nailing and plating provide equivalent long-term functional outcomes; however, plating may lead to a higher risk of treatment failure and non-operative complications.
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Affiliation(s)
- Nasir Hussain
- Central Michigan University College of Medicine, CMED Building 1280 S. East Campus St. Mt. Pleasant, MI 48859, USA
| | - Corey Sermer
- Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue Toronto, Ontario M5G 1X5, Canada
| | - Parker J Prusick
- Central Michigan University College of Medicine, CMED Building 1280 S. East Campus St. Mt. Pleasant, MI 48859, USA
| | - Laura Banfield
- Health Sciences Library, McMaster University 1280 Main St. W., HSC 2B Hamilton, Ontario L8S 4K1, Canada
| | - Amit Atrey
- West Suffolk Hospital Bury St Edmunds, Suffolk IP33 2QZ, United Kingdom
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University &Centre for Evidence-Based Orthopaedics 293 Wellington Street North, Suite 110 Hamilton, Ontario, L8L 8E7, Canada
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Chamberlain AM, Namdari S, Keener JD. What's New in Shoulder and Elbow Surgery. J Bone Joint Surg Am 2016; 98:1755-1762. [PMID: 27869628 DOI: 10.2106/jbjs.16.00823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | | | - Jay D Keener
- Washington University School of Medicine, St. Louis, Missouri
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Rongguang A, Zhen J, Jianhua Z, Jifei S, Xinhua J, Baoqing Y. Surgical Treatment of Displaced Midshaft Clavicle Fractures: Precontoured Plates Versus Noncontoured Plates. J Hand Surg Am 2016; 41:e263-6. [PMID: 27497801 DOI: 10.1016/j.jhsa.2016.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 06/21/2016] [Accepted: 06/24/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare the outcomes and complications of open reduction and internal fixation using precontoured versus noncontoured plates for the treatment of midshaft clavicle fractures. METHODS Open reduction and internal fixation using was performed on 130 patients with a midshaft clavicle fracture. Precontoured plates were used in 69 cases (group A) and noncontoured plates in 61 cases (group B). RESULTS The average follow-up in both groups was approximately 21 months. There was a significant difference between the 2 groups in mean surgery duration and blood loss, although Disabilities of the Arm, Shoulder, and Hand and Constant-Murley Shoulder scores at final follow-up were similar. Plate removal was required in 44.9% (31 of 69) of the precontoured group and 65.6% (40 of 61) of the noncontoured group. The indication was prominence of the hardware in 27.5% (19 of 69) of the precontoured group and 54.1% (33 of 61) of the noncontoured. In both groups, body mass index was lower in patients requiring implant removal because of hardware prominence. A higher proportion of females in both groups required implant removal. CONCLUSIONS Precontoured plates are associated with a lower rate of hardware removal. Body mass index and gender may be factors that influence the rate of hardware removal. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Ao Rongguang
- Department of Orthopaedics, Shanghai Pudong Hospital, Shanghai Fudan University Pudong Medical Center, Shanghai, China
| | - Jian Zhen
- Department of Orthopaedics, Shanghai Pudong Hospital, Shanghai Fudan University Pudong Medical Center, Shanghai, China
| | - Zhou Jianhua
- Department of Orthopaedics, Shanghai Pudong Hospital, Shanghai Fudan University Pudong Medical Center, Shanghai, China
| | - Shi Jifei
- Department of Orthopaedics, Shanghai Pudong Hospital, Shanghai Fudan University Pudong Medical Center, Shanghai, China
| | - Jiang Xinhua
- Department of Orthopaedics, Shanghai Pudong Hospital, Shanghai Fudan University Pudong Medical Center, Shanghai, China
| | - Yu Baoqing
- Department of Orthopaedics, Shanghai Pudong Hospital, Shanghai Fudan University Pudong Medical Center, Shanghai, China.
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Marasco S, Quayle M, Summerhayes R, Šutalo ID, Liovic P. An assessment of outcomes with intramedullary fixation of fractured ribs. J Cardiothorac Surg 2016; 11:126. [PMID: 27495253 PMCID: PMC4974717 DOI: 10.1186/s13019-016-0510-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 07/26/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgical management of fractured ribs with internal fixation is an increasingly accepted therapy. Concurrently, specific rib fixation prostheses are being developed which should improve results and minimise hardware and rib/splint construct failures. The Synthes titanium intramedullary splint lends itself to difficult to access areas such as posterior rib fractures and fractures under the scapula. We analyse a case series of patients in whom this rib fixation prosthesis has been used. METHODS Fifteen patients received 35 intramedullary splints. Follow up at 3 and 6 months was performed with three dimensional computed tomography scanning to assess for bone alignment, callus formation and healing, residual deformity, hardware failure or cut through. Computerized finite element analysis (FEA) was used to model forces acting on a posterior fracture with and without an intramedullary fixation splint in situ. RESULTS Complete healing (bony union) was noted in only 3 (9 %) of the fractures fixed with splints by 3 months. Partial healing (cartilaginous union) was noted in 28 of the 33 fractures (85 %), and non healing was noted in only 2 (6 %). In both those two patients, failure at the rib / splint interface was noted after both patients reported sneezing. No hardware failures were noted. By 6 months the fractures which had shown partial healing, had all completely healed. There were no late failures (between 3 and 6 months) of either hardware or rib/splint interfaces. FEA modelling identified sites of increased stress in the rib at the rib / splint interface and in a modelled intramedullary splint where it spans the fracture. CONCLUSIONS Further analysis of outcomes with intramedullary splints is warranted as well as further development of intramedullary rib fixation solutions.
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Affiliation(s)
- Silvana Marasco
- Cardiothoracic Surgery Department, the Alfred Hospital, 55 Commercial Rd, Prahran, 3181, Australia. .,Department of Surgery, Monash University, Melbourne, VIC, Australia.
| | - Margaret Quayle
- Cardiothoracic Surgery Department, the Alfred Hospital, 55 Commercial Rd, Prahran, 3181, Australia
| | - Robyn Summerhayes
- Cardiothoracic Surgery Department, the Alfred Hospital, 55 Commercial Rd, Prahran, 3181, Australia
| | - Ilija D Šutalo
- Faculty of Science, Monash University, Melbourne, VIC, Australia
| | - Petar Liovic
- Commonwealth Scientific and Industrial Research Organisation (CSIRO), Mathematics Informatics and Statistics, Melbourne, VIC, Australia
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Intramedullary Fixation of Clavicle Fractures: Anatomy, Indications, Advantages, and Disadvantages. J Am Acad Orthop Surg 2016; 24:455-64. [PMID: 27227985 DOI: 10.5435/jaaos-d-14-00336] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Historically, management of displaced midshaft clavicle fractures has consisted of nonsurgical treatment. However, recent literature has supported surgical repair of displaced and shortened clavicle fractures. Several options exist for surgical fixation, including plate and intramedullary (IM) fixation. IM fixation has the potential advantages of a smaller incision and decreased dissection and soft-tissue exposure. For the last two decades, the use of Rockwood and Hagie pins represented the most popular form of IM fixation, but concerns exist regarding stability and complications. The use of alternative IM implants, such as Kirschner wires, titanium elastic nails, and cannulated screws, also has been described in limited case series. However, concerns persist regarding the complications associated with the use of these implants, including implant failure, migration, skin complications, and construct stability. Second-generation IM implants have been developed to reduce the limitations of earlier IM devices. Although anatomic and clinical studies have supported IM fixation of midshaft clavicle fractures, further research is necessary to determine the optimal fixation method.
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