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Park JS, Ko SH, Hong TH, Ryu DJ, Kwon DG, Kim MK, Jeon YS. Plate fixation versus titanium elastic nailing in midshaft clavicle fractures based on fracture classifications. J Orthop Surg (Hong Kong) 2021; 28:2309499020972204. [PMID: 33258399 DOI: 10.1177/2309499020972204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The best strategy for implant selection in midshaft clavicular fractures (MCF) remains controversial. The present study aims to determine the optimal strategy for implant selection by comparing plate and Titanium Elastic Nail (TEN) with respect to outcomes and related complications and analyze the results based on fracture patterns. METHODS A total of 97 patients with MCF who underwent plate (48 patients) or TEN (49 patients) fixation were retrospectively reviewed. Both groups were divided into three subgroups by fracture type using the AO Foundation/Orthopaedic Trauma Association classification: simple fracture (type A), wedge fracture (type B), and multi-fragmentary fracture (type C). The observed outcome measures were bone union rate, related complications, functional scores, and patient satisfaction score. These outcomes were analyzed based on the fracture classification. RESULTS Both groups demonstrated excellent union rates (p = 0.495) and similar functional scores (p > 0.05). Visual analog scale (VAS) for satisfaction was better in TEN than plate fixation (p < 0.001). In type A and B subgroups, there were no significant difference in functional scores between plate and TEN fixation (p > 0.05). In type C subgroup, however, both VAS for pain and DASH score in TEN fixation were significantly worse than in plate fixation at 2 and 6 weeks postoperatively (p < 0.05). The incidences of clavicle shortening and skin irritation are higher especially in type C subgroup of TEN fixation (p < 0.05). CONCLUSION Patient satisfaction of TEN fixation was higher than that of plate fixation, but TEN fixation had a higher incidence of early postoperative pain and migration in type C fractures. Therefore, type A and B fractures can successfully be treated with plate or TEN fixation, but type C fractures should be treated with plate fixation.
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Affiliation(s)
- Jun Sung Park
- Department of Orthopaedic Surgery,65745Inha University Hospital, Incheon, Republic of Korea
| | - Sang Hyun Ko
- Department of Orthopaedic Surgery,65745Inha University Hospital, Incheon, Republic of Korea
| | - Taek Ho Hong
- Department of Orthopaedic Surgery,65745Inha University Hospital, Incheon, Republic of Korea
| | - Dong Jin Ryu
- Department of Orthopaedic Surgery,65745Inha University Hospital, Incheon, Republic of Korea
| | - Dae Gyu Kwon
- Department of Orthopaedic Surgery,65745Inha University Hospital, Incheon, Republic of Korea
| | - Myung-Ku Kim
- Department of Orthopaedic Surgery,65745Inha University Hospital, Incheon, Republic of Korea
| | - Yoon Sang Jeon
- Department of Orthopaedic Surgery,65745Inha University Hospital, Incheon, Republic of Korea
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Abraham VT, Marimuthu C. A study on the outcome of displaced midshaft non-comminuted clavicle fractures treated with anatomical locking plate versus titanium elastic nail. Journal of Orthopaedics, Trauma and Rehabilitation 2020. [DOI: 10.1177/2210491720975189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose: Fixation of displaced midshaft clavicle is well known to decrease nonunion, malunion and shoulder disability as compared to nonoperative treatment. This study was done to compare the clinical and functional outcome of group 1 clavicle fractures treated with anatomic locking plates (ALP) versus Titanium elastic nail (TEN). Methods: We studied patients presenting with displaced midshaft clavicle fractures treated with ALP or TEN. The study period was from Jan 2013 to Dec 2016. Patients were reviewed and at each visit clinical and radiological progress of union was noted, complications if any were noted, functional assessment was done using the quick Dash score and Constant Murley score. Results: A total of 116 patients met our inclusion criteria. 62 patients were treated with TEN and 54 with ALP. Bony union was achieved at an average of 11.8 weeks in the TENS group and 12.8 weeks in the ALP group post operatively and this was found to be significant. The mean postoperative Constant Murley score in the ALP and the TEN groups were 92.8 (range 80–97), and 93.7 (82–97) respectively. The mean postoperative quick dash score in the ALP and TEN groups were 2.48(range from 0 to 6.8) and 2.1 (range 0–9.1) respectively. Conclusion: Both Anatomical locking plate and TEN are good options for the treatment of non-comminuted mid clavicular fractures as they have a similar functional outcome. TEN nail insertion has the advantage of being minimally invasive, having a faster union time and may be recommended in midshaft clavicle fractures without comminution.
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Affiliation(s)
- Vineet Thomas Abraham
- Department of Orthopaedics, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth University, Pondicherry, India
| | - Chandrasekaran Marimuthu
- Department of Orthopaedics, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth University, Pondicherry, India
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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] [What about the content of this article? (0)] [Affiliation(s)] [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] [What about the content of this article? (0)] [Affiliation(s)] [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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Hoogervorst P, Konings P, Hannink G, Holla M, Schreurs W, Verdonschot N, van Kampen A. 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; 4:272-9. [PMID: 32490413 DOI: 10.1016/j.jseint.2020.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Li R, Ke T, Xiong S, Xiong G, Lin Z, Lin F. Comparison of the effectiveness of oblique and transverse incisions in the treatment of fractures of the middle and outer third of the clavicle. J Shoulder Elbow Surg 2019; 28:1308-15. [PMID: 31230782 DOI: 10.1016/j.jse.2019.03.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 03/22/2019] [Accepted: 03/27/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Iatrogenic supraclavicular nerve injury is frequent during surgical repair of clavicle fractures through a transverse incision. The use of an oblique incision may be a potential approach to avoiding this complication. This study compared the clinical effectiveness of oblique and transverse incisions in the treatment of fractures in the middle and outer thirds of the clavicle. METHODS This prospective observational study included patients with fracture of the mid-to-outer third of the clavicle between August 2011 and August 2016. We allocated the patients into 2 groups based on their choice of treatment: oblique incision (n = 62) and transverse incision (n = 64). We compared the following parameters between the 2 groups: operative time, intraoperative blood loss, postoperative fracture healing time, incision size, clinical complications, postoperative subjective satisfaction, and shoulder function. RESULTS Operative time, postoperative fracture healing time, postoperative shoulder function (Constant-Murley and disabilities of the arm, shoulder and hand [DASH] scores), and clinical complications did not differ significantly between groups (all P > .05). The oblique incision group had less intraoperative blood loss (41.4 ± 16.4 vs. 65.3 ± 10.4 mL, P < .001) and smaller surgical incisions (3.6 ± 1.6 vs. 10.3 ± 2.6 cm, P < .001). The oblique incision group showed better outcomes for postoperative satisfaction (85.5% vs. 64.1%, P = .015), absence of shoulder numbness at the last follow-up (89.3% vs. 70.3%, P = .010), and satisfaction with the scar (90.3% vs. 3.1%, P < .001). CONCLUSION Oblique incisions have several advantages over transverse incisions: less bleeding, smaller incisions, less iatrogenic injury to supraclavicular nerves, and higher patient satisfaction. These 2 approaches have equivalent effects on recovery of shoulder joint function.
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Chan G, Korac Z, Miletic M, Vidovic D, Phadnis J, Bakota B. Plate versus intramedullary fixation of two-part and multifragmentary displaced midshaft clavicle fractures - a long-term analysis. Injury 2017; 48 Suppl 5:S21-S26. [PMID: 29122117 DOI: 10.1016/s0020-1383(17)30734-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Surgical fixation of displaced midshaft clavicle fractures is predominantly achieved with intramedullary (IM) or plate fixation. Both techniques have potential pitfalls: plate fixation involves greater periosteal stripping and protuberance of the implant, whereas IM fixation may be associated with implant-related complications, such as migration or skin irritation, which may lead to further surgery for implant removal. The aim of this study was to compare these two methods in simple (Robinson 2b.1) and multifragmentary (Robinson 2b.2) displaced midshaft clavicle fractures. METHODS A total of 133 consecutive patients who underwent surgical fixation for a displaced midshaft clavicle fracture with either IM fixation using a 2.5-mm Kirschner wire or plate fixation using an 8-hole Dynamic Compression Plate (DCP) were retrospectively reviewed. Follow-up was a minimum of 1 year. The patients were allocated into two injury groups: displaced simple 2-part fractures (64 IM vs. 16 DCP) and displaced multifragmentary fractures (27 IM vs. 26 DCP). The major observed outcome measures were: infection rate, non-union rate, reoperation rate and postoperative range of motion (ROM). RESULTS Rates of non-union for displaced 2-part fractures were 2/64 (3.13%) with IM fixation and 0/16 (0.00%) with plate fixation (p = 0.477). For displaced multifragmentary fractures, rates of non-union were 2/27 (7.41%) with IM fixation and 0/26 (0.00%) with plate fixation (p = 0.161). No significant difference was observed between the two fixation modalities in patient-reported time to regain ROM on the injured side for displaced 2-part fractures (p = 0.129) and displaced multifragmentary fractures (p = 0.070). Deep infection rate was zero (p = 1.000) overall in the study, and reoperation rate for IM and plate fixation, respectively, was 3.13% and 6.25% in the Robinson 2b.1 group (p = 0.559) and 7.41% and 7.69% in the Robinson 2b.2 group (p = 0.969). CONCLUSION IM fixation of displaced midshaft clavicle fractures (Robinson 2b.1) has an equivalent non-union rate to plate fixation and similarly low complication and reoperation rates. For displaced midshaft multifragmentary clavicle fractures (Robinson 2b.2), the higher non-union rates observed with IM fixation leads us to recommend consideration of plate fixation for Robinson 2b.2 fractures.
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Affiliation(s)
- Gareth Chan
- Department of Trauma & Orthopaedics, Brighton & Sussex University Hospitals, United Kingdom
| | - Zelimir Korac
- Department of Trauma & Orthopaedics, General Hospital Karlovac, Croatia
| | - Matija Miletic
- Department of Trauma & Orthopaedics, General Hospital Karlovac, Croatia
| | - Dinko Vidovic
- Clinic for Traumatology, University Clinical Centre "Sisters of Mercy", Croatia
| | - Joideep Phadnis
- Department of Trauma & Orthopaedics, Brighton & Sussex University Hospitals, United Kingdom
| | - Bore Bakota
- Department of Trauma & Orthopaedics, Brighton & Sussex University Hospitals, United Kingdom.
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