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Lian J, Chan FJ, Levy BJ. Classification of Distal Clavicle Fractures and Indications for Conservative Treatment. Clin Sports Med 2023; 42:685-693. [PMID: 37716731 DOI: 10.1016/j.csm.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
Management of distal clavicle fractures depends on a clear understanding of the injury's proximity to the ligamentous attachments joining the clavicle and scapula. Various classification systems have been proposed to guide treatment. Despite this, controversy between operative and nonoperative management remains for certain fracture patterns. Patient-specific factors, concomitant injuries, fracture characteristics (displacement, shortening, and rotation) should all be considered when deciding on treatment. When nonoperative management is indicated, patients should be immobilized in a sling for 2 weeks, followed by gradual range of motion, and strengthening exercises.
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Affiliation(s)
- Jayson Lian
- Montefiore Einstein, Department of Orthopaedic Surgery, 1250 Waters Place, Tower 1, 11th Floor, Bronx, NY 10461, USA
| | - Ferdinand J Chan
- Montefiore Einstein, Department of Orthopaedic Surgery, 1250 Waters Place, Tower 1, 11th Floor, Bronx, NY 10461, USA
| | - Benjamin J Levy
- Montefiore Einstein, Department of Orthopaedic Surgery, 1250 Waters Place, Tower 1, 11th Floor, Bronx, NY 10461, USA.
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Mast J, VAN Beek N, Claes T. Fast rehab after midshaft clavicula fractures in elite cyclists and motocross riders. Acta Orthop Belg 2023; 89:525-530. [PMID: 37935238 DOI: 10.52628/89.3.11696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Clavicle fractures are one of the most common injuries in cyclists and motocross riders. Although a fast return to sport is imperative for athletes, there is only limited literature on short-term functional outcomes after open reduction internal fixation of a clavicle fracture in a homogenous group of athletes. The aim of this study is to evaluate early (first 6 weeks) functional outcomes, return to sports and complications of elite or high-level recreational (± 8000 km per year) cyclists and motocross riders after surgical treatment of a midshaft clavicle fracture. The main study parameters were Quick Disabilities of the Arm, Shoulder and Hand (QuickDash); QuickDash sports module, pain in rest and movement (Numeric Pain Rating Score) and time to return to sports (training indoor/outdoor and competition). All parameters were taken pre-operatively and at 2/4/6/12/24 weeks post-operative. A total of 34 cyclists (6 LTFU) and 9 motocross riders (2 LTFU) were included at baseline. A significant decrease in Quick dash scores between preoperative (33 ± 1.2) and 2 weeks PO (21.5 ± 1.2) and between 2 and 4 weeks PO (16.1 ± 1.3) was found for cyclists. The QuickDash scores of the motocross riders statistically improvement from preoperative (31.6 ± 3.3) to 6 weeks PO (14.1 ± 3.3). NRS score in rest for cyclists decreased significantly from 3.6 ± 0.2 to 1.0 ± 0.2 after two weeks. After 4 weeks, 93% of cyclists and 57% of motocross riders were training outside. After 6 weeks, 56% of cyclists and 57% of motocross riders had returned to competition. Our results show that early surgical treatment of midshaft clavicle fractures in elite cyclists and motocross riders is a safe method with few complications and good functional outcomes.
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Han Z, Dong J, Wu J, Bi C, Wang Q, Lin H, Zhang L, Wu X. A Novel and Open Classification Emphasizing on Osteoligamentous Complex for Distal Clavicle Fractures. Orthop Surg 2023; 15:2025-2032. [PMID: 36523173 PMCID: PMC10432498 DOI: 10.1111/os.13633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/14/2022] [Accepted: 11/23/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE Current X-ray-based classification methods cannot describe all distal clavicle fracture (DCF) patterns, especially the osteoligamentous injury pattern of DCFs. We aimed to develop a novel classification based on the osteoligamentous injury pattern of the DCFs and investigated its reliability. METHODS All DCFs from January 2017 to January 2022 were respectively screened and 45 cases (mean age 20-78; male 31, female 14) met the including criteria and were enrolled. Based on their Zanca view X-ray radiograph and three-dimensional CT construction images, we analyzed the osteoligamentous injury pattern of each case, particularly the acromioclavicular (AC) and coracoclavicular ligaments and their bone attachment. Then we developed a novel classification method, five types in total, sorting all DCFs according to their lesion manifestations of osteoligamentous complex. Also, we investigated the inter- and intra-observer reliability using kappa value. RESULTS A novel classification method for DCF was developed, manifesting the avulsion or rupture of conoid and trapezoid ligaments, and involvement of AC joint. Forty-five cases of DCFs were included in this study. Among them, 11 (24.4%) were Type 1 fracture, three (6.7%) cases were Type 2, six cases (13.3%) were Type 3, 21 (46.7%) were Type 4, four (8.9%) were Type 5. Kappa values for inter-observer agreement were 0.57 after first evaluation and 0.61 after second evaluation. Intra-observer agreement was 0.72 for experienced shoulder specialist and 0.63 for radiologist. CONCLUSION This new classification method is reliable to use, supplementary to current classification systems, and emphasizes on the osteoligamentous complex injury when opting for the treatment.
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Affiliation(s)
- Zhihua Han
- Trauma Center, Department of Orthopaedics and Traumatology, Shanghai General HospitalShanghai Jiaotong UniversityShanghaiChina
- Sino‐Euro Orthopaedics NetworkBerlinGermany
| | - Jingming Dong
- Department of Upper ExtremityTianjin HospitalTianjinChina
| | - Jianhong Wu
- Trauma Center, Department of Orthopaedics and Traumatology, Shanghai General HospitalShanghai Jiaotong UniversityShanghaiChina
| | - Chun Bi
- Trauma Center, Department of Orthopaedics and Traumatology, Shanghai General HospitalShanghai Jiaotong UniversityShanghaiChina
| | - Qiugeng Wang
- Trauma Center, Department of Orthopaedics and Traumatology, Shanghai General HospitalShanghai Jiaotong UniversityShanghaiChina
| | - Haodong Lin
- Trauma Center, Department of Orthopaedics and Traumatology, Shanghai General HospitalShanghai Jiaotong UniversityShanghaiChina
| | - Lei Zhang
- Department of Radiology, Shanghai General HospitalShanghai Jiaotong UniversityShanghaiChina
| | - Xiaoming Wu
- Trauma Center, Department of Orthopaedics and Traumatology, Shanghai General HospitalShanghai Jiaotong UniversityShanghaiChina
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Kihlström C, Hailer NP, Wolf O. Is the Robinson classification of clavicle fractures accurate enough within the setting of the Swedish Fracture Register? Injury 2023:S0020-1383(23)00342-X. [PMID: 37142482 DOI: 10.1016/j.injury.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 01/25/2023] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 05/06/2023]
Abstract
INTRODUCTION In the Swedish Fracture Register (SFR) clavicle fractures are classified according to the Robinson classification. This study aimed to evaluate the accuracy of the classification of clavicle fractures in the SFR. A secondary aim was to assess inter- and intraobserver agreement. MATERIALS AND METHODS Clavicle fractures (n = 132) were randomly selected from the SFR and radiographs were requested for each patient from their treating departments. Not all radiographs could be acquired, and after exclusion, 115 fractures were independently classified by three expert raters blinded to patient information. The 115 fractures were classified on two occasions, 3 months apart. The raters' consensus classification was used as a gold standard that was compared to the classification registered in the SFR. The accuracy, defined as the degree of agreement between the gold standard and SFR classifications, was reported, as was the inter- and intraobserver agreement for the expert raters. RESULTS Agreement between the classification in the SFR and the gold standard classification was fair (kappa = 0.35). Fractures with only partial displacement were often incorrectly classified as fully displaced in the SFR (n = 31 of 78 displaced fractures in the SFR). The inter- and intraobserver agreement among the expert raters was almost perfect (interobserver kappa = 0.81-0.87, intraobserver kappa = 0.84-0.94). CONCLUSIONS The accuracy of the classification of clavicle fractures in the SFR was only fair, whereas the inter- and intraobserver agreement among the expert raters was almost perfect. Accuracy in the SFR may be improved if the classification instructions in the SFR are updated by incorporating the original classification displacement criteria, both in text and in illustrated form.
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Affiliation(s)
- Caroline Kihlström
- Department of Surgical Sciences - Orthopedics, Uppsala University, SE-751 85 Uppsala, Sweden.
| | - Nils P Hailer
- Department of Surgical Sciences - Orthopedics, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Olof Wolf
- Department of Surgical Sciences - Orthopedics, Uppsala University, SE-751 85 Uppsala, Sweden
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Abstract
AIMS Distal third clavicle (DTC) fractures are increasing in incidence. Due to their instability and nonunion risk, they prove difficult to treat. Several different operative options for DTC fixation are reported but current evidence suggests variability in operative fixation. Given the lack of consensus, our objective was to determine the current epidemiological trends in DTC as well as their management within the UK. METHODS A multicentre retrospective cohort collaborative study was conducted. All patients over the age of 18 with an isolated DTC fracture in 2019 were included. Demographic variables were recorded: age; sex; side of injury; mechanism of injury; modified Neer classification grading; operative technique; fracture union; complications; and subsequent procedures. Baseline characteristics were described for demographic variables. Categorical variables were expressed as frequencies and percentages. RESULTS A total of 859 patients from 18 different NHS trusts (15 trauma units and three major trauma centres) were included. The mean age was 57 years (18 to 99). Overall, 56% of patients (n = 481) were male. The most common mechanisms of injury were simple fall (57%; n = 487) and high-energy fall (29%; n = 248); 87% (n = 748) were treated conservatively and 54% (n = 463) were Neer type I fractures. Overall, 32% of fractures (n = 275) were type II (22% type IIa (n = 192); 10% type IIb (n = 83)). With regards to operative management, 89% of patients (n = 748) who underwent an operation were under the age of 60. The main fixation methods were: hook plate (n = 47); locking plate (n = 34); tightrope (n = 5); and locking plate and tight rope (n = 7). CONCLUSION Our study is the largest epidemiological review of DTC fractures in the UK. It is also the first to review the practice of DTC fixation. Most fractures are being treated nonoperatively. However, younger patients, suffering a higher-energy mechanism of injury, are more likely to undergo surgery. Hook plates are the predominantly used fixation method followed by locking plate. The literature is sparse on the best method of fixation for optimal outcomes for these patients. To answer this, a pragmatic RCT to determine optimal fixation method is required.Cite this article: Bone Jt Open 2022;3(12):953-959.
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Affiliation(s)
- Parag Raval
- University Hospitals of Leicester, Leicester, UK,AToMS - Academic Team of Musculoskeletal Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK,Correspondence should be sent to Mr Parag Raval. E-mail:
| | - Abbas See
- Trauma and Orthopaedics, Northampton General Hospital, Kettering, UK
| | - Harvinder P. Singh
- University Hospitals of Leicester, Leicester, UK,AToMS - Academic Team of Musculoskeletal Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
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Fleischhacker E, Siebenbürger G, Gleich J, Böcker W, Gilbert F, Helfen T. The Accuracy of Distal Clavicle Fracture Classifications-Do We Need an Amendment to Imaging Modalities or Fracture Typing? J Clin Med 2022; 11:jcm11195638. [PMID: 36233506 PMCID: PMC9572249 DOI: 10.3390/jcm11195638] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 06/30/2022] [Revised: 09/11/2022] [Accepted: 09/23/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Despite its fair-to-moderate reliability, the “modified Neer classification” is widely accepted and used. The purpose of this study was to reevaluate its applicability. Methods: Of n = 59 patients with distal clavicle fractures, fractures were classified on standard radiographs. Afterwards, an MRI examination was performed, and fractures reclassified. The primary outcome parameter was quantifying the rate of misclassification. The secondary outcome parameters were the evaluation of the ligamentous injury constellations. Results: In all cases, the fracture course and ligamental integrity could be assigned to the fracture type. Correction of the classification was necessary in n = 5 (8.5%) cases. In n = 3 (5%) cases, a correction was necessary from Neer I to Craig IIc and thus from conservative to operative treatment. Mean coracoclavicular distance (CCD) in Neer I was 10.2 ± 2.1 mm versus 14.2 ± 3.9 mm in Craig IIc (p = 0.02). The mean fracture angle in Neer I was 25.1 ± 3.3° versus 36.8 ± 4.4° in Craig IIc (p = 0.02). Conclusion: Cross-sectional imaging resulted in higher precision. Nevertheless, recommendations remain for standard radiographs. The CCD and fracture angle should be considered. An angle of >30° can be assumed as a parameter of instability. A previously undescribed fracture type does not seem to exist. The modified Neer classification is an appropriate and complete fracture classification.
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Cunningham G, Culebras Almeida LA, Gauthier M. All-suture technique for fixation of unstable displaced distal clavicle fracture. JSES Rev Rep Tech 2022; 2:168-173. [PMID: 37587969 PMCID: PMC10426583 DOI: 10.1016/j.xrrt.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Displaced Neer type II and V clavicle fractures are usually treated surgically in active patients. However, distal fragment fixation remains a challenge, and no consensus has been established regarding the optimal surgical treatment. Osteosuture techniques have been popularized over the last decade, and multiple different techniques have been described. The aim of this study was to describe an all-suture technique in patients with displaced type II and V clavicle fractures and report its outcome in a prospective case series. Methods Between 2017 and 2020, 15 patients with displaced acute distal clavicle fractures were treated with an all-suture open technique performed by one shoulder specialized surgeon, with a minimum follow-up of 1 year. Osteosuture repair consisted in a coracoclavicular cerclage with 4 no6 Ethibonds and a figure-of-0 and figure-of-8 fracture cerclage with 2 no2 SutureTapes. Single assessment numerical evaluation (SANE) and adjusted Constant score were recorded at 6 months and 1 year. The radiologic union was assessed on plain radiographs. Results At 12 months, all patients reported excellent clinical results, with a mean SANE of 98.2 [± 5.2, range 80 to 100] and a mean adjusted Constant score of 99.0 [± 1.9, range 94 to 100]. One patient developed shoulder stiffness that resolved before the final follow-up. Fractures consolidated in 93% of the cases, with union happening between 3 and 6 months [range 3 to 12 months]. One patient developed an asymptomatic malunion. Conclusion Excellent clinical and radiological outcomes can be achieved with this minimally invasive all-suture fixation technique for displaced distal clavicle fractures, which allows for an anatomic reduction and stable fixation. This pilot study showed low complications and a high level of union after a follow-up of 1 year. Among the numerous advantages are a smaller exposure than for plate fixation, avoidance of hardware-related complications such as screw failure, coracoid fracture from drilling, or rotator cuff damage caused by hook-plates. Furthermore, it avoids a reoperation to remove symptomatic hardware.
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Affiliation(s)
- Gregory Cunningham
- Division of Orthopaedics and Traumatology, University Hospitals of Geneva, Geneva, Switzerland
- Shoulder and Elbow Center, Hirslanden Clinique La Colline, Geneva, Switzerland
| | - L. Alejandro Culebras Almeida
- Shoulder and Elbow Center, Hirslanden Clinique La Colline, Geneva, Switzerland
- Department of Orthopaedics, Balgrist University Hospital, Zürich, Switzerland
| | - Morgan Gauthier
- Division of Orthopaedics and Traumatology, University Hospitals of Geneva, Geneva, Switzerland
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Fields MW, Kaushal NK, Patel NM, McCormick SK, Eberson CP, Schmitz ML, Swarup I, Blanco JS, Crawford LM, Edobor-Osula OF. Variability in evaluation and treatment of tibial tubercle fractures among pediatric orthopedic surgeons. J Pediatr Orthop B 2022; 31:e141-e146. [PMID: 34561383 DOI: 10.1097/bpb.0000000000000919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to determine the variability in clinical management of tibial tubercle fractures among a group of pediatric orthopedic surgeons. Nine fellowship-trained academic pediatric orthopedic surgeons reviewed 51 anteroposterior and lateral knee radiographs with associated case age. Respondents were asked to describe each fracture using the Ogden classification (type 1-5 with A/B modifiers), desired radiographic workup, operative vs. nonoperative treatment strategy and plans for post-treatment follow-up. Fair agreement was reached when classifying the fracture type using the Ogden classification (k = 0.39; P < 0.001). Overall, surgeons had a moderate agreement on whether to treat the fractures operatively vs. nonoperatively (k = 0.51; P < 0.001). Nonoperative management was selected for 80.4% (45/56) of type 1A fractures. Respondents selected operative treatment for 75% (30/40) of type 1B, 58.3% (14/24) of type 2A, 97.4% (74/76) of type 2B, 90.7% (39/43) of type 3A, 96.3% (79/82) of type 3B, 71.9% (87/121) of type 4 and 94.1% (16/17) of type 5 fractures. Regarding operative treatment, fair/slight agreement was reached when selecting the specifics of operative treatment including surgical fixation technique (k = 0.25; P < 0.001), screw type (k = 0.26; P < 0.001), screw size (k = 0.08; P < 0.001), use of washers (k = 0.21; P < 0.001) and performing a prophylactic anterior compartment fasciotomy (k = 0.20; P < 0.001). Furthermore, surgeons had fair/moderate agreement regarding the specifics of nonoperative treatment including degree of knee extension during immobilization (k = 0.46; P < 0.001), length of immobilization (k = 0.34; P < 0.001), post-treatment weight bearing status (k = 0.30; P < 0.001) and post-treatment rehabilitation (k = 0.34; P < 0.001). Significant variability exists between surgeons when evaluating and treating pediatric tibial tubercle fractures.
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Affiliation(s)
- Michael W Fields
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Neil K Kaushal
- Department of Pediatric Orthopedic Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Neeraj M Patel
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | - Craig P Eberson
- Warren Alpert Medical School of Brown University, Providence Rhode Island
| | | | - Ishaan Swarup
- University of California San Francisco, San Francisco, California
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Kihlström C, Hailer NP, Wolf O. Surgical Versus Nonsurgical Treatment of Lateral Clavicle Fractures: A Short-Term Follow-Up of Treatment and Complications in 122 Patients. J Orthop Trauma 2021; 35:667-672. [PMID: 34554717 DOI: 10.1097/bot.0000000000002112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess the total number of procedures in initially surgically and nonsurgically treated patients with lateral clavicle fractures and to compare patient-reported outcome measures (PROMs). DESIGN Retrospective cohort study. SETTING Level 1 trauma center. PATIENTS One hundred twenty-two patients with lateral clavicle fractures treated at Uppsala University Hospital from 2013 to 2015 were included in a patient record review. A subgroup of 30 patients was assessed at a study follow-up visit at a median of 3 years postinjury. INTERVENTION Comparisons between initially surgically and nonsurgically treated patients. MAIN OUTCOME MEASUREMENTS Rates of surgical treatment, reoperations, and delayed surgeries. PROM subgroup: Constant score; Disabilities of the Arm, Shoulder and Hand score; and Visual Analog Scale over satisfaction with the cosmetic results and interview-based information on subjective complaints and reflections. RESULTS Of 23 surgically treated patients (22 Neer type II and V fractures), 10 underwent subsequent implant removal, after which 1 developed symptomatic nonunion. Of 99 nonsurgically treated patients (36 Neer type II and V fractures), 2 underwent delayed surgery because of symptomatic nonunion. In the PROM subgroup, the surgically treated patients had worse Constant scores, complained of infraclavicular sensory deficits, and were less satisfied with the cosmetic result than the nonsurgically treated patients. CONCLUSIONS Half of the surgically treated patients underwent implant removal, whereas delayed surgeries in nonsurgically treated patients were very rare. Nonsurgical treatment should be considered more often as an alternative to surgery even for the usually surgically treated Neer type II and V lateral clavicle fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Caroline Kihlström
- Department of Orthopedics, Institute of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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Zhang Y, Yu P, Zhuang C, Liu J, Li G, Ye T, Wang L. Revising the modified Neer classification for distal clavicle fractures: Description and reliability. Injury 2021; 54 Suppl 2:S56-S62. [PMID: 34952695 DOI: 10.1016/j.injury.2021.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 07/29/2021] [Revised: 10/09/2021] [Accepted: 11/09/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND The modified Neer classification is the most widely used classification system for distal clavicle fractures. However, it provides limited information for treatment decisions. The objective of this study was to revise the modified Neer classification to make it more suitable for treatment decision-making. HYPOTHESIS The revised version of the modified Neer classification has good intra- and interobserver agreements and provides an instructive treating algorithm. STUDY DESIGN Cohort study METHODS: Six observers, including three experienced shoulder specialists and three junior orthopaedic residents, independently reviewed plain radiographs of 52 patients with distal clavicle fractures. They were asked to classify the fracture types according to the modified Neer classification and our revised new classification separately to determine treatment approaches for each patient. Images were mirrored and randomized to verify the intraobserver agreement. Reliabilities were measured using the Fleiss kappa values. RESULTS Both the modified Neer classification and our revised version had near perfect intraobserver agreement (κ values: 0.87-1.00), whereas our revised Neer classification had a better interobserver agreement (κ values: 0.78 vs. 0.70, z = 4.70, p < 0.01) and stronger relevance to treatment decisions (coefficient of contingency: 0.70 vs. 0.44). CONCLUSION Our study demonstrated a near-perfect intraobserver and substantial interobserver agreement of the revised new classification, indicating that our revised new classification was better than the modified Neer classification. Meanwhile, our revised classification brought few disputes in treatment selection. CLINICAL RELEVANCE The modified Neer classification was revised to make it more accurate and suitable for guiding treatment. TYPE OF STUDY Study of diagnostic test LEVEL OF STUDY: Level II.
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Affiliation(s)
- Yin Zhang
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, China 200025
| | - Pei Yu
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, China 200025
| | - Chengyu Zhuang
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, China 200025
| | - Jingfeng Liu
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, China 200025
| | - Gen Li
- Shanghai Institute of Traumatology and Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tingjun Ye
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, China 200025
| | - Lei Wang
- Department of Orthopedics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, China 200025.
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Sharma V, Modi A, Armstrong A, Pandey R, Sharma D, Singh H. The Management of Distal Clavicle Fractures - A Survey of UK Shoulder and Elbow Surgeons. Cureus 2021; 13:e17305. [PMID: 34567861 PMCID: PMC8451541 DOI: 10.7759/cureus.17305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Accepted: 08/19/2021] [Indexed: 11/24/2022] Open
Abstract
Background Distal clavicle fractures (DCF) are a management challenge frequently encountered by shoulder surgeons. Despite an array of surgical fixation strategies, the indications and role of surgery are unclear, with there being no gold standard or consensus regarding their management. The aim of this study was to identify current United Kingdom (UK) clinical practices relating to DCFs and to inform a future randomised control trial (RCT). Methods An online survey was sent to the consultant surgeon members of the British Elbow and Shoulder Society (BESS). Questions covered respondent indications for surgical fixation, important factors considered for management of DCFs, fixation strategies, the volume of patients treated, and willingness to participate in the conduct of a randomized trial. Results The response rate was 84/327 (26%). 64-67% of respondents reported surgically managing DCFs classified as Neer type 2A, 2B and 5. The most important factors considered by surgeons when deciding between operative and nonoperative intervention were degree of displacement (90%), clinical assessment of impending open fracture (87%), and age of the patient (74%). For conservatively managed DCFs, the preferred length of complete immobilization was 2-4 weeks (46%), followed by 4-8 weeks (17%). 30% reported not immobilizing their patients at all. For operative intervention, the locking plate was the preferred fixation method by most respondents (68%), although there was no clear consensus regarding other fixation methods. Most surgeons (52%) reported treating a low volume of patients with DCFs (0-10) per year. 58% of respondents were willing to randomize patients to non-operative treatment in a multi-centre RCT, with a further 22% undecided. Finally, 68% (n=79) of respondents would consider being co-investigators in such a trial. Conclusion There is considerable heterogeneity in the management of patients with DCFs in the UK. The indications for surgery and the optimal surgical fixation method remain uncertain. There is a clear need for pragmatic multi-centre clinical research in this area.
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Affiliation(s)
- Vivek Sharma
- Department of Trauma and Orthopaedics, Leicester Royal Infirmary, Leicester, GBR
| | - Amit Modi
- Department of Trauma and Orthopaedics, Leicester Royal Infirmary, Leicester, GBR
| | - Alison Armstrong
- Department of Trauma and Orthopaedics, Leicester Royal Infirmary, Leicester, GBR
| | - Radhakant Pandey
- Department of Trauma and Orthopaedics, Leicester Royal Infirmary, Leicester, GBR
| | - Dhiraj Sharma
- Department of Trauma and Orthopaedics, Norfolk and Norwich University Hospital, Norwich, GBR
| | - Harvinder Singh
- Department of Trauma and Orthopaedics, Leicester Royal Infirmary, Leicester, GBR
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Levy GM, Pinto NE, Woods BJ, Hermans D, Duckworth DG. Operative management of an extra-lateral distal clavicle fracture pattern: a study of 48 patients and a proposed update to the modified Neer classification. J Shoulder Elbow Surg 2021; 30:1931-1937. [PMID: 33197593 DOI: 10.1016/j.jse.2020.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Received: 07/21/2020] [Revised: 10/02/2020] [Accepted: 10/07/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to determine the efficacy of operative management for the treatment of patients with an extra-lateral distal clavicle fracture pattern. This fracture pattern is not currently included in the modified Neer classification. METHODS We retrospectively reviewed 48 patients who underwent open reduction and internal fixation of an acute extra-lateral distal clavicle fracture pattern between August 2005 and March 2019. The postoperative clinical outcomes were time to union; active shoulder range of motion; scar size; patient sensation of a "normal" shoulder; and Disabilities of the Arm, Shoulder and Hand score. RESULTS Postoperatively, all patients achieved union at an average of 7.9 weeks (range, 4-20 weeks). All patients regained full active shoulder range of motion at an average of 10.1 weeks (range, 5-44 weeks) and had a scar size of 3-4 cm; 93.8% of patients reported that their shoulder felt normal again after union. The mean Disabilities of the Arm, Shoulder and Hand score was 1.7 (range, 0-28) at 12 months postoperatively. CONCLUSION The patients had very good clinical outcomes following operative management of an extra-lateral distal clavicle fracture pattern. We recommend that this fracture pattern be added to the current modified Neer classification as a type IIC fracture.
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Affiliation(s)
- Gavin M Levy
- School of Medicine, University of Notre Dame Australia, Sydney, NSW, Australia.
| | | | | | | | - David G Duckworth
- Hornsby Hospital, Sydney, NSW, Australia; San Clinic, Sydney, NSW, Australia
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Panagopoulos A, Solou K, Nicolaides M, Triantafyllopoulos IK, Kouzelis A, Kokkalis ZT. Coracoclavicular fixation techniques for Neer IIb and ‘extra-lateral’ fractures of the distal clavicle: A systematic review. JSES Reviews, Reports, and Techniques 2021. [DOI: 10.1016/j.xrrt.2021.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Oberle L, Pierpoint L, Spittler J, Khodaee M. Epidemiology of Clavicle Fractures Sustained at a Colorado Ski Resort. Orthop J Sports Med 2021; 9:23259671211006722. [PMID: 34026919 PMCID: PMC8120545 DOI: 10.1177/23259671211006722] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/25/2021] [Indexed: 12/26/2022] Open
Abstract
Background Although clavicle fractures are a common sports injury, there are limited studies on the incidence and causes of clavicle fractures among winter sports athletes. Purpose To evaluate the characteristics and injury mechanisms associated with clavicle fractures among patients evaluated at a Colorado ski resort. Study Design Descriptive epidemiology study. Methods This was a retrospective descriptive analysis of patients with clavicle fractures at the Denver Health Winter Park Medical Center during the 2012-2013 to 2016-2017 ski seasons. Chart review was performed on the patient cohort to confirm clavicle fracture diagnosis and to evaluate factors associated with clavicle fracture. Results A total of 393 clavicle fractures (6.2% of total clinic visits) occurred during the study period, corresponding to an overall clavicle fracture incidence of 8.4 per 100,000 participant-visits. The mean patient age was 26.4 years (range, 5-73 years). The majority were middle-third fractures (85.5%), occurring mainly in men (87.3%). More than half of the fractures were comminuted (54.5%) and occurred in snowboarders (55.0%). The most common mechanism of injury was a fall onto snow while skiing or snowboarding (92.4%). Women sustained more clavicle fractures while skiing compared with snowboarding (82.0% vs 18.0%; P < .001), while men sustained more fractures while snowboarding compared with skiing (60.3% vs 39.7%; P < .001). Conclusion Clavicle fractures are relatively common, but there are scant incidence data for clavicle fractures in mountain sports. Consistent with prior studies, clavicle fractures were more common in younger patients and men. The most common anatomic fracture location was the midclavicle. A greater proportion of clavicle fractures among men were sustained during snowboarding and among women during skiing.
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Affiliation(s)
- Lauren Oberle
- Department of Family Medicine and Orthopedics, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Lauren Pierpoint
- Center for Outcomes-Based Orthopaedic Research, Steadman Philippon Research Institute, Vail, Colorado, USA
| | - Jack Spittler
- Department of Family Medicine and Orthopedics, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Morteza Khodaee
- Department of Family Medicine and Orthopedics, University of Colorado School of Medicine, Denver, Colorado, USA
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Stenson J, Baker W. Classifications in Brief: The Modified Neer Classification for Distal-third Clavicle Fractures. Clin Orthop Relat Res 2021; 479:205-209. [PMID: 32826407 PMCID: PMC7899602 DOI: 10.1097/corr.0000000000001456] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/21/2020] [Indexed: 01/31/2023]
Affiliation(s)
- James Stenson
- J. Stenson, W. Baker, Department of Orthopaedic Surgery, Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
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Abstract
Background: The management of lateral clavicle fractures is often challenging because of
difficulties in identifying displacement patterns that indicate an unstable
fracture. Hypothesis: The aim of this study was to evaluate displacement patterns through analysis
using 3-dimensional (3D) rendering software for displaced lateral clavicle
fractures. We hypothesized that most displaced lateral clavicle fractures
would have posterior displacement and angulation as well as superior
displacement of the medial fragment. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Radiographs of 37 displaced lateral clavicle fractures were imported into the
3D rendering software to reconstruct the fracture model. For the
computational simulation of fracture reduction, the medial fragment was
manipulated and returned into place using the software’s moving tools. Two
corresponding points were marked between the medial and lateral fragments to
measure 3D spatial location in the x-axis (shortening),
y-axis (horizontal displacement), and
z-axis (vertical displacement). The displacement angle
on the cranial view was also measured based on the medial end of the
clavicle. Results: There were 32 cases (86.5%) of superior displacement of the medial fragment
(mean, 5.8 mm; range, –6.5 to 19.0 mm), 35 cases (94.6%) of posterior
displacement of the medial fracture fragment (mean, 8.8 mm; range, –3.2 to
18.3 mm), and 23 cases (62.2%) of distraction of the fracture site (mean,
2.1 mm; range, –9.2 to 12.2 mm). All 37 patients revealed posterior
angulation of the fracture site (mean, 8.9°; range, 2.2°-39.4°). Conclusion: Most displaced lateral clavicle fractures have posterior displacement and
angulation as well as superior displacement of the medial fragment. Our
results revealed that 3D evaluation of lateral clavicle fracture
displacement patterns is useful for assessing fracture stability and making
treatment decisions.
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Affiliation(s)
- Chul-Hyun Cho
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Beom-Soo Kim
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Du-Han Kim
- Department of Orthopaedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Gu-Hee Jung
- Department of Orthopedic Surgery, Gyeongsang National University, College of Medicine, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
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Brereton DS, Robker JG, Gamez M, Burkhead WZ, Moen TC. Clinical and radiographic outcomes of a transosseous suture technique for displaced lateral clavicle fractures. J Shoulder Elbow Surg 2020; 29:S101-S106. [PMID: 32643604 DOI: 10.1016/j.jse.2020.04.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Received: 01/07/2020] [Revised: 04/16/2020] [Accepted: 04/21/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the clinical and radiographic outcomes of a transosseous suture fixation technique for the treatment of unstable lateral clavicle fractures. The appropriate treatment for lateral clavicle fractures is controversial. Many authors have argued for nonsurgical treatment of these injuries; however, recent literature has shown a role for the surgical treatment of unstable fractures. The paucity of lateral clavicular bone and the unique anatomy of this area of the shoulder makes surgical treatment of these injuries challenging. This article reports a single-surgeon experience with a transosseous suture fixation technique for the treatment of unstable lateral clavicle fractures. MATERIALS AND METHODS A retrospective review of all patients with unstable lateral clavicle fractures treated with a transosseous suture technique from 2015-2018 was performed. The indication for surgery was significant displacement between the main medial and lateral clavicle fragments. The surgical technique used was a modification of the technique as described by Levy. Patients were followed postoperatively with active and passive range of motion (ROM) measurements, strength testing, and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, visual analog scale score, and standard radiographs. Patients were followed to radiographic union. RESULTS Twelve patients underwent surgical fixation of unstable lateral clavicle fractures from 2015-2018. All patients had excellent function, full ROM, minimal pain, and improved functional scores at final follow-up. Eleven patients achieved complete union of the fracture. One patient healed with a fibrous union; however, the fracture had maintained alignment and the patient was asymptomatic and satisfied with the result. No patient required a second surgery. CONCLUSION We found that the transosseous suture technique for fixation is an effective treatment for unstable lateral clavicle fracture. This technique is reproducible, cost effective, and limits the need for revision surgery often encountered with other techniques.
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Affiliation(s)
- Daniel S Brereton
- W.B. Carrell Memorial Clinic, Dallas, TX, USA; Synergy Orthopedic Specialists Medical Group, San Diego, CA, USA.
| | | | - Marci Gamez
- W.B. Carrell Memorial Clinic, Dallas, TX, USA
| | | | - Todd C Moen
- W.B. Carrell Memorial Clinic, Dallas, TX, USA
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Abstract
Distal clavicle fractures are less common than mid-shaft fractures in adults and there is no consensus on the best classification system or the ideal treatment approach considering that high nonunion rates have been reported. Although there are numerous treatment options for distal clavicle fractures, a gold standard treatment has not yet been established. Each surgical technique has its pros and cons. In this review article, we provide an overview of classification systems and treatment methods for distal clavicle fractures.
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Affiliation(s)
- Dong-Wan Kim
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Du-Han Kim
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Beom-Soo Kim
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Chul-Hyun Cho
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
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19
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Porter DA, Yagnik GP. Response to Van Tongel and De Wilde regarding: "A biomechanical comparison of a novel technique for distal clavicle fracture repair versus locked plating". J Shoulder Elbow Surg 2020; 29:e97. [PMID: 32067717 DOI: 10.1016/j.jse.2019.09.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 09/13/2019] [Indexed: 02/01/2023]
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20
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Moverley R, Little N, Gulihar A, Singh B. Current concepts in the management of clavicle fractures. J Clin Orthop Trauma 2020; 11:S25-S30. [PMID: 31992912 PMCID: PMC6978197 DOI: 10.1016/j.jcot.2019.07.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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] [Received: 04/15/2019] [Revised: 07/23/2019] [Accepted: 07/24/2019] [Indexed: 10/26/2022] Open
Abstract
Clavicle fractures comprise approximately 3% of all adult fractures and there is evidence that the incidence is increasing. Fractures of the lateral and middle third of the clavicle present distinct challenges in both surgical fixation techniques and clinical outcome, as such they should be recognised as separate clinical entities. Despite conflicting evidence, most studies indicate that superior clinical results are found in patients with united clavicle fractures rather than those that go onto non-union. Furthermore there is level-1 evidence that operative treatment of clavicle fractures leads to significantly increased rates of union. Despite these findings, significant controversy still exists on which patients would benefit from primary fixation and those who could successfully be managed non-operatively. We present an evidence-based review of clavicle fracture management including surgical indications, techniques, and results.
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Affiliation(s)
| | - Nick Little
- Epsom & St Helier Hospitals NHS Trust, London, UK
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21
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Rauer T, Boos M, Neuhaus V, Ellanti P, Kaufmann RA, Pape HC, Allemann F. Inter- and intraobserver agreement of three classification systems for lateral clavicle fractures - reliability comparison between two specialist groups. Patient Saf Surg 2020; 14:4. [PMID: 31911821 PMCID: PMC6945566 DOI: 10.1186/s13037-019-0228-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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] [Received: 11/26/2019] [Accepted: 12/30/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Although of great value in the management of lateral clavicle fractures, substantial variation in their classification exists. We performed a retrospective study to address the inter- and intraobserver reliability of three different classification systems for lateral clavicle fractures. METHODS Radiographs of 20 lateral clavicle fractures that represented a full spectrum of adult fracture patterns were graded by five experienced radiologists and five experienced trauma surgeons according to the Orthopaedic Trauma Association (OTA), the Neer, and the Jäger/Breitner classification systems. This evaluation was performed at two different time points separated by 3 months. To measure the observer agreement, the Fleiss kappa coefficient (κ) was applied and assessed according to the grading of Landis and Koch. RESULTS The overall interobserver reliability showed a fair agreement in all three classification systems. For the OTA classification system, the interobserver agreement showed a mean kappa value of 0.338 ranging from 0.350 (radiologists) to 0.374 (trauma surgeons). Kappa values of the interobserver agreement for the Neer classification system ranged from 0.238 (trauma surgeons) to 0.276 (radiologists) with a mean κ of 0.278. The Jäger/Breitner classification system demonstrated a mean kappa value of 0.330 ranging from 0.306 (trauma surgeons) to 0.382 (radiologists).The overall intraobserver reliability was moderate for the OTA and the Jäger/Breitner classification systems, while the overall intraobserver reliability for the Neer classification system was fair.The kappa values of the intraobserver agreements showed, in all classification systems, a wide range with the OTA classification system ranging from 0.086 to 0.634, the Neer classification system ranging from 0.137 to 0.448, and a range from 0.154 to 0.625 of the Jäger/Breitner classification system. CONCLUSIONS The low inter- and intraobserver agreement levels exhibited in all three classification systems by both specialist groups suggest that the tested lateral clavicle fracture classification systems are unreliable and, therefore, of limited value. We should recognize there is considerable inconsistency in how physicians classify lateral clavicle fractures and therefore any conclusions based on these classifications should be recognized as being somewhat subjective.
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Affiliation(s)
- Thomas Rauer
- Department of Trauma Surgery, UniversityHospital Zurich, Rämistrasse 100, Zurich, Switzerland
| | - Matthias Boos
- Department of Trauma Surgery, UniversityHospital Zurich, Rämistrasse 100, Zurich, Switzerland
| | - Valentin Neuhaus
- Department of Trauma Surgery, UniversityHospital Zurich, Rämistrasse 100, Zurich, Switzerland
| | - Prasad Ellanti
- Department of Trauma Surgery, UniversityHospital Zurich, Rämistrasse 100, Zurich, Switzerland
| | | | - Hans-Christoph Pape
- Department of Trauma Surgery, UniversityHospital Zurich, Rämistrasse 100, Zurich, Switzerland
| | - Florin Allemann
- Department of Trauma Surgery, UniversityHospital Zurich, Rämistrasse 100, Zurich, Switzerland
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Cho CH, Kim BS, Kim DH, Choi CH, Dan J, Lee H. Distal clavicle fractures: A new classification system. Orthop Traumatol Surg Res 2018; 104:1231-1235. [PMID: 30393071 DOI: 10.1016/j.otsr.2018.05.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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] [Received: 11/10/2017] [Revised: 04/05/2018] [Accepted: 05/29/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Existing various classification systems for distal clavicle fractures have low interobserver and intraobserver reliability and provide limited information for treatment decision. The objective of this study was to determine interobserver and intraobserver reliability of the new classification system and the associated treatment choice for distal clavicle fractures. HYPOTHESIS The new classification system has good reliability. METHODS Eight observers including 4 experienced shoulder specialists and 4 orthopedic fellows independently reviewed routine plain radiographs of 74 patients with distal clavicle fractures. They were asked to determine the fracture type according to the new classification system and the treatment choice for each case through web-based survey. Images from each case were randomly presented to the observers in 2 rounds 4 weeks apart. Reliability was assessed on the basis of Fleiss κ values. RESULTS Interobserver and intraobserver reliability of the classification system were moderate (κ=0.434) and substantial (κ=0.644), respectively. Interobserver and intraobserver reliability of the treatment choice were moderate (κ=0.593) and substantial (κ=0.698), respectively. There were no significant differences in the level of reliability between experienced shoulder specialists and orthopedic fellows for any κ values (all p>0.05). CONCLUSION Our study demonstrated moderate interobserver and substantial intraobserver reliability of the new classification system and the associated treatment choice for distal clavicle fractures. We believe that our novel classification system will help physicians to choose treatment and implants. LEVEL OF EVIDENCE III, Cohort study, Diagnosis study.
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Affiliation(s)
- Chul-Hyun Cho
- Pain Research Center, Department of Orthopedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, 56 Dalseong-ro, Jung-gu, Daegu, South Korea.
| | - Beom-Soo Kim
- Pain Research Center, Department of Orthopedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, 56 Dalseong-ro, Jung-gu, Daegu, South Korea
| | - Du-Han Kim
- Pain Research Center, Department of Orthopedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, 56 Dalseong-ro, Jung-gu, Daegu, South Korea
| | - Chang-Hyuk Choi
- Department of Orthopedic Surgery, Daegu Catholic University Medical Center, Daegu, South Korea
| | - Jinmyoung Dan
- Department of Orthopedic Surgery, Gumi CHA Hospital, CHA University, Gumi, South Korea
| | - HoMin Lee
- Department of Orthopedic Surgery, Gyeongju Hospital, College of Medicine, Dongguk University, Gyeongu, South Korea
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Sandstrom CK, Gross JA, Kennedy SA. Distal clavicle fracture radiography and treatment: a pictorial essay. Emerg Radiol 2018; 25:311-9. [DOI: 10.1007/s10140-018-1586-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 01/24/2018] [Indexed: 10/18/2022]
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Lanier PJ, Speirs J, Koehler L, Bader J, Abdelgawad A, Waterman BR. Predictors of Persistent Pain After Fixation of Distal Clavicle Fractures in an Active Military Population. Orthopedics 2018; 41:e117-e126. [PMID: 29192935 DOI: 10.3928/01477447-20171127-02] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 10/03/2017] [Indexed: 02/03/2023]
Abstract
Patients who undergo open reduction and internal fixation of distal clavicle fractures have a high rate of hardware removal and persistence of symptoms, particularly when attempting to return to high-demand activities. This study evaluated the outcomes of military servicemembers after surgical treatment of distal clavicle fractures. The authors performed a retrospective analysis of active duty servicemembers who underwent open reduction and internal fixation of Neer type II distal clavicle fractures between October 17, 2007, and July 20, 2012, with a minimum of 2-year clinical follow-up. The electronic health record was queried to extract demographic features and clinical outcomes, primarily persistence of pain, removal of hardware, and postoperative return to high-level activity. A total of 48 patients were identified, with mean follow-up of 3.8 years. A total of 44% of patients underwent subsequent hardware removal. All fractures achieved radiographic union, and 35% of patients had persistence of symptoms. Patients who were treated with hook plating had a 3.64-fold higher risk of persistence of pain compared with those treated with conventional plating techniques. A total of 35% of patients successfully returned to full military function and completed a postoperative military deployment. Coracoclavicular reconstruction did not improve outcomes. Persistence of symptoms and requirement for hardware removal were not associated with the rate of postoperative deployment. Achieving excellent functional outcomes with open reduction and internal fixation of distal clavicle fractures remains a challenge. Where possible, conventional plate fixation should be considered over hook plate fixation. However, subsequent hardware removal and continuing shoulder pain do not preclude a return to high-level activity. [Orthopedics. 2018; 41(1):e117-e126.].
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Robertson GA, Wood AM, Oliver CW. Displaced middle-third clavicle fracture management in sport: still a challenge in 2018. Should you call the surgeon to speed return to play? Br J Sports Med 2017; 52:348-349. [PMID: 28500080 DOI: 10.1136/bjsports-2016-097349] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2017] [Indexed: 01/17/2023]
Affiliation(s)
- Greg A Robertson
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Christopher W Oliver
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh, UK.,Physical Activity for Health Research Centre, The University of Edinburgh, Edinburgh, UK
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Cano-martínez J, Nicolás-serrano G, Andrés-grau J, Bento-gerard J. Treatment of distal-third clavicular fractures (Neer type II-b) with a triple button device. Rev Esp Cir Ortop Traumatol (Engl Ed) 2016; 60:378-386. [DOI: 10.1016/j.recote.2016.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Cano-Martínez JA, Nicolás-Serrano G, Andrés-Grau J, Bento-Gerard J. Treatment of distal-third clavicular fractures (Neer type ii-b) with a triple button device. Rev Esp Cir Ortop Traumatol (Engl Ed) 2016; 60:378-386. [PMID: 27435987 DOI: 10.1016/j.recot.2016.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/25/2016] [Accepted: 06/02/2016] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The purpose of this study is to describe the outcomes of using a triple button device for the treatment of displaced distal-third clavicle fractures (Neer, type ii-b). MATERIAL AND METHOD A retrospective review was conducted on a series of patients between November 2011 and December 2014. Fourteen patients initially met the inclusion criteria, but 2 were excluded, leaving 12 patients (83.3% male; mean age 32.2 years) for the final analysis at a mean follow-up of 26±11.24 months (range, 12-48). Post-operative follow-up was performed at 2 weeks (two first months), and monthly thereafter, until was achieving clinically and radiological healing. The functional outcome was evaluated using the Constant score, and DASH score in the last follow-up. RESULTS The mean Constant Score was 95.5±5.2 points (range, 85-100), with a mean DASH score of 3.3±4.4 points (range, 0-12.5). The mean time to clinical healing was10.3±3.1 weeks (range, 8-16), and the mean time to radiological healing was 13.6±2.6 weeks (range, 12-20). There were no major complications. There were 5 minor complications without clinical impact: 2 coracoclavicular calcifications, 1 hypertrophic scar, 1 patient with discomfort due to the device, and 1 superficial wound infection. All patients returned their previous activity. CONCLUSION Good clinical results can be achieved with the triple button device in unstable distal fractures of the clavicle, without the need to remove the hardware.
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Affiliation(s)
- J A Cano-Martínez
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Los Arcos del Mar Menor, Facultad de Medicina, Universidad de Murcia, Pozo Aledo, Murcia, España.
| | - G Nicolás-Serrano
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Los Arcos del Mar Menor, Facultad de Medicina, Universidad de Murcia, Pozo Aledo, Murcia, España
| | - J Andrés-Grau
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Los Arcos del Mar Menor, Facultad de Medicina, Universidad de Murcia, Pozo Aledo, Murcia, España
| | - J Bento-Gerard
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Los Arcos del Mar Menor, Facultad de Medicina, Universidad de Murcia, Pozo Aledo, Murcia, España
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Schwarting T, Lechler P, Bockmann B, Debus F, Ziring E, Frink M. RETRACTED ARTICLE: The benefit of arthroscopically assisted therapy for concomitant glenohumeral injuries in patients with unstable lateral clavicle fractures. Knee Surg Sports Traumatol Arthrosc 2016; 24:3376. [PMID: 26658572 DOI: 10.1007/s00167-015-3909-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 11/26/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Tim Schwarting
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Philipp Lechler
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Benjamin Bockmann
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Florian Debus
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Ewgeni Ziring
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Michael Frink
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Baldingerstrasse, 35043, Marburg, Germany.
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Abstract
INTRODUCTION This review aims to provide information on the return rates and return times to sport following clavicle fractures. SOURCES OF DATA A systematic search of Medline, EMBASE, CINAHAL, Cochrane, Web of Science, PEDro, SPORTDiscus, Scopus and Google Scholar was performed using the keywords 'clavicle', 'clavicular', 'fractures', 'athletes', 'sports', 'non-operative', 'conservative', 'operative', 'return to sport'. AREAS OF AGREEMENT Twenty-three studies were included: 10 reported on mid-shaft fractures, 14 on lateral fractures. The management principles for athletic patients were to attempt non-operative management for undisplaced fractures to undertake operative intervention for displaced lateral fractures and to recommend operative intervention for displaced mid-shaft fractures. AREAS OF CONTROVERSY The optimal surgical modality for mid-shaft and lateral clavicle fractures. GROWING POINTS Operative management of displaced mid-shaft fractures offers improved return rates and times to sport compared to non-operative management. Suture fixation and non-acromio-clavicular joint (ACJ)-spanning plate fixation of displaced lateral fractures show promising results. AREAS TIMELY FOR DEVELOPING RESEARCH Future prospective studies should aim to establish the optimal treatment modalities for clavicle fractures.
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Affiliation(s)
- G A J Robertson
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK.
| | - A M Wood
- Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK
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Janssen SJ, Molleman J, Guitton TG, Ring D. What middle phalanx base fracture characteristics are most reliable and useful for surgical decision-making? Clin Orthop Relat Res 2015; 473:3943-50. [PMID: 26084850 PMCID: PMC4626472 DOI: 10.1007/s11999-015-4394-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 06/01/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Fracture-dislocations of the proximal interphalangeal joint are vexing because subluxation and articular damage can lead to arthrosis and the treatments are imperfect. Ideally, a surgeon could advise a patient, based on radiographs, when the risk of problems merits operative intervention, but it is unclear if middle phalanx base fracture characteristics are sufficiently reliable to be useful for surgical decision making. QUESTIONS/PURPOSES We evaluated (1) the degree of interobserver agreement as a function of fracture characteristics, (2) the differences in interobserver agreement between experienced and less-experienced hand surgeons, and (3) what fracture characteristics and surgeon characteristics were associated with the decision for operative treatment. METHODS Ninety-nine (33%) of 296 hand surgeons evaluated 21 intraarticular middle phalanx base fractures on lateral radiographs. Eighty-one surgeons (82%) were in academic practice and 57 (58%) had less than 10 years experience. Participants assessed six fracture characteristics and recommended treatment (nonoperative or operative: extension block pinning, external fixation, open reduction and internal fixation, volar plate arthroplasty, or hemihamate autograft arthroplasty) for all cases. RESULTS With all surgeons pooled together, the interobserver agreement for fracture characteristics was substantial for assessment of a 2-mm articular step or gap (kappa, 0.73; 95% CI, 0.60-0.86; p < 0.001), subluxation or dislocation (kappa, 0.72; 95% CI, 0.58-0.86; p < 0.001), and percentage of articular surface involved (intraclass correlation coefficient [ICC], 0.67; 95% CI, 0.54-0.81; p < 0.001); moderate for comminution (kappa, 0.55; 95% CI, 0.39-0.70; p < 0.001) and stability (kappa, 0.54; 95% CI, 0.39-0.69; p < 0.001); and fair for the number of fracture fragments (ICC, 0.39; 95% CI, 0.27-0.57; p < 0.001). When recommending treatment, interobserver agreement was substantial (kappa, 0.69; 95% CI, 0.50-0.88; p < 0.001) for the recommendation to operate or not to operate, but only fair (kappa, 0.34; 95% CI, 0.21-0.47; p < 0.001) for the specific type of treatment, indicating variation in operative techniques. There were no differences in agreement for any of the fracture characteristics or treatment preference between less-experienced and more-experienced surgeons, although statistical power on this comparison was low. None of the surgeon characteristics was associated with the decision for operative treatment, whereas all fracture characteristics were, except for stable and uncertain joint stability. Articular step or gap (β, 0.90; R-squared, 0.89; 95% CI, 0.75-1.05; p < 0.001), likelihood of subluxation or dislocation (β, 0.80; R-squared, 0.76; 95% CI, 0.59-1.02; p < 0.001), and unstable fractures (β, 0.88; R-squared, 0.81; 95% CI, 0.67-1.1; p < 0.001), are most strongly associated with the decision for operative treatment. CONCLUSIONS We found that assessment of a step or gap and likelihood of subluxation were most reliable and are strongly associated with the decision for operative treatment. Surgeons largely agree on which fractures might benefit from surgery, and the variation seems to be with the operative technique. Efforts at improving the care of these fractures should focus on the comparative effectiveness of the various operative treatment options. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Stein J. Janssen
- Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Yawkey Center, Massachusetts General Hospital, Suite 2100, 55 Fruit Street, Boston, 02114 MA USA
| | - Jeroen Molleman
- Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Yawkey Center, Massachusetts General Hospital, Suite 2100, 55 Fruit Street, Boston, 02114 MA USA
| | - Thierry G. Guitton
- Department of Orthopaedic Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - David Ring
- Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Yawkey Center, Massachusetts General Hospital, Suite 2100, 55 Fruit Street, Boston, 02114 MA USA
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Cho CH, Oh JH, Jung GH, Moon GH, Rhyou IH, Yoon JP, Lee HM. The Interrater and Intrarater Agreement of a Modified Neer Classification System and Associated Treatment Choice for Lateral Clavicle Fractures. Am J Sports Med 2015; 43:2431-6. [PMID: 26264768 DOI: 10.1177/0363546515593949] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [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: 01/31/2023]
Abstract
BACKGROUND As there is substantial variation in the classification and diagnosis of lateral clavicle fractures, proper management can be challenging. Although the Neer classification system modified by Craig has been widely used, no study has assessed its validity through inter- and intrarater agreement. PURPOSE To determine the inter- and intrarater agreement of the modified Neer classification system and associated treatment choice for lateral clavicle fractures and to assess whether 3-dimensional computed tomography (3D CT) improves the level of agreement. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 3. METHODS Nine experienced shoulder specialists and 9 orthopaedic fellows evaluated 52 patients with lateral clavicle fractures, completing fracture typing according to the modified Neer classification system and selecting a treatment choice for each case. Web-based assessment was performed using plain radiographs only, followed by the addition of 3D CT images 2 weeks later. This procedure was repeated 4 weeks later. Fleiss κ values were calculated to estimate the inter- and intrarater agreement. RESULTS Based on plain radiographs only, the inter- and intrarater agreement of the modified Neer classification system was regarded as fair (κ = 0.344) and moderate (κ = 0.496), respectively; the inter- and intrarater agreement of treatment choice was both regarded as moderate (κ = 0.465 and 0.555, respectively). Based on the plain radiographs and 3D CT images, the inter- and intrarater agreement of the classification system was regarded as fair (κ = 0.317) and moderate (κ = 0.508), respectively; the inter- and intrarater agreement of treatment choice was regarded as moderate (κ = 0.463) and substantial (κ = 0.623), respectively. There were no significant differences in the level of agreement between the plain radiographs only and plain radiographs plus 3D CT images for any κ values (all P > .05). CONCLUSION The level of interrater agreement of the modified Neer classification system for lateral clavicle fractures was fair. Additional 3D CT did not improve the overall level of interrater or intrarater agreement of the modified Neer classification system or associated treatment choice. To eliminate a common source of disagreement among surgeons, a new classification system to focus on unclassifiable fracture types is needed.
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Affiliation(s)
- Chul-Hyun Cho
- Pain Research Center, Department of Orthopedic Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, South Korea
| | - Joo Han Oh
- Department of Orthopedic Surgery, Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Gu-Hee Jung
- Department of Orthopedic Surgery, Gospel Hospital, Kosin University School of Medicine, Busan, South Korea
| | - Gi-Hyuk Moon
- Department of Orthopedic Surgery, Pohang St Mary's Hospital, Pohang, South Korea
| | - In Hyeok Rhyou
- Upper Extremity and Microsurgery Center, Department of Orthopedic Surgery, Pohang Semyeng Christianity Hospital, Pohang, South Korea
| | - Jong Pil Yoon
- Department of Orthopedic Surgery, Kyungpook National University Hospital, Daegu, South Korea
| | - Ho Min Lee
- Department of Orthopedic Surgery, Gyeongju Hospital, Dongguk University College of Medicine, Gyeongju, South Korea
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