Does plate type influence the clinical outcomes and implant removal in midclavicular fractures fixed with 2.7-mm anteroinferior plates? A retrospective cohort study

Dual- Versus Single-Plate Fixation of Clavicle Fractures: Understanding the Rationale Behind both Approaches

Clavicle fractures are a common injury resulting from a high-energy force, such as a fall onto the shoulder, motor vehicle accident, or sporting activity. Although some clavicle fractures may be treated nonoperatively, operative treatment results in higher union rates and faster return to activity. Here we discuss the operative treatment options for plating of clavicle fractures; specifically, a single plate placed either superiorly or anteriorly or two plates placed orthogonally. Because both techniques provide adequate stability, fracture and patient characteristics should guide the surgical decision making regarding single versus dual plating of clavicle fractures.

Indications for the removal of implants after fracture healing: A comparison between human and veterinary medicine

Indications for implant removal after fracture healing are still under debate in both human and veterinary medicine. Although hardware removal is a common procedure, it should not be undertaken lightly. Intra and post-operative complications are common and a thorough evaluation of the risks and benefits should be performed. This review aimed to collect and summarise published data on the indications for implant removal in small animals, compare the collected data with human and equine medicine, and investigate the existence of guidelines for this purpose. There is no international consensual agreement for implant removal after fracture healing, neither in small animals nor in human orthopaedics. Decision-making processes are still controversial in some scenarios, thus clear evidence-based protocols for implant removal are needed.

Low rate of secondary surgery and implant removal following superior, precontoured plating of midshaft clavicle fractures

Background

Surgical fixation of midshaft clavicle fractures with a single 3.5 mm superior clavicular plate has been associated with a high rate of hardware removal due to symptomatic hardware. Because of this, dual-plating techniques with lower-profile implants have been proposed. However, dual-plating systems have disadvantages, including increased cost and increased surgical morbidity. The aim of this study was to define the rate of symptomatic hardware removal for all midshaft clavicle fractures.

Methods

We retrospectively reviewed information on all patients from 2014 to 2018 at a single level 1 trauma institution with surgeries performed by two fellowship-trained orthopedic trauma surgeons. Documented removal of hardware and the reason for removal were recorded. We then contacted all patients at their listed telephone number to confirm the hardware was still in place and to administer patient outcome questionnaires. If patients did not answer, attempts were made to contact them multiple times on multiple days. Those who were not reached but had documented hardware removal were included in the total number of patients with hardware removal.

Results

The search revealed 158 patients, of whom 89 (61.8%) were included in the study. Average follow up was 4.09 years (range 2.02-6.50 years). Five patients (5.56%) underwent hardware removal. Removal was for symptomatic or irritating hardware in two of these patients (2.22%). Average abbreviated Disability of Arm, Shoulder, and Hand score was 6.27, and average American Society of Shoulder and Elbow Surgeons shoulder score was 93.6.

Conclusion

In our series, the rate of symptomatic hardware removal was 2.22%, well below reported removal rates. Hardware removal rates for prominent symptomatic superior clavicular plates may be significantly lower than previously reported, and these fractures may be adequately treated with a single, superior plate.

Are two plates better than one? A systematic review of dual plating for acute midshaft clavicle fractures

BACKGROUND

The rate of operative fixation of acute midshaft clavicle fractures has exponentially increased in recent years; however, the rate of reoperation for symptomatic hardware removal remains high and the optimal fixation strategy unknown. This systematic review aimed to summarize available evidence for dual plating of acute displaced midshaft clavicle fractures.

METHODS

EMBASE, MEDLINE, and PubMed searches identified clinical studies evaluating dual plate fixation of acute midshaft clavicle fractures. Pooled analysis was performed using a random-effects model in RevMan 5.3.

RESULTS

Eleven studies including 672 patients were included. Hardware removal occurred in 4.4% and 12.3% of patients undergoing dual and single plate fixation, respectively. Compared to single plating, dual plating had significantly lower odds of hardware removal (P = 0.001) with no difference in union rates. There were no significant differences in reoperation (excluding hardware removal), complications, and patient-reported outcomes between the two groups (P > 0.05).

CONCLUSIONS

This study suggests that dual plating of acute displaced midshaft clavicle fractures may lead to lower rates of reoperation for symptomatic hardware removal without compromising fracture healing. Ultimately, well-designed randomized trials are needed to further investigate the findings from this systematic review.

Results of pre-contoured titanium anterior plating of midshaft clavicle fractures

BACKGROUND

Plating midshaft clavicle fractures anteriorly is gaining popularity because of low complication rates. Improvements in plate fixation constructs for midshaft clavicle fractures have unclear clinical significance. The purpose of this study was to present the early clinical and radiographic outcomes of pre-contoured titanium anterior plates for the treatment of midshaft clavicle fractures.

METHODS

Skeletally mature patients who underwent plate fixation of a midshaft clavicular fracture from 2008 to 2015 using pre-contoured titanium anterior plates were included in this retrospective investigation. The primary outcome measures were union rate and hardware removal rate. The secondary outcome measures included reoperation for all causes and mechanical implant failure.

RESULTS

A total of 26 patients were included. Complete healing occurred in 96% of patients without further surgical intervention, and all patients achieved union. Medical complications occurred in 2 patients (7.7%), consisting of cellulitis (n = 1) and chronic pain (n = 1). In 1 patient (3.8%), delayed union occurred and the use of a bone stimulator was required postoperatively to achieve union. Finally, 2 patients (7.7%) had symptomatic implants that required removal.

CONCLUSIONS

In the acute fracture setting, the anterior plating system used in this study led to a high rate of union with decreased rates of implant irritation. Only 7.7% of patients required hardware removal for symptomatic hardware, as opposed to the estimated 20%-60% reported in the literature in patients with symptomatic superior clavicle plates.

Peri-implant distal clavicle fracture: Case report (overlaying plate fixation: Solution for peri-implant clavicle fractures)

Introduction and importance

Surgical treatment for clavicle injuries is indicated for displaced and shortened fractures. Osteosyntheses with plate fixation may present with complications in 6.3% to 8.5% of patients. Peri-implant clavicle fractures (PIF) are rare, and we have not found any previous cases in our literature search.

Case presentation

A 25-year-old male with previously (six years earlier) surgically treated clavicle fracture presented with a peri-implant clavicle fracture requiring surgical treatment. The management involved overlaying an implant to fix the lateral clavicle fracture without removing the previous plate. Complete bone healing was observed without any further complication.

Clinical discussion

Despite the low rate of implant failure in clavicle fractures, this complication occurs mainly in elderly patients with poor bone quality. No PIF have been described in the literature prior to this. This case report demonstrates a young patient with good bone quality and previous fracture fixation presenting with PIF which has now shown complete bone healing.

Conclusion

In this case, overlying an additional plate on the lateral clavicle portion without removing the previous plate increased the stability of the fracture. It demonstrates the value of overlaying plate osteosyntheses for patients with clavicle PIF.

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Peri-implant clavicle fracture is a rare situation.

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The management of peri-implant fracture is challenging.

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Overlaying plate fixation can be the solution for peri-implant clavicle fractures.

Examining the novel use of continuous compression implants in clavicle reconstruction: A biomechanical study

BACKGROUND

Current implants for clavicle fractures are known to cause poor cosmesis and irritation, which may require implant removal. Low-profile shape-memory staples provide an attractive alternative, but their biomechanical utility in clavicle reconstruction is unknown. We hypothesized that shape-memory reconstructions would be more compliant compared to traditional constructs but would also outperform conventional plates during cyclic loading to failure.

METHODS

This study was performed with 36 synthetic clavicles and 12 matched pairs of cadaveric specimens. The synthetic study tested four reconstructions: a single superiorly placed staple (n = 6), a single anteroinferiorly-placed staple (n = 6), a 3.5 mm reconstruction plate (n = 12), and two orthogonally placed staples (n = 12). The cadaveric study tested three constructs: reconstruction plate (n = 8), two orthogonal staples (n = 8), and a 2.7 mm reconstruction plate combined with a superior staple (n = 8). Non-destructive 4-point bending, compression, and torsion assays were performed prior to destructive cantilever bending and cyclic torsion tests.

FINDINGS

The single staple and double staple groups demonstrated significantly decreased resistance to bending (p < 0.001) and torsion (p ≤ 0.027) when compared to reconstruction plate groups. The double staple group sustained significantly fewer cycles to failure than the reconstruction plate group in cyclic torsional tests (p = 0.012). The synthetic models produced higher stiffness and failure mechanisms that were completely different from cadaveric specimens.

INTERPRETATION

Shape memory alloy implants provided inadequate stiffness for clavicle fixation but may have utility in other orthopaedic applications when used as a supplementary compression device in conjunction with traditional plated constructs. Synthetic bones have limited capacity for modeling fragility fractures.

Comparative effectiveness of treatment options for displaced midshaft clavicle fractures : a systematic review and network meta-analysis

Aims

The aims of this network meta-analysis (NMA) were to examine nonunion rates and functional outcomes following various operative and nonoperative treatments for displaced mid-shaft clavicle fractures.

Methods

Initial search strategy incorporated MEDLINE, PubMed, Embase, and the Cochrane Library for relevant randomized controlled trials (RCTs). Four treatment arms were created: nonoperative (NO); intramedullary nailing (IMN); reconstruction plating (RP); and compression/pre-contoured plating (CP). A Bayesian NMA was conducted to compare all treatment options for outcomes of nonunion, malunion, and function using the Disabilities of the Arm Shoulder and Hand (DASH) and Constant-Murley Shoulder Outcome scores.

Results

In all, 19 RCTs consisting of 1,783 clavicle fractures were included in the NMA. All surgical options demonstrated a significantly lower odds ratio (OR) of nonunion in comparison to nonoperative management: CP versus NO (OR 0.08; 95% confidence interval (CI) 0.04 to 0.17); IMN versus NO (OR 0.07; 95% CI 0.02 to 0.19); RP versus NO (OR 0.07; 95% CI: 0.01 to 0.24). Compression plating was the only treatment to demonstrate significantly lower DASH scores relative to NO at six weeks (mean difference -10.97; 95% CI -20.69 to 1.47).

Conclusion

Surgical fixation demonstrated a lower risk of nonunion compared to nonoperative management. Compression plating resulted in significantly less disability early after surgery compared to nonoperative management. These results demonstrate possible early improved functional outcomes with compression plating compared to nonoperative treatment. Surgical fixation of mid-shaft clavicle fractures with compression plating may result in quicker return to activity by rendering patients less disabled early after surgery.

Cite this article: Bone Jt Open 2021;2(8):646–654.

A multicentric study on the newly developed reconstruction locking plate for midshaft clavicular fracture

Objectives: To examine the efficacy and clinical and radiological outcomes of the use of a streamlined clavicle plate^® (MEIRA, Aichi, Japan) for midshaft clavicular fractures. Methods: This was a retrospective cohort study of 155 patients with displaced midshaft clavicular fractures treated using a streamlined clavicle plate between 2015 and 2019 in 18 hospitals across Japan. A questionnaire regarding bone union and postoperative complications was used, and 136 cases were followed up for one year or until bone union. Plate fitting was evaluated retrospectively using surgical records, radiographic findings, and surgeon's opinion. Results: During surgery, plate bending was needed in 19 cases (12.3%), poor fitting was observed in 8 cases (5.2%), and bone union was achieved in 133 cases (97.8%). Total implantation failure, including plate breakage and screw loosening, occurred in 10 cases (6.5%) from the intraoperative to postoperative period. Subjective complications were observed in 26 cases (16.8%): incongruity around the surgical scar or in the anterior chest in 23, and contracture of the shoulder in three. Plate removal was performed in 66 cases (48.5%) per patient's request. Conclusion: The use of a streamlined clavicle plate is effective for midshaft fractures of the clavicle, and the success rates of bone union and implantation using this approach are comparable to those of other existing plates.

Mechanical Evaluation of 2.7- Versus 3.5-mm Plating Constructs for Midshaft Clavicle Fractures

OBJECTIVES

This study compares the mechanical performance of 2.7- and 3.5-mm plating constructs for the treatment of midshaft clavicle fractures.

METHODS

Twenty-four synthetic clavicles were randomly divided into four treatment groups-Synthes 2.7-mm cold-worked calcaneal reconstruction plate with 6 (CRP6) or 8 bicortical screws (CRP8); Synthes 3.5-mm LCP reconstruction plate (RP; and Synthes 3.5-mm LCP precontoured superior-anterior clavicle plate (PCRP). All clavicles were plated, a wedge-shaped inferior cortical defect was created, and testing was performed using a cantilever bending model to determine bending stiffness and yield point for each construct.

RESULTS

Bending stiffness for the 3.5-mm PCRP construct was markedly higher when compared with the other three constructs, whereas the 3.5-mm RP construct was markedly stiffer than both of the 2.7-mm CR constructs. The yield point for the 3.5-mm PCRP construct was greater than the other three constructs; however, the yield point for the 2.7-mm CRP with six screws and with eight screws was higher than the 3.5-mm RP construct. The amount of displacement required to reach the yield point was highest for the 2.7-mm CRP with six screws. and this was markedly higher than the values for the other three constructs.

DISCUSSION

The 3.5-mm plates demonstrated increased bending stiffness compared with the 2.7-mm plates. Despite the lower resistance to bending forces, the cold-worked 2.7-mm plate exhibited a markedly higher yield point and required markedly more superior to inferior displacement to initiate plastic deformation when compared with the 3.5-mm LCP RP.

LEVEL OF EVIDENCE

Level IV.

Risk factors for hardware removal following operative treatment of middle- and distal-third clavicular fractures

BACKGROUND

The incidence of hardware removal (HWR) after operative fixation of clavicular fractures varies widely. Risk factors related to HWR remain incompletely understood. The aim of this study was to evaluate the incidence of and risk factors for HWR after plate fixation of middle- and distal-third clavicular fractures. We hypothesized that (1) the total HWR incidence would be <20%, (2) the HWR incidence of operatively treated distal- and middle-third clavicular fractures would not be statistically different, and (3) symptomatic implants would be the most common HWR indication.

METHODS

We performed a multi-hospital retrospective study of skeletally mature patients who underwent plate fixation of middle- and distal-third clavicular fractures from November 2008 to November 2018. Data included patient demographic characteristics, mechanism of injury, operative records, hardware-related symptoms, subsequent HWR, and complications.

RESULTS

A total of 103 patients (aged 16-75 years, 76.7% male patients) were included. Of the patients, 87 (84.5%) underwent plate fixation for midshaft clavicular fractures and 16 (15.5%) underwent plate fixation for distal-third clavicular fractures. HWR was performed in 13 patients (12.6%). A significantly higher percentage of HWR procedures were performed for distal clavicular fractures (50%) than for middle-third clavicular fractures (4.9%, P < .0001). An initial high-energy mechanism of injury was associated with HWR (P = .0025). The most common indication for HWR was symptomatic hardware (69.2%). The overall complication rate was 14.5%.

CONCLUSION

The overall incidence of clavicular HWR was 12.6%. A distal fracture location was associated with a significantly higher incidence of HWR. An initial high-energy mechanism of injury was a significant risk factor for HWR. The primary indication for HWR was symptomatic hardware.

Experiencia en fracturas de clavícula mediodiafisaria con placa de reconstrucción en posición anteroinferior en pacientes del Hospital José Carrasco Arteaga, IESS 2017 Cuenca – Ecuador

Las fracturas mediodiafisarias de clavícula corresponden del 75% al 80% de los casos de fracturas claviculares. En el contexto quirúrgico, existen dos técnicas para reparar este tipo de fracturas: la colocación de placa en posición superior y en posición anteroinferior. La primera técnica es la más usada; sin embargo, la segunda brinda una temprana recuperación, minimiza pérdida de sangre y disminuye intervenciones secundarias con reducción económica en salud. Demostrando ser más efectiva. El objetivo del presente trabajo fue evaluar las ventajas de la técnica de colocación de placa en posición anteroinferior para fractura mediodiafisaria de clavícula. Se estudiaron una serie de casos que describe las ventajas de la técnica de colocación de placa en posición anteroinferior por fractura mediodiafisaria de clavícula en el hospital José Carrasco Arteaga, entre enero a diciembre del año 2017. Analizado mediante estadística descriptiva. Se estudiaron 12 pacientes masculinos entre los 18 y 30 años, previo consentimiento informado y cumplieron con criterios de inclusión. Los datos se obtuvieron de resultados de procedimientos quirúrgicos y fueron analizados en Microsoft Excel. Todas las fracturas mediodiafisarias de clavícula se trataron con colocación de una placa de 6 a 8 orificios de 3.5mm de reconstrucción en posición anteroinferior. No se presentaron complicaciones intra ni posoperatorios. Consolidaron al mes y medio con un buen resultado funcional. La técnica de colocación de placa en posición anteroinferior ofrece el retorno temprano de la función del hombro y evita el riesgo de lesión neurovascular. Además, presenta una baja tasa de prominencia del implante.

Clinical outcome and operative cost comparison: Locked compression plate versus reconstruction plate in midshaft clavicle fractures

OBJECTIVE

The aim of this study was to compare the clinical outcomes and operative cost of a locked compression plate (LCP) and a nonlocked reconstruction plate in the treatment of displaced midshaft clavicle fracture.

METHODS

From January 2013 till March 2018, a total of 55 patients with acute unilateral closed midshaft clavicle fracture were treated with either a 3.5-mm pre-contoured LCP [32 patients; 25 men and 7 women; mean age: 35 years (range: 19-63 years)] or a 3.5-mm nonlocked reconstruction plate [23 patients; 20 men and 3 women; mean age: 31.4 years (range: 17-61 years)]. The clinical outcomes in terms of fracture union, Quick Disability of Arm, Shoulder and Hand (DASH) score, implant irritation, failure rate, and reoperation rate were evaluated retrospectively. The patient billing records were reviewed to obtain primary operation, reoperation, and total operative cost for midshaft clavicle fracture. These values were analyzed and converted from Malaysia Ringgit (RM) to United States Dollar (USD) at the exchange rate of RM 1 to USD 0.24. All patients were followed up for at least one-year duration.

RESULTS

The mean time to fracture union, implant irritation, implant failure, and reoperation rate showed no significant difference between the two groups of patients. The mean Quick DASH score was significantly better in the reconstruction plate group with 13 points compared with 28 points in the LCP group (p=0.003). In terms of total operative cost, the LCP group recorded a cost of USD 391 higher than the reconstruction plate group (p<0.001).

CONCLUSION

The 3.5-mm reconstruction plate achieved not only satisfactory clinical outcomes but was also more cost-effective than the LCP in the treatment of displaced midshaft clavicle fractures.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Dual Versus Single-Plate Fixation of Midshaft Clavicular Fractures: A Retrospective Comparative Study

Background

Implant-related symptoms are the most common reason for reoperation after open reduction and internal fixation (ORIF) of midshaft clavicular fractures. Dual mini-fragment plate fixation is a relatively new solution that may decrease implant prominence while maintaining fixation strength and function. There are minimal published data comparing reoperation rates and clinical outcomes between single, superior-plate constructs and dual mini-fragment plate constructs in the fixation of midshaft clavicular fractures. We hypothesized that reducing plate size with the use of dual mini-fragment plating compared with standard, 3.5-mm, superior plating would minimize implant symptoms and the corresponding need for reoperation while still providing sufficient fixation to allow fracture-healing and return to function.

Methods

We retrospectively reviewed the cases of 44 consecutive patients who underwent ORIF of displaced midshaft clavicular fractures utilizing either a single, 3.5-mm, superior plate construct (21 patients) or a dual, 2.7-mm and 2.4-mm, plate construct (23 patients). Outcomes at a minimum of 2 years were assessed. Primary outcome measures included reoperation for any reason and the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, patient self-report section.

Results

There was a 100% union rate in both groups. None (0%) of the 23 patients who received the dual (2.7-mm and 2.4-mm) plate construct and 6 (29%) of the 21 patients who received the single (3.5-mm) plate construct underwent reoperation for implant-related symptoms. Using a Fisher exact test, the rate of reoperation was compared between the groups, and the difference was found to be significant (p = 0.008). Using an unpaired t test, the difference in mean ASES scores was not significant (p = 0.138) between the dual-plate group (98 of 100) and the single superior plate group (96 of 100) with retained implants.

Conclusions

In our comparative retrospective series, dual fixation utilizing a 2.7-mm superior plate and a 2.4-mm anterior plate for the treatment of displaced midshaft clavicular fractures was associated with a significantly lower rate of reoperation when compared with single, 3.5-mm, superior plate fixation.

Level of Evidence

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clavicle nonunion and plate breakage after locking compression plate fixation of displaced midshaft clavicular fractures

Open reduction and plate fixation have been widely used for the treatment of displaced midshaft clavicular fractures (DMCF). The nonunion rate after plate fixation of DMCF has been reported to be between 0.1 and 15% and the construct failure rate is approximately 5%. Few studies have discussed the risk factors of construct failure. The aim of the present study was to identify possible risk factors of construct failure in plate fixation of DMCF and discuss the subsequent treatment strategies. Six patients who experienced plate breakage and clavicle nonunion between 2015 and 2017 were evaluated. All these patients were treated with open reduction and plate fixation of DMCF using a 3.5-mm locking compression plate. The plate breakage occurred 3-6 months after the initial injury. After the diagnosis of plate breakage, four patients underwent surgical management and two patients underwent nonoperative treatment. Potential risk factors for construct failure and efficacy of the subsequent treatment strategies were analyzed. We found that a risk factor for plate breakage was the increased stress in free hole area around the fracture zone. A second surgery for plate renewal and bone grafting may be necessary in a large percentage of these individuals. Based on the results of this study, our recommendation is that monocortical screws or simple obturators for the holes around the fracture zone should be used to protect the comminuted fragment for further damage and enhance plate strength. If a clavicle nonunion and plate breakage does occur, surgical repair and bone grafting provide high union rates and should be a necessary remedy.

Comparison of implant failure rates of different plates for midshaft clavicular fractures based on fracture classifications

Backgrounds

The aim of our study was to investigate failure rates of reconstruction plate and non-reconstruction plate, and find the best strategy for implant selection for different fracture types for midshaft clavicular fractures.

Patients and methods

Two hundred twenty-six consecutive patients with midshaft clavicular fractures who received open reduction and plate fixation during Jan 2012 to July 2017 were reviewed. The correlations between implant failure rates and risk factors including demographic data, fracture classifications, and implant types were analyzed.

Results

AO/OTA fracture classification and plate types are the most important factors affecting implant failure for midshaft clavicular fractures. Reconstruction plate had a significantly higher failure rate (53%) than that of non-reconstruction plates (3%) in comminuted midshaft clavicular (AO/OTA 15-2C) fractures (P value < 0.01). However, the difference was not significant in AO/OTA 15-2A and 2B classifications.

Conclusion

Patients with comminuted midshaft clavicular (AO/OTA 15-2C) fractures treated with reconstruction plates had very high implant failure rates compared to non-reconstruction plates. We suggested that patients with comminuted midshaft clavicular (AO/OTA 15-2C) fractures treated with reconstruction plates need more protection and more frequent follow-up in the postoperative period.

Mechanical failure of plate breakage after open reduction and plate fixation of displaced midshaft clavicle fracture - a possible new risk factor: a case report

Background

Plate breakage is one form of construct failure after a clavicle fracture treated with an open reduction and plate fixation. A recent study evaluated construct failure after an open reduction and plate fixation and reported a construct failure rate of 6.9% of which 1.9% were related to broken plates. Plate breakage is rare, thus, there are insufficient data regarding risk factors, pathogenesis, or how to avoid it.

Case presentation

This case report presents an unusual case of a 35-year-old Caucasian man, 7 weeks after open reduction and internal plate fixation of a fracture in the middle third of his clavicle, who developed breakage of the implant. Surgery was advised, the implant was retrieved, the fracture was reduced, and a new bridging locking plate was implanted.

Conclusions

In the current case it seems that the use of a bridging plate, the fundamental anatomical structure of the clavicle and the forces that are applied on it, the lack of discipline in complying with the postoperative functional restrictions, and an unclear “patient expectation” process were the main reasons for the failure. These aspects should be carefully considered and addressed in clavicle fractures.

The first 100 patients treated with a new anatomical pre-contoured locking plate for clavicular midshaft fractures

BACKGROUND

Pre-contoured locking plates were recently introduced in the management of clavicular midshaft fractures. These plates may offer advantages such as no necessity for intraoperative bending and reduced plate irritation. The purpose of this study was to review the clinical and radiographical outcome of the first 100 patients treated with a new anatomical pre-contoured locking plate.

METHODS

In a retrospective single-center study, 100 consecutive patients (16 female, 84 male) with a median age of 40 years (range 15-82) who underwent surgery for clavicular midshaft fractures with a VariAx locking plate (Stryker Corporation Kalmazoo, MI, USA) between March 2012 and January 2016 were included. Postoperative follow-up was performed until union was clinically and radiographically achieved. Fracture type, surgical time, intraoperative need for contouring the plate, further surgery such as revision or hardware removal and complications were recorded.

RESULTS

One-hundred patients with a dislocated midshaft clavicular fracture with a mean follow-up of 21.9 months (standard deviation 13.2) were included. Ninety-three patients reported normal shoulder function at latest follow-up. Median surgical time was 75.5 min (range, 35-179). In three patients, intraoperative bending of the plate was necessary. In two patients, plates designed for the other side were implanted. Five patients needed revision surgery: One patient with wound healing problems, one patient with a re-fracture after early (13 months) hardware removal and minor trauma, one patient with postoperative shoulder stiffness and two patients with failed osteosynthesis because of surgical implantation fault. One asymptomatic nonunion without further treatment was observed. In 30 patients, the plate was removed after a mean of 17.5 months (SD 4.2) because of subjective plate discomfort.

CONCLUSIONS

With this new pre-contoured locking plate, good to excellent intraoperative fit to the anatomical shape of the clavicle can be achieved. The implant seems to be reliable regarding handling and complications. Clinical and radiological results are comparable to results reported in the literature. Hardware removal rate is comparable to other studies with a pre-contoured plate and lower compared to non-pre-contoured.

Are commercially-available precontoured anatomical clavicle plating systems offering the purported superior optimum fitting to the clavicle? A cadaveric analysis and review of literature

PURPOSE

The indication for operative treatment of displaced midshaft clavicle fractures remains controversial. However, if plate fixation is considered, implant prominence and skin irritation are the most common causes for re-operation. Low profile implants as well as closely contouring plates to the individual anatomy may reduce these complications. The aim of this study was to compare the fitting accuracy and implant prominence of 3.5mm pelvic reconstruction plates (PRP) with pre-contoured anatomical clavicle plates (PACP) for midshaft clavicle fractures.

METHODS

Three-dimensional data of the largest, median and smallest male and female clavicle of an existing database of 89 cadaveric clavicles were included for analysis. A three-dimensional model of a commercially available PACP was used for digitally positioning of the plate on the segmented clavicles. Three-dimensional printouts of each clavicle were produced and the 3.5mm reconstruction plates were manually bent and positioned by the senior author. Computed tomography scans and three-dimensional reconstructions were then obtained to digitally compare the fitting accuracy and implant prominence.

RESULTS

Pelvic reconstruction plates offered superior fitting accuracy and lower implant prominence compared to PACP. The largest difference in implant prominence was observed in large sized female clavicles and measured 3.6mm.

CONCLUSION

Both, the less costly PRP plates and commercially available PACP for midshaft fractures of the clavicle demonstrated a clinically acceptable fitting accuracy. The manually bent pelvic-reconstruction plates demonstrated reduced implant prominence with superior fitting. Hypothetically this might contribute to a reduced rate of reoperation.

LEVEL OF EVIDENCE

Level IV cadaveric study.

Are clinical outcomes affected by type of plate used for management of mid-shaft clavicle fractures?

Background

Open reduction and internal fixation (ORIF) using plate osteosynthesis for midshaft clavicle fractures is often complicated by the prominence of the implant due to the subcutaneous position of the clavicle. Reoperation rates for symptomatic clavicle plate removal have been reported to be as high as 53%. We sought to determine to which degree do clinical outcomes (all cause reoperation rate and rate of fracture union) differ between types of clavicle plates.

Materials and methods

A retrospective chart review was performed using our hospital database for patients treated with ORIF for mid-shaft clavicle fractures (OTA/AO type 15-B). Implants included in this review were 2.7 mm reconstruction plates, 3.5 mm reconstruction plates, 3.5 mm precontoured clavicle plates and 3.5 mm locking compression plates. The primary outcome measure was the all cause reoperation rate. Secondary outcomes compared the rate fracture union, documented infection, hardware failures and clinical symptoms at the surgical site among the various plate types. Data was collected and descriptive statistics were analyzed. p values < 0.05 were considered statistically significant.

Results

A total of 102 midshaft clavicle fractures treated with ORIF were included in this study. The majority of patients were ≤ 50 years old (83.3%) and male (72.5%). The overall union rate for all plating constructs was 97.1%. We found that age, sex and smoking were not associated with the rate of re-operation. In addition, the fracture classification, type of implant used and number of screws used didn’t increase the risk of revision surgery. In addition, more than 50% of patients complaining of pain at 6 weeks post-operatively required a second surgery for removal of hardware. Moreover, there was no association between age, sex, smoking, fracture classification or plate type and the rate of union. Interestingly, clavicle fractures fixed with 3.5 mm reconstruction plates were more likely to have hardware failure due to plastic deformation, whereas 2.7 mm plates were more likely to fail by plate breakage.

Conclusion

Although different types of implants have different biomechanical properties, no difference in reoperation, union and plate removal rates were found between the various plate types. Future studies with a larger sample size are required to further examine these outcomes.

Level of evidence

Level III.

Midshaft clavicle fractures: Current concepts

Clavicle fractures are common fractures and the optimal treatment strategy remains debatable. The present paper reviews the available literature and current concepts in the management of displaced and/or shortened midshaft clavicle fractures.

Operative treatment leads to improved short-term functional outcomes, increased patient satisfaction, an earlier return to sports and lower rates of non-union compared with conservative treatment. In terms of cost-effectiveness, operative treatment also seems to be advantageous.

However, operative treatment is associated with an increased risk of complications and re-operations, while long-term shoulder functional outcomes are similar.

The optimal treatment strategy should be one tailor-made to the patient and his/her specific needs and expectations by utilizing a shared decision-making model.

Cite this article: EFORT Open Rev 2018;3:374-380. DOI: 10.1302/2058-5241.3.170033

[Complications after intramedullary stabilization of clavicle fractures]

BACKGROUND

Operative treatment of clavicle fractures by intramedullary nailing with titanium elastic nailing (TEN) has been established as an alternative to plate osteosynthesis for many years. The main complication after TEN osteosynthesis is nail migration. The goal of this study was evaluation of predictors for medial nail migration and comparison with plate osteosynthesis.

MATERIAL AND METHODS

A retrospective analysis of electronic patient charts, surgical protocols and radiographs of all operatively treated clavicle shaft fractures between 2010-2014 (n = 141) was performed. When evaluating the patient charts and the surgical protocols special attention was paid to the fracture type, the duration of the operation, the need for an open reduction and the onset of complications as well as the duration until implant removal. Radiographs were analyzed concerning the implant location and an implant migration.

RESULTS

Surgery time (39 vs. 83 min) as well as the time to implant removal (226 vs. 495 days) were significantly reduced (p = 0.00), while complication (39% vs. 21.4%) as well as reoperation rates (15% vs. 7.1%; p = 0.033) were increased in TEN compared to plate osteosynthesis. The main complication was medial nail migration. The following predictors regarding medial migration could be identified: open or closed reduction (p = 0.021), multifragmentary fractures (p = 0.049), oblique fractures (p = 0.08) and TEN thickness (33% at 2 mm, 0% at 3 mm).

DISCUSSION

Advantages of TEN are a shorter surgery time as well as a shorter duration until implant removal. The TEN osteosynthesis led to a significantly increased complication rate, with nail migration representing the major reason. When predictors for medial TEN migration are considered, type B and C fractures can also be sufficiently treated by a large diameter TEN.

The challenge of nonunion after osteosynthesis of the clavicle: is it a biomechanical or infection problem?

Introduction

The nonunion rate has been reported between 0.1% and 15%. There are also several predisposing factors for the onset of complications: general factors connected with the patient and specific factors related to the fracture site. The purpose of our study is to review the etiology of nonunion of the clavicle in its atrophic form and investigate the outcomes of the revision treatment in a single step.

Materials and methods

Retrospective study on 71 patients suffering from nonunions due to the following treatments: conservative in 13 patients; plate fixation in 12; closed reduction and fixation with K-wire in 24; open reduction and fixation with K-wire. All patients were operated on in beach chair position and classic approach to the clavicle by incising the previous surgical scar. The clinical and radiographic criteria for evaluating the outcomes were: the Short Form (12) Health Survey (SF-12), the Constant Shoulder Score (CSS) and the Disability Disabilities of the Arm, Shoulder and Score (DASH) and radiographic Union Score (RUS) for bone healing. The evaluation endpoint was set at 12 months.

Results

Blood and culture tests showed 22 infected nonunions and 49 atrophic or oligoatrophic. In only 10 cases, before surgery, the inflammatory markers were positive. The isolated microorganisms were resistant to common antibiotics. In 70 out of 71 cases, plates and screws on the upper side and fibula allogenic splints at the bottom, associated with cancellous bone grafts taken from the patients' iliac crests, were implanted. In one case, however, it was decided to implant the plate on the front edge of the clavicle and the fibula allogeneic splint on the posterior margin, also associated with a cancellous bone graft taken from the patient's iliac crest. The radiographic bone healing was observed in 107.8 (range 82-160) days for the aseptic nonunions, while in 118.4 (range 82-203) days for the septic ones. The non-healing case was a serious failure that led to asubtotal excision of the clavicle.

Conclusions

The importance of classification and study of nonunions are essential to achieve positive outcomes. The guiding principle of our work is that aseptic nonunions heal in the operating room, while infected nonunions can be challenged and defeated on the operating table. Restoring the correct length of the clavicle interconnection between the sternum and the shoulder cingulum is indispensable to avoid functional deficits of the upper limb. The fibula splint and the tricorticale bone graft have both mechanical and strong biological values to quickly heal the nonunion. The return to pre-injury quality of life has to be our main goal.

Midshaft Fractures of the Clavicle: A Meta-analysis Comparing Surgical Fixation Using Anteroinferior Plating Versus Superior Plating

OBJECTIVE

To compare the outcomes of clavicle fracture fixation using anteroinferior versus superior plate placement.

METHODS

We performed a meta-analysis of studies that have reported on outcomes after superior or anteroinferior plate fixation for acute midshaft clavicle fractures (Orthopaedic Trauma Association 15-B). A computerized literature search in the Pubmed, Scopus, and Cochrane Library databases was used to identify relevant articles. Only full text articles without language restrictions were evaluated. The inclusion criteria consisted of: (1) fracture of the midshaft clavicle; (2) surgery for acute fractures (within 1 month of the fracture); (3) adult patients (16 years of age and older); and (4) open reduction and internal fixation with plate application in either the anteroinferior or superior position. Studies were excluded if they did not specify plate location, evaluated multitrauma patients, investigated minimally invasive procedures, or studied operations for revision, nonunion, malunion, or infection. The primary measured outcomes were symptomatic hardware (implant prominence or irritation) and surgery for implant removal. The secondary outcomes were time to union, fracture union, nonunion, malunion, Disabilies of the Arm, Shoulder and Hand score, Constant score, and implant failure. Frequencies and proportions of cases were recorded for binary outcomes, whereas mean and standard deviations were recorded for continuous outcomes. Other summary statistics provided were used to impute mean and standard deviations under the assumption of normality when these were not reported. Continuous outcomes were compared between groups using linear mixed effects models, whereas binary outcomes were compared using mixed effects logistic regression models, including fixed group effects and random study effects. P-values less than 0.05 were considered statistically significant. All analyses were performed using SAS v. 9.4 (SAS Institute Inc, Cary, NC).

RESULTS

A total of 1428 articles were identified among the 3 databases, of which 897 remained after removing duplicates. From that pool, 57 relevant studies were evaluated. Articles were excluded because of an inability to specify plate location (6), a subject pool not exclusively consisting of acute fractures (4) or midshaft fractures (2), a minimally invasive surgical approach (6), use of nonstandard plates (1), poor reporting of functional outcomes (2), and a duplicate group of patients (2). This left 34 articles to be used in the meta-analysis. Of these, 8 studies reported on patients with anteroinferior plating (N = 390) and 27 studies reported on patients with superior plating (N = 1104). No significant differences were found with respect to the functional shoulder scores (Disabilies of the Arm, Shoulder and Hand and Constant) between the 2 groups. There was no significant difference between each group for the probability of having a union (P = 0.41), malunion (P = 0.28), nonunion (0.29), or implant failure (P = 0.39). Patients in the superior plating group had a significantly higher probability of suffering from symptomatic hardware (0.17) as compared to patients in the anteroinferior plating group (0.08), (P = 0.005). In addition, the superior plating group had a significantly higher rate of surgery for implant removal (0.11 vs. 0.05), (P = 0.008).

CONCLUSIONS

The findings of this investigation demonstrate that plating along the superior and anteroinferior aspects of the clavicle lead to similar operative outcomes with respect to union, nonunion, malunion, and implant failure, as well as similar functional outcomes scores. Plates applied to the superior aspect of the clavicle are associated with higher rates of symptomatic hardware and more frequent implant removal.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mid-term outcome following revision surgery of clavicular non- and malunion using anatomic locking compression plate and iliac crest bone graft

Background

Treatment of clavicular non- and malunion is still challenging. Current surgical procedures often result in frustrating functional outcome along with high-grade subjective impairment and increased rates of revision surgery. However, the combination of biological augmentation with vital bone graft and a biomechanically sufficient fixation system seems to be a promising concept of treatment.

Methods

In this retrospective study, 14 patients with a mean age of 44 years (26–67 years) suffering from non-union (n = 11) and/or malunion (n = 3) of the clavicle were enrolled. All patients were surgically treated using an anatomical precontoured locking compression plate (LCP) and autologous iliac crest bone graft. Functional outcome was assessed using the age- and sex-specific relative Constant Score.

Results

Mean follow-up was 27 months (range 12–44 months). The relative Constant Score significantly improved from preoperative 61 ± 8 (43–72) to 82 ± 10 (65–100) points at the final follow-up examination (p < 0.05). All patients showed bony union radiographically. One patient presented with a re-fracture of the clavicle nearly 3 years after revision surgery and 5 weeks after implant removal. Secondary fractures at the donor site of the anterior superior iliac spine were recorded in two patients.

Conclusions

Iliac crest bone graft and anatomic locking plate fixation allow for a safe and adequate stabilization and radiographical bony union in non- and malunions of the clavicle with a high degree of patient satisfaction. However, secondary fractures of the anterior superior iliac spine constitute relevant complications and the time of hardware removal should be considered carefully.

Construct failure after open reduction and plate fixation of displaced midshaft clavicular fractures

INTRODUCTION

Worldwide, implants mostly used for fixation of displaced midshaft clavicular fractures (DMCF) are the easily to bend reconstruction plate and the stiffer small fragment locking compression plate. Construct failure rates after plate fixation of DMCF are reported around 5 percent. Possible risk factors for construct failure are implant type and fracture type. However, little is known about the influence of fracture fixation method on construct failure. The aim of this study was to assess construct failure in plate fixation of DMCF and to identify possible risk factors.

METHODS

All consecutive patients treated in a level 1 trauma centre with open reduction and fixation of DMCF using a 3.5-mm reconstruction plate or 3.5-mm small fragment locking compression plate between 2007 and 2015 were evaluated. Potential risk factors for construct failure were analysed using univariate analysis.

RESULTS

Two hundred and fifty-nine patients were analysed. Fifty DMCF (19%) were fixated with a reconstruction plate and 209 (81%) with a small fragment locking compression plate. Construct failure was seen in 18 patients (6.9%), including 5 broken plates and 13 with screw loosening. Eight percent of all reconstruction plates broke in contrast to 0.5 percent of all small fragment locking compression plates (p=0.001). All broken implants were used as a bridging plate. Loosening of screws was seen in older patients and when the plate was fixated with less than three bicortical screws on one side of the fracture (p=0.002).

CONCLUSIONS

Overall construct failure after open reduction and plate fixation of DMCF occurred in 6.9 percent. Risk factors for plate breakage were the use of a reconstruction plate and a bridging method for fracture fixation. Risk factors for screw loosening were an increasing patient age and plate fixation with less than three bicortical screws on one side of the fracture.

RECOMMENDATIONS

Based on the results of this study our recommendation is to use a small fragment locking compression plate for open reduction and internal fixation of DMCF. The surgeon should always strive to fixate the plate on both sides of the fracture with at least three bicortical screws.

Reconstruction plates for midshaft clavicular fractures: A retrospective cohort study

BACKGROUND

For the fixation of displaced midshaft clavicular fractures different plates are available, each with its specific pros and cons. The ideal plating choice for this lesion remains subject to ongoing discussion. Reconstruction plates are cheap and easily bendable, but their strength and stability have been questioned. The aim of this study was to evaluate the failure rate of reconstruction plates in the fixation of clavicular fractures.

MATERIALS AND METHODS

A multicenter, retrospective cohort study of all consecutive patients with a displaced, midshaft clavicular fracture (Robinson type 2a/2b) treated with a 3.5-mm reconstruction plate between 2006 and 2013 were evaluated. The primary outcome measure was reoperation rate due to implant failure. Secondary outcome measures were nonunion, symptomatic malunion and elective plate removal.

RESULTS

One hundred and eleven patients were analyzed. During a median follow-up of 8 months, 14 patients (12.6%) had implant failure, of which 7 (6.3%) required a reoperation. Three nonunions (2.7%) and no symptomatic malunions occurred. Plate removal was indicated in 37.8% of patients because of implant irritation.

DISCUSSION

The incidence of reoperation due to implant failure following clavicular plate fixation with a reconstruction plate is 6.3%. Although comparison with other plate types is difficult since rates in literature vary greatly, reoperation rates in other plates are reported around 2-3%, suggesting that reconstruction plates have a higher incidence of implant failure warranting reoperation. Therefore, especially in patients with known risk factors for complications (e.g. smoking, osteoporosis, comminuted fractures), a stronger plate than a reconstruction plate should be considered.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

The Treatment of Mid-shaft Clavicle Fractures

OBJECTIVE

Through reviewing the relevant literature from the past decades, to summarize the assessment and management of fractures of the clavicle, and provide an overview of the clinical results of a range of treatment options.

DATA SOURCES

The data analyzed in this review are mainly from articles included in PubMed and EMBASE, published from 1960 to 2015.

STUDY SELECTION

Studies involving assessment of fractures of the clavicle were reviewed. Further literatures were gathered regarding the conservative and surgical treatment of these fractures, including the methods of fixation and the surgical approaches used. Both conservative and surgical treatments were then compared and contrasted.

RESULTS

Through retrieving and reading the abstract, a total of 42 representative articles were selected, which covered all aspects of the conservative treatment and surgical treatment, and compared the advantages and disadvantages of different treatment options.

CONCLUSIONS

Although the majority of recent data suggest that surgery may be more appropriate as it improves functional outcome and reduces the risk of complications, we recommend that the treatment should be individually assessed.

Operative versus nonoperative treatment for displaced midshaft clavicle fractures: a meta-analysis based on current evidence

Literature searches of the Cochrane Library, PubMed, EMBASE, Web of Science, LILACS, China National Knowledge Infrastructure, and Wanfang Data databases were performed from 1966 to September 2014. Only randomized and quasi-randomized controlled clinical trials comparing operative and nonoperative treatments for displaced midshaft clavicle fractures were included. Data collection and extraction, quality assessment, and data analyses were performed according to the Cochrane standards. Thirteen studies were considered in the meta-analysis. Constant scores and the Disabilities of the Arm, Shoulder and Hand scores were improved in the operative fixation group at a follow up of one year or more. The nonunion and symptomatic malunion rates were significantly lower in the operative group. Additionally, the nonoperative group had a higher likelihood of neurological symptoms compared with the operative group. A significantly higher risk of complications was found in patients treated conservatively than in those who underwent operative fixation. However, when patients with nonunion and symptomatic malunion were excluded from the analysis, no significant differences in the complication rate were found. We concluded that based on the current clinical reports, operative treatment is superior to nonoperative treatment in the management of displaced midshaft clavicle fractures. However, we do not support the routine use of primary operative fixation for all displaced midshaft clavicle fractures in adults.